Atrial fibrillation electrocardiogram
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Atrial fibrillation is diagnosed on an electrocardiogram, an investigation performed routinely whenever irregular heart beat is suspected. Characteristic findings are the absence of P waves, with unorganized electrical activity in their place, and irregularity of R-R interval due to irregular conduction of impulses to the ventricles.
Electrocardiogram
- ECG is essential in diagnosis of atrial fibrillation. If paroxysmal atrial fibrillation is suspected and 12-lead ECG is normal, usage of a 24-hour ambulatory ECG monitor is recommended.[1][2]
- ECG is helpful to identify:
- Rhythm (verify AF)
- LV hypertrophy
- P-wave duration and morphology or fibrillary waves
- Preexcitation
- Bundle-branch block
- Prior MI
- Other atrial arrhythmias
- To measure and follow the RR, QRS, and QT intervals in conjunction with antiarrhythmic agent
Summary of Electrocardiographic Findings
- Absent P waves
- Irregularly irregular ventricular response rate. Regular RR intervals are possible in the presence of AV block or interference due to ventricular or junctional tachycardia.
- An atrial rate that ranges from 400 to 700 BPM.
- Sometimes lead V1 may look as though there is atrial flutter. This may be because the electrode overlies a portion of the RA with rhythmic activity.
- Some authors believe that fine f waves (<.5 mm) are associated with coronary artery disease and that coarse F waves are associated with LA enlargement and rheumatic heart disease.
- The ventricular rate is usually between 100 and 180 BPM.
- If the atrial rate is greater than 200 BPM, then consider WPW or an accessory pathway.
- In the presence of AV junctional disease, the ventricular rate may be below 70 bpm.
- A rapid, irregular, sustained, wide-QRS-complex tachycardia strongly suggests AF with conduction over an accessory pathway or AF with underlying bundle-branch block.
- Complete AV block is indicated by a slow ventricular rhythm with a regular RR interval.
- In patients with electronic pacemakers, diagnosis of AF may require temporary inhibition of the pacemaker to expose atrial fibrillary activity.
- Differential diagnosis includes an ECG artifact such as a tremor. The oscillations in this case are largest in the limb leads.
When are Electrocardiograms Used for Screening?
The SAFE trial found that electronic software, primary care physicians and the combination of the two had the following sensitivities and specificities:[3]
- Interpreted by software: sensitivity = 83%, specificity = 99%.
- Interpreted by a primary care physician: sensitivity = 80%, specificity = 92%.
- Interpreted by a primary care physician with software: sensitivity = 92%, specificity = 91%.
If paroxysmal AF is suspected but the electrocardiogram shows a regular rhythm, episodes may be documented with the use of Holter monitoring (continuous ECG recording for 24 hours). If the symptoms are very infrequent, longer periods of continuous monitoring may be required.
Shown below is an EKG showing rapid ventricular response (short R-R interval) and no P waves suggestive of atrial fibrillation.
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing a rapid ventricular rate (short R-R interval) and no P waves suggestive of atrial fibrillation.
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing absent P waves with a slow ventricular response suggestive of atrial fibrillation.
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
Shown below is an EKG showing absent P waves throughout the precordium, suggestive of atrial fibrillation.
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
- For more EKG examples of atrial fibrillation click here.
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[4]
- AF is a supraventricular tachyarrhythmia with uncoordinated atrial activation and consequently ineffective atrial contraction. Electrocardiogram (ECG) characteristics include:
- Irregular R-R intervals (when atrioventricular conduction is present)
- Absence of distinct repeating P waves
- Irregular atrial activity
Clinical Evaluation
| Class I |
| "1. Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C) " |
Sources
References
- ↑ Tse HF, Newman D, Ellenbogen KA, Buhr T, Markowitz T, Lau CP; et al. (2004). "Effects of ventricular rate regularization pacing on quality of life and symptoms in patients with atrial fibrillation (Atrial fibrillation symptoms mediated by pacing to mean rates [AF SYMPTOMS study])". Am J Cardiol. 94 (7): 938–41. doi:10.1016/j.amjcard.2004.06.034. PMID 15464683.
- ↑ 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). - ↑ Mant J, Fitzmaurice DA, Hobbs FD; et al. (2007). "Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial". doi:10.1136/bmj.39227.551713.AE. PMID 17604299.
- ↑ 4.0 4.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline 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 Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.