. Author manuscript; available in PMC: 2015 Dec 11.

Published in final edited form as: Circulation. 2014 Mar 28;130(23):e199–e267. doi: 10.1161/CIR.0000000000000041

Appendix 4. Initial Clinical Evaluation in Patients With AF.

Minimum Evaluation
1. History and physical examination, to define	• Presence and nature of symptoms associated with AF
	• Clinical type of AF (paroxysmal, persistent, or permanent)
	• Onset of the first symptomatic attack or date of discovery of AF
	• Frequency, duration, precipitating factors, and modes of initiation or termination of AF
	• Response to any pharmacological agents that have been administered
	• Presence of any underlying heart disease or reversible conditions (e.g., hyperthyroidism or alcohol consumption)
2. ECG, to identify	• Rhythm (verify AF)
	• LVH
	• P-wave duration and morphology or fibrillatory waves
	• Pre-excitation
	• Bundle-branch block
	• Prior MI
	• Other atrial arrhythmias
	• To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy
3. TTE, to identify	• VHD
	• LA and RA size
	• LV and RV size and function
	• Peak RV pressure (pulmonary hypertension)
	• LV hypertrophy
	• LA thrombus (low sensitivity)
	• Pericardial disease
4. Blood tests of thyroid, renal, and hepatic function	• For a first episode of AF
4. Blood tests of thyroid, renal, and hepatic function	• When the ventricular rate is difficult to control
Additional Testing (1 or several tests may be necessary)
1. 6-min walk test	• If the adequacy of rate control is in question
2. Exercise testing	• If the adequacy of rate control is in question
	• To reproduce exercise-induced AF
	• To exclude ischemia before treatment of selected patients with a type IC^* antiarrhythmic drug
3. Holter or event monitoring	• If diagnosis of the type of arrhythmia is in question
3. Holter or event monitoring	• As a means of evaluating rate control
4. TEE	• To identify LA thrombus (in the LAA)
4. TEE	• To guide cardioversion
5. Electrophysiological study	• To clarify the mechanism of wide-QRS-complex tachycardia
	• To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia
	• To seek sites for curative AF ablation or AV conduction block/modification
6. Chest radiograph, to evaluate	• Lung parenchyma, when clinical findings suggest an abnormality
6. Chest radiograph, to evaluate	• Pulmonary vasculature, when clinical findings suggest an abnormality

Type IC refers to the Vaughan-Williams classification of antiarrhythmic drugs.

AF indicates atrial fibrillation; AV, atrioventricular; ECG, electrocardiogram; LA, left atrial; LAA, left atrial appendage; LV, left ventricular; LVH, left ventricular hypertrophy; MI, myocardial infarction; RA, right atrial; RV, right ventricular; TEE, transesophageal echocardiography; TTE, transthoracic echocardiogram; and VHD, valvular heart disease. Modified from Fuster, et al. (4).