What is the workup for Atrial Fibrillation (Afib)?

From the Guidelines

A comprehensive atrial fibrillation (AFib) workup should begin with a 12-lead ECG to confirm the diagnosis, followed by a thorough history and physical examination to identify potential triggers and comorbidities, as recommended by the 2024 ESC guidelines for the management of AFib 1. The initial evaluation of a patient with suspected or proven AFib involves characterizing the pattern of the arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extracardiac factors pertinent to the etiology, tolerability, and management 1. Key components of the workup include:

• Laboratory tests: complete blood count, comprehensive metabolic panel, thyroid function tests, and cardiac biomarkers
• Transthoracic echocardiography to assess cardiac structure and function
• 24-hour Holter monitor or longer-term event recorder to determine AFib burden and pattern
• Stroke risk assessment using the CHA₂DS₂-VASc score, with anticoagulation recommended for patients with a score ≥2 in men or ≥3 in women 1
• Rate control medications, such as beta-blockers (e.g., metoprolol 25-100mg twice daily), calcium channel blockers (e.g., diltiazem 120-360mg daily), or digoxin (0.125-0.25mg daily)
• Rhythm control in appropriate candidates, using antiarrhythmic drugs like amiodarone, flecainide, propafenone, or sotalol, with dosing based on patient characteristics Additional testing may include sleep studies for sleep apnea and stress tests to evaluate for coronary artery disease, as these conditions can trigger or worsen AFib. The 2024 ESC guidelines emphasize the importance of a patient-centered, shared decision-making approach, with a focus on comorbidity and risk factor management, avoidance of stroke and thromboembolism, reduction of symptoms, and evaluation and dynamic reassessment 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis and Initial Evaluation

• The diagnosis of atrial fibrillation (Afib) is based on history and physical examination findings and should be confirmed with 12-lead electrocardiography or other recording device 2.
• The initial evaluation should include:
  • Transthoracic echocardiography
  • Serum electrolyte levels
  • Complete blood count
  • Thyroid, kidney, and liver function tests 2
• Stroke risk should be assessed in patients with Afib using the CHA2DS2-VASc score 2, 3

Management Strategies

• There are 3 general strategies for the management of patients with Afib:
  1. Restoration and maintenance of sinus rhythm
  2. Control of ventricular rate
  3. Prevention of stroke 4
• More than 1 strategy may be appropriate in some patients, and either pharmacologic or nonpharmacologic options can be chosen in certain situations 4

Anticoagulation Therapy

• Anticoagulation therapy is recommended for patients with Afib who have had a prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism 3
• The choice of anticoagulant depends on the patient's risk factors and other clinical considerations, with options including warfarin and direct oral anticoagulants 2, 3

Rhythm Control and Rate Control

• Rhythm control, using medications or procedures, should be considered in patients with hemodynamic instability or in some patients based on risk factors and shared decision-making 2
• Rate control is often the initial treatment for hemodynamically stable patients, with the goal of controlling ventricular rate and preventing symptoms 2

Screening for Afib

• The U.S. Preventive Services Task Force has concluded that there is insufficient evidence to assess the benefits and harms of screening asymptomatic adults older than 50 years for Afib 2, 5
• However, some guidelines recommend active screening for Afib in patients older than 65 years, particularly those with risk factors for stroke 5