• Know the initial evaluation of patients with newly diagnosed atrial fibrillation and to identify secondary causes of atrial fibrillation.
• Know the indications and management strategies for rate control vs. rhythm in patients with atrial fibrillation.
• Understand how to stratify, know anti-thrombolic indications and management in patients with atrial fibrillation.

Carlos Estrada, MD
Associate Professor of Medicine
University of Alabama at Birmingham

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

This online course represents the first part of a series of two courses on the evaluation and management of Atrial Fibrillation.

Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by uncoordinated atrial activation. The p wave is absent on EKG and the rhythm on the physical exam is usually irregular-irregular. The prevalence of atrial fibrillation increases with age. In apidemiological studies, the mortality is increased in patients with AF.[1]

Atrial fibrillation lasting more than 30 seconds can be:

• Paroxysmal (recurrent episodes lasting 1-7 days)
• Persistent (episodes lasting > 7 days, can be terminated by cardioversion)
• Recurrent (>= 2 episodes)
• Permanent (lasts > 1 year)
• "Lone" (age < 60 years, no cardiac or pulmonary disease)

The above categories are not mutually exclusive, i.e.: a patient may have more than one category.[1]

The level of evidence indicated in the answers were reported in the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation (highest to lowest):

• Level of Evidence A: Data from multiple randomized cliical trials or meta-analyses.
• Level of Evidence B: Data from a single randomized trial, or non-randomized studies.
• Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.

Similarly, recommendations were classified[1] as:

• Class I: Evidence available and/or general agreement that approach is beneficial.
• Class II: Conflicting evidence and/or lack of agreement that approach is beneficial.
• Class III: Evidence available and/or general agreement that approach is NOT beneficial.

A 46-year-old woman sees you because of anxiety. Over the past 2-3 months she feel anxious all of the time, has lost 10 lbs (unintentional) and has experienced palpitations. She is otherwise healthy and takes no medications. She is married and has 2 young children. She does not smoke.

On physical examination, her blood pressure if 144/80mmHg, her pulse if 124/min (irregular-irregular), and her temperature is normal. She has a mild tremor, mild exophtalmus, terse skin, mild pre-tibial non-pitting edema, and brisk deep tendon reflexes. She also has a mildly enlarged non-tender thyroid with a bruit. Her cardiovascular exam shows normal neck veins, a non-enlarged heart, normal heart sounds and a soft flow murmur. Her electrocardiogram shows atrial fibrillation.