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MY APPROACH to Detecting Atrial Fibrillation*
Author's Accepted Manuscript
My Approach to Detecting Atrial Fibrillation Rod Passman MD, MSCE
www.elsevier.com/locate/tcm
PII: DOI: Reference:
S1050-1738(14)00032-2 http://dx.doi.org/10.1016/j.tcm.2014.05.004 TCM5992
To appear in: trends in cardiovascular medicine
Cite this article as: Rod Passman MD, MSCE, My Approach to Detecting Atrial Fibrillation, trends in cardiovascular medicine, http://dx.doi.org/10.1016/j. tcm.2014.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
MY APPROACH MY APPROACH to Detecting Atrial Fibrillation
Rod Passman MD, MSCE Professor of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine
Commentary Atrial fibrillation (AF) can be an elusive and serious disease. Symptoms alone are often unreliable as some patients are altogether unaware that they have an arrhythmia. Furthermore, even those that are symptomatic from their AF may feel only a small proportion of episodes. Given the fact that AF may be intermittent and asymptomatic, heart rhythm monitoring is the key to making the diagnosis. There are two main situations in which I search for AF. The first is when the patient has intermittent symptoms potentially caused by AF. Common symptoms include palpitations, shortness of breath, or dizziness. If my physical exam and ECG do not show AF, then ambulatory monitoring is the next step. I guide my monitoring selection to the frequency, duration, and severity of symptoms. If a patient tells me that he has daily palpitations, then a 24- to 48-hour Holter monitor would be appropriate. For a patient with symptoms once every few weeks, an event monitor or mobile cardiac outpatient telemetry monitor would be my first option. For the patient with an episode every few months, particularly if it’s associated with severe symptoms such as syncope or pulmonary edema, I would still start with a 2- to 4-week external monitor, hoping to pick up an episode. If the short-term external monitor shows no AF, I next recommend an implantable cardiac monitor. These miniature devices are placed subcutaneously in a procedure taking less than 1 minute, have a battery life of 3 years, can be followed remotely, and are highly sensitive for picking up AF episodes. The other situation in which an intensive search for AF is warranted is in the patient with a clinical condition potentially due to AF even in the absence of the previously mentioned symptoms. As stroke is a major consequence of AF, it makes sense to look for AF in a stroke survivor in whom the stroke mechanism has not been elucidated with routine investigation. It is quite possible that some of these “cryptogenic” strokes may, in fact, be due to previously unrecognized AF. As these patients are at high risk of recurrent events, I am aggressive in my search for AF. If the patient has already received telemetry monitoring during the
stroke hospitalization, I usually don’t bother with external monitors and have been going straight to an implantable cardiac monitor instead. The AF yield for this approach is significantly higher than routine follow-up care, and finding AF changes the management of a cryptogenic stroke patient from antiplatelet therapy to anticoagulation. One major unanswered question is whether we should be screening for AF in an asymptomatic population with other stroke risk factors (i.e., congestive heart failure, hypertension, advanced age, and diabetes) in order to diagnose AF and anticoagulate before a thromboembolic event occurs. Finding a cost-effective approach for AF screening remains a challenge, and I do not routinely screen my patients for AF beyond the history, physical, and office ECG.
First published on PracticeUpdate on May 6, 2014. Republished with permission. Corresponding author: [email protected]
My Approach to Detecting Atrial Fibrillation Rod Passman MD, MSCE
www.elsevier.com/locate/tcm
PII: DOI: Reference:
S1050-1738(14)00032-2 http://dx.doi.org/10.1016/j.tcm.2014.05.004 TCM5992
To appear in: trends in cardiovascular medicine
Cite this article as: Rod Passman MD, MSCE, My Approach to Detecting Atrial Fibrillation, trends in cardiovascular medicine, http://dx.doi.org/10.1016/j. tcm.2014.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
MY APPROACH MY APPROACH to Detecting Atrial Fibrillation
Rod Passman MD, MSCE Professor of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine
Commentary Atrial fibrillation (AF) can be an elusive and serious disease. Symptoms alone are often unreliable as some patients are altogether unaware that they have an arrhythmia. Furthermore, even those that are symptomatic from their AF may feel only a small proportion of episodes. Given the fact that AF may be intermittent and asymptomatic, heart rhythm monitoring is the key to making the diagnosis. There are two main situations in which I search for AF. The first is when the patient has intermittent symptoms potentially caused by AF. Common symptoms include palpitations, shortness of breath, or dizziness. If my physical exam and ECG do not show AF, then ambulatory monitoring is the next step. I guide my monitoring selection to the frequency, duration, and severity of symptoms. If a patient tells me that he has daily palpitations, then a 24- to 48-hour Holter monitor would be appropriate. For a patient with symptoms once every few weeks, an event monitor or mobile cardiac outpatient telemetry monitor would be my first option. For the patient with an episode every few months, particularly if it’s associated with severe symptoms such as syncope or pulmonary edema, I would still start with a 2- to 4-week external monitor, hoping to pick up an episode. If the short-term external monitor shows no AF, I next recommend an implantable cardiac monitor. These miniature devices are placed subcutaneously in a procedure taking less than 1 minute, have a battery life of 3 years, can be followed remotely, and are highly sensitive for picking up AF episodes. The other situation in which an intensive search for AF is warranted is in the patient with a clinical condition potentially due to AF even in the absence of the previously mentioned symptoms. As stroke is a major consequence of AF, it makes sense to look for AF in a stroke survivor in whom the stroke mechanism has not been elucidated with routine investigation. It is quite possible that some of these “cryptogenic” strokes may, in fact, be due to previously unrecognized AF. As these patients are at high risk of recurrent events, I am aggressive in my search for AF. If the patient has already received telemetry monitoring during the
stroke hospitalization, I usually don’t bother with external monitors and have been going straight to an implantable cardiac monitor instead. The AF yield for this approach is significantly higher than routine follow-up care, and finding AF changes the management of a cryptogenic stroke patient from antiplatelet therapy to anticoagulation. One major unanswered question is whether we should be screening for AF in an asymptomatic population with other stroke risk factors (i.e., congestive heart failure, hypertension, advanced age, and diabetes) in order to diagnose AF and anticoagulate before a thromboembolic event occurs. Finding a cost-effective approach for AF screening remains a challenge, and I do not routinely screen my patients for AF beyond the history, physical, and office ECG.
First published on PracticeUpdate on May 6, 2014. Republished with permission. Corresponding author: [email protected]