Atrial Fibrillation: Common Questions and Answers About Diagnosis and Treatment

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.