From the Guidelines
Diagnosing atrial fibrillation (AF) during hospitalization is crucial and typically involves continuous cardiac monitoring, with a 12-lead ECG as the initial diagnostic tool, to identify AF and guide management. The diagnosis of AF requires ECG documentation by at least single-lead ECG recording during the dysrhythmia, which may be facilitated by review of emergency department records, Holter monitoring, or transtelephonic or telemetric recordings 1.
Diagnostic Approach
The standard approach to diagnosing AF during hospitalization includes:
- Continuous cardiac monitoring for patients admitted with symptoms like palpitations, dizziness, or syncope
- A 12-lead ECG as the initial diagnostic tool to identify AF by showing irregular R-R intervals and absence of P waves
- Continuous telemetry monitoring throughout hospitalization for patients with suspected paroxysmal AF to increase detection rates significantly
- Additional diagnostic methods such as 24-48 hour Holter monitoring or event recorders for patients with intermittent symptoms
Laboratory Tests and Echocardiography
Laboratory tests should include:
- Thyroid function tests
- Electrolytes
- Complete blood count to identify potential triggers or contributing factors Echocardiography is recommended to assess cardiac structure and function, particularly left atrial size and ventricular function, which can help determine the underlying cause and guide management 1.
Management and Consultation
For hospitalized patients with newly diagnosed AF, prompt cardiology consultation is advisable to establish appropriate rate or rhythm control strategies and assess stroke risk using the CHA₂DS₂-VASc score to determine the need for anticoagulation. Early diagnosis during hospitalization allows for timely intervention, potentially reducing complications and improving outcomes. The incidence of AF in patients with ACS ranges from 10% to 21% and increases with patient age and severity of MI, and AF is associated with increased in-hospital mortality, 30-day mortality, and 1-year mortality 1.
From the Research
Diagnosis of Atrial Fibrillation During Hospitalization
- Atrial fibrillation (AF) is a supraventricular arrhythmia that can be detected during hospitalization for other conditions 2.
- The diagnosis of AF during hospitalization is crucial, as it is associated with a high risk of long-term AF recurrence and warrants clinical attention during acute hospitalization and over long-term follow-up 2.
- The initial evaluation of AF should include transthoracic echocardiography, serum electrolyte levels, complete blood count, and thyroid, kidney, and liver function tests 3.
- The CHA2DS2-VASc score should be used to assess stroke risk in patients with AF 4, 5, 3.
Detection and Monitoring of Atrial Fibrillation
- Implantable loop recorders (ILRs) can be used to detect AF and provide high-quality electrocardiographic data over an extended monitoring period 6.
- ILRs are the gold standard for detecting AF and can be used to monitor patients following AF ablation 6.
- Home monitoring is recommended if there is clinical suspicion of arrhythmia despite normal test results 4.
Management of Atrial Fibrillation During Hospitalization
- Acute management of AF requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition 2.
- The acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy 2.
- Anticoagulation should be managed according to the patient's stroke risk, with warfarin and direct oral anticoagulants reducing the risk of stroke by preventing atrial thrombus formation and subsequent cerebral or systemic emboli 4, 5, 3.