Atrial fibrillation: diagnostic and treatment
1. Big picture
Atrial fibrillation (AF) is the most common sustained arrhythmia. The ECG pattern is simple but exam-critical:
Irregularly irregular rhythm + no organized P waves = atrial fibrillation
The danger of AF is not only palpitations. The two major clinical problems are:
- Fast, irregular ventricular response → dyspnea, chest pain, hypotension, heart failure.
- Left atrial appendage thrombus → embolic stroke/systemic embolism.
So, in the exam, always answer AF with three parallel decisions:
1. Is the patient unstable? → immediate synchronized cardioversion
2. Stroke prevention? → anticoagulation according to CHA₂DS₂-VASc / CHA₂DS₂-VA
3. Symptom/rhythm control? → rate control or rhythm control
The 2023 ACC/AHA guideline emphasizes AF diagnosis, thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, ablation, and risk factor modification. The 2024 ESC guideline uses an integrated AF-CARE approach and simplifies stroke-risk assessment with CHA₂DS₂-VA, removing sex as an independent risk factor. ([HRS][1])
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