First-line investigations |
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1. History and clinical examination |
- Thrombosis risk factors (CHA2DS2VASc score, see Indications for and Implementation of Anticoagulant Therapy in Atrial Fibrillation)
- Severity of symptoms (EHRA score)
- Type of atrial fibrillation (paroxysmal, persistent, permanent)
- Cardiac diseases and other factors predisposing to atrial fibrillation
- Rough assessment of cognitive functioning (memory test as required)
- Medication and other forms of treatment
- How does the arrhythmia begin and end, frequency, duration?
- Careful clinical cardiovascular examination
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2. ECG |
- To diagnose the arrhythmia and to monitor treatment
- To diagnose other cardiac conditions (left ventricular hypertrophy, bundle branch block, old infarction, delta wave)
- To assess the effect of medication
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3. Laboratory investigations |
- Basic blood count with platelet count, plasma sodium, potassium, creatinine, fasting glucose, TSH and lipids, urinary screening (proteinuria, glucosuria), to be taken after the first episode of AF, when planning prophylactic treatment and when AF recurs unexpectedly.
- In addition, drug-specific safety tests may be necessary (e.g. amiodarone, dronedarone).
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4. Echocardiography |
- Once for all patients with atrial fibrillation to exclude structural heart diseases
- Always when planning to start actual anti-arrhythmic medication (group I or III drugs)
- May be omitted, at discretion, in elderly patients with no signs suggestive of heart diseases, if rate control is chosen as the line of treatment.
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Second-line investigations |
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1. Other imaging studies |
- Chest x-ray if there is a suspicion of other heart or lung disease
- CT or MRI scan of the heart, as considered necessary by a cardiologist
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2. Ambulatory ECG recording or an event ECG recording |
- To diagnose the arrhythmia and to monitor treatment
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3. Clinical exercise test |
- To diagnose the arrhythmia and to monitor treatment
- To rule out coronary disease when the initiation of flecainide medication is being planned.
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4. Transoesophageal echocardiogram (TEE) |
- When early (TEE-guided) cardioversion is being planned
- Prior to catheter-induced ablation for AF
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5. Electrophysiological studies |
- To diagnose the arrhythmia (to analyse the mechanism of broad complex tachycardia, to identify an underlying primary arrhythmia)
- When catheter ablation is being planned (underlying primary arrhythmia that triggers AF, focal AF or ablation of the atrioventricular node)
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Modified from source: Atrial fibrillation. Current Care Guideline, Duodecim. 2021. |