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| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]
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{{Template:Atrial fibrillation}}
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{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} {{Anahita}}


==Overview==
==Overview==
Performing an echocardiogram in the setting of atrial fibrillation is essential to identify certain characteristics of the heart, including [[valvular heart disease]], hypertrophy, presence of thrombus, the size and function of the left ventricle, the size of the atria, and the possible presence of pericardial disease.
Performing an [[Echocardiography|echocardiogram]] in the setting of [[atrial fibrillation]] is essential to identify certain characteristics of the [[heart]], including [[valvular heart disease]], [[hypertrophy]], presence of [[thrombus]], the size and function of the [[left ventricle]], the size of the [[atrium|atria]], and the possible presence of [[Pericarditis|pericardial disease]]. [[Echocardiogram#Transesophageal echocardiogram|transesophageal echocardiogram]] is more sensitive, compared to the [[Standard views and measurements in transthoracic echocardiography|transthoracic echocardiography]]. [[Echocardiography]] is essential to identify some of the characteristics in the setting of [[atrial fibrillation]], such as [[valvular heart disease]], [[atrium|atrial]] size, [[left ventricle]] ([[Left ventricle|LV]]) size and function, and peak [[right ventricle]] [[pressure]] ([[pulmonary hypertension]]).


==Echocardiography==
==Echocardiography==
Echocardiography is essential to identify the following characteristics int he setting of atrial fibrillation;
*[[Echocardiography]] is essential to identify the following characteristics in the setting of [[atrial fibrillation]]:<ref name="pmid8313561">{{cite journal| author=Vaziri SM, Larson MG, Benjamin EJ, Levy D| title=Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. | journal=Circulation | year= 1994 | volume= 89 | issue= 2 | pages= 724-30 | pmid=8313561 | doi=10.1161/01.cir.89.2.724 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8313561  }} </ref><ref name="pmid2960225">{{cite journal| author=Keren G, Etzion T, Sherez J, Zelcer AA, Megidish R, Miller HI | display-authors=etal| title=Atrial fibrillation and atrial enlargement in patients with mitral stenosis. | journal=Am Heart J | year= 1987 | volume= 114 | issue= 5 | pages= 1146-55 | pmid=2960225 | doi=10.1016/0002-8703(87)90190-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2960225  }} </ref>
* Valvular heart disease
** [[Valvular heart disease]]
* Left and right atrial size
** Left and right [[atrium|atrial]] size
* LV size and function
** [[Left ventricle]] ([[Left ventricle|LV]]) size and function
* Peak RV pressure ([[pulmonary hypertension]])
** Peak [[right ventricle]] [[pressure]] ([[pulmonary hypertension]])
*[[LV hypertrophy]]
** [[Left ventricular hypertrophy]]
* [[LA thrombus]] (low sensitivity)
** [[Left atrium]] [[thrombus]] (low [[Sensitivity (tests)|sensitivity]])
* Pericardial disease
** [[Pericarditis|Pericardial disease]]
*Based on a study done on 486 [[patients]] with [[atrial fibrillation]], some of the [[echocardiography|echocardiographic features]] can work as predictors.<ref name="pmid7639159">{{cite journal| author=Flaker GC, Fletcher KA, Rothbart RM, Halperin JL, Hart RG| title=Clinical and echocardiographic features of intermittent atrial fibrillation that predict recurrent atrial fibrillation. Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. | journal=Am J Cardiol | year= 1995 | volume= 76 | issue= 5 | pages= 355-8 | pmid=7639159 | doi=10.1016/s0002-9149(99)80100-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7639159  }} </ref>
**Detecting left [[atrium]] enlargement could be associated with the recurrent intermittent [[atrial fibrillation]] ([[AF]])
**Detecting left [[ventricle]] could be associated with transformation to the constant [[atrial fibrillation]] ([[AF]])
*[[atrium|Left atrial appendage]] [[thrombus]] could be even seen in [[patients]] with acute [[atrial fibrillation]], similar to [[Chronic (medical)|chronic]] cases.


==Transesophageal echocardiography (TEE)==
===Transesophageal Echocardiography (TEE)===
A normal [[echocardiography]] (transthoracic or TTE) has a low sensitivity for identifying [[thrombus|thrombi]] (blood clots) in the heart. If this is suspected - e.g. when planning urgent electrical [[cardioversion]] - a [[Echocardiogram#Transesophageal echocardiogram|transesophageal echocardiogram]] (TEE) is preferred.<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
*A normal [[echocardiography]] ([[Standard views and measurements in transthoracic echocardiography|transthoracic]] or [[Echocardiography|TTE]]) has a low [[Sensitivity (tests)|sensitivity]] for identifying [[thrombus|thrombi]] ([[Thrombus|blood clots]]) in the [[heart]]. If [[atrial fibrillation]] is suspected and urgent electrical [[cardioversion]] is planned a [[Echocardiogram#Transesophageal echocardiogram|transesophageal echocardiogram]] ([[Echocardiography|TEE]]) is preferred.<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>


The TEE has much better visualization of the [[left auricular appendix|left atrial appendage]] than transthoracic echocardiography. This structure, located in the [[left atrium]], is the place where thrombus most commonly is formed in the setting of atrial fibrillation or flutter. TEE has a very high sensitivity for locating thrombus in this area and can also detect sluggish bloodflow in this area that is suggestive of thrombus formation.
*The [[Echocardiography|TEE]] has much better visualization of the [[left auricular appendix|left atrial appendage]] than [[Echocardiography|transthoracic echocardiography]]. This structure, located in the [[left atrium]], is the place where [[thrombus]] most commonly is formed in the setting of [[atrial fibrillation]] or [[atrial flutter]]. [[Echocardiography|TEE]] has a very high [[Sensitivity (tests)|sensitivity]] for locating [[thrombus]] in this area and can also detect sluggish [[blood]] flow in this area that is suggestive of [[thrombus]] formation.


