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Atrial Fibrillation: Common Questions and Answers About Diagnosis and Treatment

Sarah Holder, DO
Paula Amin, MD

American Family Physician. 2024;109(5):398-404.

Author disclosure: No relevant financial relationships.

Atrial fibrillation is a supraventricular arrhythmia that increases the risk of stroke and all-cause mortality. It is the most common cardiac dysrhythmia in adults in the primary care setting, and its prevalence increases with age. The U.S. Preventive Services Task Force concluded that there is insufficient evidence to assess the benefits and harms of screening asymptomatic adults older than 50 years for atrial fibrillation. Many patients with atrial fibrillation are asymptomatic, but symptoms can include palpitations, exertional dyspnea, fatigue, and chest pain. Diagnosis is based on history and physical examination findings and should be confirmed with 12-lead electrocardiography or other recording device. The initial evaluation should include transthoracic echocardiography; serum electrolyte levels; complete blood count; and thyroid, kidney, and liver function tests. Stroke risk should be assessed in patients with atrial fibrillation using the CHA2DS2-VASc score. Warfarin and direct oral anticoagulants reduce the risk of stroke by preventing atrial thrombus formation and subsequent cerebral or systemic emboli. Hemodynamically unstable patients, including those with decompensated heart failure, should be evaluated and treated emergently. Most hemodynamically stable patients should be treated initially with rate control and anticoagulation. 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. Electrical cardioversion may be appropriate as first-line rhythm control. 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.

Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by uncoordinated electrical activation of the atria leading to ineffective atrial contractions.1 It is the most common cardiac dysrhythmia in adults in the primary care setting.2 It is estimated that 3 million to 6 million adults in the United States are living with AF.2,3 Older adults are more commonly affected.1–3 Patients with AF have a higher risk of stroke, heart failure, and all-cause mortality.1,2

WHAT'S NEW ON THIS TOPIC

Atrial Fibrillation
In 2022, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to assess the benefits and harms of screening asymptomatic adults older than 50 years for atrial fibrillation with electrocardiography, continuous monitors, or blood pressure monitoring devices.
Smartphones (94% sensitivity and 96% specificity) and smartwatches (94% sensitivity and 93% specificity) have similar diagnostic accuracy in detecting atrial fibrillation.
In some patients with atrial fibrillation and heart failure, catheter ablation may improve left ventricular ejection fraction.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
The CHA2DS2-VASc score should be used to assess stroke risk and the need for anticoagulation in patients with AF.1,5,8,16 C Consensus guidelines
Patients with AF who require anticoagulation should be treated with a direct oral anticoagulant to reduce the risk of stroke, embolic events, and all-cause mortality; there is less risk of major bleeding compared with warfarin. Warfarin is preferred in patients with moderate to severe mitral stenosis or a mechanical heart valve.5,16,18,21 A Consensus guidelines supported by randomized controlled trials and meta-analyses
Hemodynamically stable patients with a new diagnosis of AF should be treated initially with rate control and anticoagulation, with consideration of rhythm control for some patients based on risk factors and shared decision-making.1,2,5,8,22,23 C Clinical practice guidelines
Rhythm control may be preferred in patients with hemodynamic instability, younger patients, or those with a shorter duration of AF, reduced LVEF, or persistent symptoms despite treatment with rate control.1,2,5,8 C Clinical practice guidelines
In younger patients with fewer comorbidities who have paroxysmal AF and desire rhythm control, catheter ablation may be used as first-line therapy.8 C Clinical practice guideline

AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure, hypertension, age 75 years or older (doubled), diabetes mellitus, stroke/transient ischemic attack/thromboembolism (doubled), vascular disease, age 65 to 74 years, sex category (female); LVEF = left ventricular ejection fraction.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SARAH HOLDER, DO, FAAFP, is the program director of the AtlantiCare Regional Medical Center Family Medicine Residency Program, Atlantic City, N.J.

PAULA AMIN, MD, is faculty at AtlantiCare Regional Medical Center Family Medicine Residency Program.

Address correspondence to Sarah Holder, DO, FAAFP, Medical Education, 7 S. Ohio Ave., Atlantic City, NJ 08401 (sholder@atlanticare.org). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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