From the Guidelines
Atrial Fibrillation Workup
The workup for atrial fibrillation (AFib) should start with a thorough medical history and physical examination to identify risk factors and comorbidities, as recommended by the 2024 ESC guidelines 1.
Diagnostic Tests
The following diagnostic tests are essential:
- 12-lead ECG to confirm rhythm, determine ventricular rate, and look for signs of structural heart disease, conduction defects, or ischemia 1
- Blood tests to detect concomitant conditions that may exacerbate AF or increase the risk of bleeding and/or thromboembolism, including kidney function, serum electrolytes, liver function, full blood count, glucose/glycated haemoglobin (HbA1c), and thyroid tests 1
- Echocardiogram to determine left atrial (LA) and left ventricular (LV) dimensions, LV wall thickness, and function, as recommended by the ACC/AHA/ESC guidelines 2
- Chest radiograph to detect enlargement of the cardiac chambers and heart failure (HF), although it is less important than echocardiography for the routine evaluation of patients with AF 2
Additional Tests
Additional tests may include:
- 24-hour Holter monitor or event monitor to detect and record arrhythmic episodes, especially in patients with paroxysmal AF 2
- Cardiac imaging tests like cardiac MRI or CT scan to evaluate cardiac structure and function
Goal of the Workup
The goal of the workup is to determine the underlying cause of the fibrillation, assess the risk of stroke and other complications, and guide treatment to restore a normal heart rhythm and prevent future episodes. This is in line with the recommendations from the European Heart Journal 1, 3, 4, 5, 6, 2.
Treatment
Treatment may involve medications such as beta blockers (e.g., metoprolol) or anti-arrhythmic drugs (e.g., flecainide) to control heart rate and rhythm, as well as anticoagulants like apixaban or rivaroxaban to prevent stroke, especially in patients with atrial fibrillation 3.
From the Research
Workup for Atrial Fibrillation (AFib)
The workup for atrial fibrillation (AFib) involves several steps to diagnose and manage the condition. The following are the key components of the workup:
- Diagnosis is based on history and physical examination findings and should be confirmed with 12-lead electrocardiography or other recording device 7
- The initial evaluation should include: + Transthoracic echocardiography + Serum electrolyte levels + Complete blood count + Thyroid, kidney, and liver function tests 7
- Stroke risk should be assessed in patients with atrial fibrillation using the CHA2DS2-VASc score 7
- Evaluation of cardiac function, valvular and ischemic heart disease, and thyroid, kidney, and liver function is recommended on initial diagnosis of atrial fibrillation (AF) 8
- A thorough collection of medical history, physical examination, blood pressure measurement, laboratory tests, ECG, echocardiography, and possibly chest x-ray and exercise testing is necessary for patients with lone AF 9
Diagnostic Tests
Several diagnostic tests can be used to detect AFib, including:
- 12-lead electrocardiogram (ECG) 7, 10
- Lead-I ECG devices, which are handheld instruments that can be used to detect AF at a single time point in people who present with relevant signs or symptoms 10
- RR interval and ECG signals, which can be useful to track AF events 11
Management
The management of AFib involves:
- Rate control and anticoagulation for most hemodynamically stable patients 7
- Rhythm control, using medications or procedures, for patients with hemodynamic instability or based on risk factors and shared decision-making 7
- Electrical cardioversion may be appropriate as first-line rhythm control 7
- Conversion to sinus rhythm with catheter ablation may be considered in patients who are unable or unwilling to take rate or rhythm control medications long-term or if medications have been ineffective 7