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  1. Alastair Bradley, academic training fellow1,
  2. Paul Sheridan, consultant cardiologist and electrophysiologist2
  1. 1Academic Unit of Primary Medical Care, Northern General Hospital, Sheffield S5 7AU, UK
  2. 2Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield
  1. Correspondence to: A Bradley a.bradley{at}sheffield.ac.uk
  • Accepted 1 March 2013

A 67 year old woman presents with recent onset of “palpitations,” lethargy, and shortness of breath, usually related to exercise. She experiences a fluttering in her chest and has hypertension and type 2 diabetes.

What you should cover

Atrial fibrillation is the commonest cardiac arrhythmia, increasing in frequency with age. It causes various symptoms including palpitations, lethargy, shortness of breath, and chest pain and increases the risk of stroke sixfold.1 It can be intermittent (paroxysmal) or continuous (persistent (>7 days to 1 year), longstanding persistent (>1 year), or permanent). Controlling symptoms is important, but reducing stroke risk is paramount.

Consider:

  • Are the palpitations caused by atrial fibrillation?

  • Do you need to refer the patient to hospital?

  • Treatment to control the heart rate and improve symptoms.

  • Stroke risk and stroke prevention strategies.

  • Patient anxiety over symptoms and taking oral anticoagulants.

What you should do

Initial assessment

  • Check the apical heart beat for the irregularly irregular rhythm of atrial fibrillation.

  • Record ventricular rate, blood pressure, and heart sounds. Haemodynamically unstable patients require urgent admission.

  • Ask about chest pain and shortness of breath.

  • Ask about vascular events such as stroke, transient ischaemic attack, and peripheral emboli.

  • Exclude and document other potential causes of symptoms: anaemia, myocardial infarction, pneumonia, and pulmonary embolus.

  • Identify predisposing factors for atrial fibrillation and correct treatable causes (see box 1).

Box 1: Causes of atrial fibrillation

  • Valvular heart disease, especially mitral stenosis

  • Congestive heart failure

  • Alcohol ingestion

  • Thyrotoxicosis

  • Hypertension and ischaemic heart disease

  • Lung problems such as pneumonia, pulmonary …

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