Education And Debate


BMJ 1995; 311 doi: (Published 09 December 1995) Cite this as: BMJ 1995;311:1562
  1. Gregory Y H Lip,
  2. S P Singh,
  3. R D S Watson

    Certain points should be considered when deciding how to manage patients with atrial fibrillation. Firstly, is the diagnosis of atrial fibrillation certain? It is also important to distinguish between chronic and paroxysmal atrial fibrillation as the two conditions have to be managed differently. Secondly, the underlying aetiological or predisposing factor should be sought. Finally, in acute presentations of atrial fibrillation the presence of any acute precipitating factors—for example, infection—should be considered.

    When a new patient apparently has atrial fibrillation

    Is it atrial fibrillation?

    Why did the patient develop it? (What is the underlying cause?)

    Why does the patient have it now? (Are any precipitating factors present?)


    The investigation of a patient with atrial fibrillation requires taking a careful clinical history (including medical history), with emphasis on certain clinical features—for example, whether the symptoms are sustained or intermittent and whether any complications, such as heart failure, stroke, or thromboembolism, are present. At the first consultation basic blood tests should be done, including full blood count and tests of renal function, electrolytes, and thyroid function.

    Diagnosing and assessing atrial fibrillation

    Recording of patient's history and clinical features—for example, paroxysmal atrial fibrillation

    Documentation of the arrhythmia—for example, with a 24 hour Holter monitor

    Echocardiography, especially in young patients

    Exercise testing if ischaemic heart disease is present (caution needed in interpreting result if patient is taking digoxin)


    The arrhythmia should then be documented, firstly with a conventional 12 lead electrocardiogram. This may provide a clue to the aetiology or electrophysiological features that may cause arrhythmia—for example, ischaemic heart disease (previous myocardial infarction), left ventricular hypertrophy, or a pre-excitation syndrome ((delta) wave in the Wolff-Parkinson-White syndrome if in sinus rhythm).

    Demonstration of 24 hour Holter monitor.

    A 24 hour Holter monitor may be needed to document paroxysmal atrial fibrillation or the sick sinus syndrome. This …

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