History and exam

Key diagnostic factors

common

palpitations

The cardinal symptom.[1][3][32][33][37]

  • Might be described by the patient as 'heart racing' or 'fluttering in the chest' .

  • Can last for minutes to hours; occuring on rest or on activity.

irregular pulse rate

Irregularity of pulse rate can be difficult to discern during rapid pulse rates.[3]

risk factors

Specifically consider:

  • Advancing age[14] 

    • Prevalence of AF: 0.5% in people aged 50 to 59 years; 8.8% in people aged 80 to 89 years[15] 

  • Hypertension

    • Reported prevalence rates range from 49% to 90%[62]

  • Heart failure

    • Approximately 40% of patients admitted with heart failure and reduced ejection fraction and 50% of patients admitted with heart failure and preserved ejection fraction have AF on ECG[16]

  • Diabetes

    • Associated with a 50% increase in risk of AF[13] 

  • Obstructive sleep apnoea

    • Prevalence among people with AF estimated at 50% or higher[17][18]

  • Obesity

    • Associated with a 50% increase in the risk of AF[19] 

  • Coronary artery disease

    • Prevalence in AF: 41%[21]

  • Valve disease (in particular, mitral valve disease and rheumatic heart disease)

  • Other cardiac disease (e.g., valvular, congenital, cardiomyopathy)[22] 

  • Alcohol use[24] 

  • Previous cardiothoracic interventions

  • Previous atrial arrhythmias

  • Previous stroke/transient ischaemic attack

  • Hyperthyroidism

  • Athletic levels of physical activity

    • Limited data suggest that athletes may have a higher risk of developing AF.[27]

Other diagnostic factors

common

breathlessness/dyspnoea

May be secondary to obesity or underlying:[1][3][32][33][37] 

  • Coronary artery disease

  • Left ventricular dysfunction with or without acute pulmonary oedema. See Acute heart failure

  • Pulmonary disease.

May be directly related to the rapid and irregular ventricular rate.

symptomatic hypotension

Systolic blood pressure <90 mmHg; a key feature of haemodynamic instability.[1]

chest pain/tightness/discomfort

Often due to the rapid and irregular ventricular rate.[1][3][32][37] Ensure you exclude rate-related ischaemia.

fatigue

Owing to rapid and irregular ventricular rate.[1][37]

anxiety

Owing to rapid and irregular ventricular rate.[37]

uncommon

cognitive impairment

Owing to rapid and irregular ventricular rate.[33]

dizziness

Owing to rapid and irregular ventricular rate.[3][37]

polyuria

Due to both a tachycardia-induced diuresis and natriuresis.[33]

abnormal breath sounds

Auscultate the lungs.[32] Check for:

  • Crackles[48]

    • If bilateral: suggests heart failure

    • If unilateral: might suggest pneumonia

  • Cardiac wheeze

    • Secondary to heart failure ± pulmonary oedema.

additional heart sounds

Auscultate the heart.[32] Check for variable intensity of first heart sound.[47] 

elevated jugular venous pressure

New-onset AF may be associated with heart failure.

evidence of stroke

Look for focal neurological deficits such as hemiplegia or dysphasia.

  • Bear in mind that the first presentation of AF may be with a stroke.[38] See Ischaemic stroke and Stroke due to spontaneous intracerebral haemorrhage. 

pre-syncope and syncope

As a result of rapid and irregular ventricular rate leading to reduced cardiac output and subsequent reduced cerebral perfusion.[1][3][37]

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