Atrial fibrillation electrocardiogram

Atrial fibrillation is diagnosed with the electrocardiogram, an investigation performed routinely whenever irregular heartbeat 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. If paroxysmal atrial fibrillation is suspected and 12-lead ECG is normal, usage of a 24-hour ambulatory ECG monitor is recommended. Typical electrocardiogram findings in a patient with atrial fibrillation are absent P waves, irregularly irregular ventricular response rate, and an atrial rate that ranges from 400 to 700 BPM. A rapid, irregular, sustained, wide-QRS-complex tachycardia strongly suggests atrial fibrillation (AF) with conduction over an accessory pathway or atrial fibrillation (AF) with underlying bundle-branch block.

• 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][3]
• ECG is helpful to identify:
  • Rhythm (verify atrial fibrillation (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
• ECG also could be used as a predictor of atrial fibrillation. One of the strongest predictors is the P index, which is an estimation of disorganized atrial depolarization.^[4]

• 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 Wolff-Parkinson-White syndrome (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 atrial fibrillation (AF) with conduction over an accessory pathway or atrial fibrillation (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 atrial fibrillation (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.

The SAFE trial found that electronic software, primary care physicians and the combination of the two had the following sensitivities and specificities:^[5]

• 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 atrial fibrillation (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.^[3]

Shown below is an ECG 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 ECG 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 ECG 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 ECG 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 ECG examples of atrial fibrillation click here.

• 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

• 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation^[6]

• John Vozenilek’s (MD) ECG Collection

• ECGpedia

Template:WH Template:WS CME Category::Cardiology