If no thrombus is seen on TEE, the incidence of stroke immediately after cardioversion is performed is very low.
*If no [[thrombus]] is seen on [[Echocardiography|TEE]], the incidence of [[stroke]] immediately after [[cardioversion]] is very low.
*The following are indications of [[Transesophageal echocardiography (TEE)|transesophageal echocardiography]] ([[Transesophageal echocardiography (TEE)|TEE]]) in [[atrial fibrillation]] [[patients]], based on NICE guideline: <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
**When an abnormal condition, such as [[valvular heart disease]] has been detected on [[echocardiography|transthoracic echocardiography]] and further investigation is required
**When performing [[echocardiography|transthoracic echocardiography]] is not possible or when the findings of it is not absolutely clear
**When [[cardioversion|TOE-guided cardioversion]] is considered


==Transthoracic echocardiography (TTE)==
===Transthoracic Echocardiography (TTE)===
A transthoracic [[echocardiogram]] is generally performed in newly diagnosed [[AF]], as well as if there is a major change in the patient's clinical state. This ultrasound-based scan of the heart may help identify [[valvular heart disease]] (which may increase the risk of [[stroke]] manifold), left and right atrial size (which indicates likelihood that [[AF]] may become permanent), left ventricular size and function, peak right ventricular pressure ([[pulmonary hypertension]]), presence of left ventricular hypertrophy and pericardial disease.<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
*A [[Transthoracic echocardiography|transthoracic echocardiogram]] is generally performed in newly [[diagnosis|diagnosed]] [[atrial fibrillation]] ([[AF]]), as well as if there is a major change in [[patient]]'s clinical state. This [[ultrasound]]-based scan of the [[heart]] may help identify [[valvular heart disease]] (which may increase the risk of [[stroke]]), [[atrium|left and right atrial]] size (which indicates likelihood of [[atrial fibrillation]] changing into the permanent type), [[left ventricle|left ventricular size]] and dysfunction, peak [[right ventricle|right ventricular pressure]] ([[pulmonary hypertension]]), presence of [[left ventricular hypertrophy]] and [[Pericarditis|pericardial disease]].<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
 
*Significant enlargement of both the [[atrium|left and right atria]] is associated with long-standing [[atrial fibrillation]] and, if noted at the initial presentation of [[atrial fibrillation]], suggests that the [[atrial fibrillation]] is likely of a longer duration than the individual's [[symptoms]].
Significant enlargement of both the left and right atria is associated with long-standing [[atrial fibrillation]] and, if noted at the initial presentation of [[atrial fibrillation]], suggests that the [[atrial fibrillation]] is likely of a longer duration than the individual's symptoms.
*Indications of [[Transthoracic echocardiography|transthoracic echocardiogram]] in [[atrial fibrillation]] [[patients]], based on NICE guideline: <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
 
**As a baseline [[Echocardiography|echocardiogram]] for prolonged management
==Sources==
**If [[treatment]] strategies such as [[cardioversion]] (both electrical and [[pharmacology|pharmacological]]) has been considered
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
**When conditions such as [[structural heart disease]] or functional [[heart disease]] (which may present with [[heart failure]] or [[heart murmur]] is suspected
 
**When clarification of clinical risk stratification is required for [[antithrombotic therapy]]
*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


{{WH}}
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[[CME Category::Cardiology]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Arrhythmia]]
[[Category:Electrophysiology]]
[[Category:Electrophysiology]]
[[Category:Cardiology]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
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Latest revision as of 06:46, 21 October 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3]

Overview

Performing an echocardiogram in the setting of atrial fibrillation is essential to identify certain characteristics of the heart, including valvular heart disease, hypertrophy, presence of thrombus, the size and function of the left ventricle, the size of the atria, and the possible presence of pericardial disease. transesophageal echocardiogram is more sensitive, compared to the transthoracic echocardiography. Echocardiography is essential to identify some of the characteristics in the setting of atrial fibrillation, such as valvular heart disease, atrial size, left ventricle (LV) size and function, and peak right ventricle pressure (pulmonary hypertension).

Echocardiography

Transesophageal Echocardiography (TEE)

Transthoracic Echocardiography (TTE)

References

  1. ↑ Vaziri SM, Larson MG, Benjamin EJ, Levy D (1994). "Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study". Circulation. 89 (2): 724–30. doi:10.1161/01.cir.89.2.724. PMID 8313561.
  2. ↑ Keren G, Etzion T, Sherez J, Zelcer AA, Megidish R, Miller HI; et al. (1987). "Atrial fibrillation and atrial enlargement in patients with mitral stenosis". Am Heart J. 114 (5): 1146–55. doi:10.1016/0002-8703(87)90190-6. PMID 2960225.
  3. ↑ Flaker GC, Fletcher KA, Rothbart RM, Halperin JL, Hart RG (1995). "Clinical and echocardiographic features of intermittent atrial fibrillation that predict recurrent atrial fibrillation. Stroke Prevention in Atrial Fibrillation (SPAF) Investigators". Am J Cardiol. 76 (5): 355–8. doi:10.1016/s0002-9149(99)80100-3. PMID 7639159.
  4. ↑ 4.0 4.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
  5. ↑ 5.0 5.1 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).

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