ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation- Clinical Evaluation

AHA 2006 guidelines for management of Atrial Fibrillation

Clinical Evaluation in Patients With AF:

Minimum evaluation:

1. History and physical examination, to define

Presence and nature of symptoms associated with AF

Clinical type of AF (first episode, paroxysmal, persistent, or permanent)

Onset of the first symptomatic attack or date of discovery of AF

Frequency, duration, precipitating factors, and modes of termination of AF

Response to any pharmacological agents that have been administered

Presence of any underlying heart disease or other reversible conditions (e.g., hyperthyroidism or alcohol consumption)

2. Electrocardiogram, to identify

Rhythm (verify AF)

LV hypertrophy

P-wave duration and morphology or fibrillatory waves

Preexcitation

Bundle-branch block

Prior MI

Other atrial arrhythmias

To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy

3. Transthoracic echocardiogram, to identify

Valvular heart disease

LA and RA size

LV size and function

Peak RV pressure (pulmonary hypertension)

LV hypertrophy

LA thrombus (low sensitivity)

Pericardial disease

4. Blood tests of thyroid, renal, and hepatic function

For a first episode of AF, when the ventricular rate is difficult to control

Additional testing

One or several tests may be necessary.

1. Six-minute walk test

If the adequacy of rate control is in question

2. Exercise testing

If the adequacy of rate control is in question (permanent AF)

To reproduce exercise-induced AF

To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug

3. Holter monitoring or event recording

If diagnosis of the type of arrhythmia is in question

As a means of evaluating rate control

4. Transesophageal echocardiography

To identify LA thrombus (in the LA appendage)

To guide cardioversion

5. Electrophysiological study

To clarify the mechanism of wide-QRS-complex tachycardia

To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia

To seek sites for curative ablation or AV conduction block/modification

6. Chest radiograph, to evaluate

Lung parenchyma, when clinical findings suggest an abnormality

Pulmonary vasculature, when clinical findings suggest an abnormality

Management:

Management of patients with AF involves 3 objectives—

1. Rate control,

2. Prevention of thromboembolism, and

3. Correction of the rhythm disturbance, and these are not mutually exclusive.

The initial management decision involves primarily a rate-control or rhythm-control strategy.

Under the rate-control strategy, the ventricular rate is controlled with no commitment to restore or maintain sinus rhythm.

The rhythm-control strategy attempts restoration and/or maintenance of sinus rhythm. The latter strategy also requires attention to rate control. Regardless of whether the rate-control or rhythm-control strategy is pursued, attention must also be directed to antithrombotic therapy for prevention of thromboembolism.

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