SOURCE FROM “SOAP FOR INTERNAL MEDICINE”

1. Is the pt experiencing an irregular heart rhythm or palpitations? These are the most common
symptoms reported by pts. Asymptomatic atrial fibrillation is even more common. If the
duration is longer than 48 hrs or unknown, evaluate for possible atrial thrombus.
2. Are there symptoms of shortness of breath, chest pain, or altered mental status? These
symptoms may indicate shock, myocardial infarction, or pulmonary edema. If they are
present, strongly consider urgent cardioversion.
3. Does the pt have a history of hypertension, coronary artery disease, valvular heart disease,
atrial septal defect, hyperthyroidism, pericarditis, or chest surgery? These are common
medical and surgical causes of atrial fibrillation.
4. Is the pt taking any medications? Does he or she use any drugs or alcohol? Theophylline and -
agonists are common medications that can cause atrial fibrillation. Excessive alcohol intake
(“holiday heart”) is a common cause of atrial fibrillation that is often transient and self-
resolving.
5. Does the pt have a history of congestive heart failure, diabetes, hypertension, valvular
disorders, or prior stroke? Is he or she older than 75 years of age? A “yes” answer to any one
of these questions identifies someone who is at significantly increased risk of stroke and
should be considered for anticoagulation.
 Perform a focused PE
1. Pulse: A resting heart rate higher than 100 beats per minute is defined as
rapid ventricular rate and warrants rate control with medications or
cardioversion. Note that not all ventricular beats translate into a palpable
radial pulse. The difference between the ventricular and radial pulse is
known as the“pulse deficit.”
2. Blood pressure: Without atrial systole and with a rapid ventricular rate,
stroke volume can fall dramatically. Severe hypotension is an indication for
urgent cardioversion.
3. Lungs:Pulmonaryedema,characterizedbyralesandbibasilardecreasedbreaths
ounds, may be another indication for urgent cardioversion.
4. Heart: The classic finding is an irregularly irregular heart beat. An S4
representing an “atrial kick” is, by definition, absent in these pts.
 Examine the ECG
Atrial activity should be disorganized, with an atrial rate between 400 to
600 beats per minute. This is represented by the “fibrillating baseline.”
There will be no discernible P-waves, and their presence should lead you
to another diagnosis. The ventricular rate, represented by QRS
complexes, should be irregular. It may or may not be rapid (> 100 bpm). If
the pt has paroxysmal atrial fibrillation, the ECG may be normal. Evidence
of ischemia or infarction on ECG warrants prompt preparation for urgent
cardioversion (see Acute Coronary Syndromes, p. 34).
 Review the CXR

Evidence of pulmonary congestion or edema warrants urgent

cardioversion.
 Atrial fibrillation with or without rapid ventricular response. A normally functioning
heart should beat approximately 60 to 100 times per minute. In atrial fibrillation, foci
discharge all over the atria and prevent coordinated atrial contraction. In general, an
adult atrioventricular node will not transmit faster than 160 to 170 beats per minute,
which is why the rate in atrial fibrillation is usually about 160 to 170.
Differential diagnosis :
 Atrial flutter: very similar to atrial fibrillation and treated the same Characterized by
“sawtooth” pattern on ECG
 Paroxysmal supraventricular tachycardia: A rapid rate requiring a reentry pathway
around the atrioventricular node. Although there are no P-waves, it should be regular.
 Sinus or junctional tachycardias: Monofocal rapid rhythms. P-waves will be present.
 Sinus rhythms with premature beats: Premature atrial or ventricular beats; if frequent
enough can make a rhythm seem irregular.