Clinical evaluation of atrial fibrillation

Clinical evaluation

A thorough medical history should be obtained in order to characterise whether AF is paroxysmal or persistent and the symptoms it produces, and to look for possible causes, precipitating factors or possible underlying heart disease (1).

The initial clinical evaluation in AF should include:

• determination of the European Heart Rhythm Association (EHRA) score
• estimation of stroke risk - e.g. CHADS2 score, CHA2DS2-VASc score
• search for conditions that predispose to AF e.g. - hypertension, valvular heart diseases, cardiomyopathy
• for complications of the arrhythmia e.g. - death, stroke and other thromboembolic events

Physical examination should include:

• blood pressure
• heart rate
• presence of cardiac murmurs (such as aortic or mitral stenosis)
• evidence of heart failure (pulmonary rales, S3 gallop, peripheral pulses, and jugular venous distention)

NICE suggest (2):

Stroke risk

• Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
  • symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
  • atrial flutter
  • a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

Bleeding risk

• assess the risk of bleeding when:
  • considering starting anticoagulation in people with atrial fibrillation and
  • reviewing people already taking anticoagulation
• use the ORBIT bleeding risk score to assess bleeding risk
• offer monitoring and support to modify risk factors for bleeding, including (2):
  • uncontrolled hypertension
  • poor control of international normalised ratio (INR) in patients on vitamin K antagonists
  • Concurrent medication, including antiplatelets, selective serotonin reuptake inhibitors (SSRIs) and non-steroidal anti-inflammatory drugs (NSAIDs)
  • harmful alcohol consumption
  • reversible causes of anaemia

Reference:

1. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020 Aug 29
2. NICE. Atrial fibrillation: diagnosis and management. NICE guideline NG196. Published April 2021, last updated June 2021