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Atrial fibrillation - Making a diagnosis
When should I suspect atrial fibrillation?
- Suspect atrial fibrillation (AF) in people with an irregular pulse, with or without any of the following:
- Breathlessness.
- Palpitations.
- Chest discomfort.
- Syncope or dizziness.
- Reduced exercise tolerance, malaise, or polyuria.
- A potential complication of AF, such as stroke, transient ischaemic attack, or heart failure.
- Absence of an abnormal pulse makes a diagnosis of AF unlikely, but its presence does not reliably indicate AF — see sensitivity and specificity values in table 1.
- Suspect paroxysmal AF if symptoms are episodic and last less than 48 hours (see Definition).
Clarification / Additional information
Table 1. Diagnostic accuracy of pulse palpation for detecting atrial fibrillation.
Diagnostic accuracy | Men 65–74 years | Men 75+ years |
|---|
Sensitivity | 100% (54 to 100) | 95% (75 to 100) |
Specificity | 79% (74 to 84) | 71% (65 to 77) |
Positive predictive value | 12% (4 to 23) | 23% (14 to 34) |
Negative predictive value | 100% (98 to 100) | 99% (96 to 100) |
All values are percentages with 95% confidence intervals. Values for women are not included but are similar to those for men. |
|
Basis for recommendation
The National Institute for Health and Clinical Excellence reviewed evidence from nine studies. All studies included people with atrial fibrillation (AF) presenting to secondary care, and as most people presenting to hospital with AF have more severe symptoms, these findings may not be generalizable to primary care [National Collaborating Centre for Chronic Conditions, 2006].
Irregular pulse
- In one UK study of 916 people older than 65 years of age, an irregular pulse was found to be sensitive (93–100%) to the presence of AF. The negative predictive values ranged from 99–100% depending on age. In other words, AF can be confidently excluded if the person does not have an irregular pulse.
Symptoms
- Many people with AF have no symptoms, and the irregular pulse is detected incidentally.
- In two studies with 410 participants, breathlessness, chest pain, and palpitations were found to be the most common presenting symptoms in emergency admissions with newly diagnosed or previously diagnosed AF.
- In one study with 756 participants, breathlessness was the most commonly reported symptom in chronic and recent onset AF (47%) and palpitations was the most commonly reported symptom in paroxysmal AF (79%).
- Reduced exercise tolerance and malaise may occur due to a rapid heart rate or to a complication, such as heart failure [MeReC, 2002; Snow et al, 2003].
- Polyuria may occur owing to the release of atrial natriuretic peptide during episodes of AF [Fuster et al, 2006a].
Complication of AF
- In two studies, stroke was reported as a presenting symptom of AF at rates of 5% and 3%.
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