Atrial fibrillation (AF) is the most common type of cardiac arrhythmia seen in clinical practice. The prevalence of AF increases with age: approximately 1% of individuals with AF are <60 years of age while up to 12% are between ages 75 and 84.1 Other risk factors for AF include hypertension, heart disease, diabetes, thyroid disease, and sleep apnea.

AF may increase the risk of stroke by as much as 5-fold2; stroke risk also increases with advancing age.3 Symptoms commonly associated with AF include palpitations, chest discomfort, fatigue, dizziness, and/or shortness of breath. However, some people with the condition do not experience any symptoms. In fact, for approximately 20% of patients who have had a stroke associated with AF, stroke was the first clinical manifestation.4 Detecting previously undiagnosed, asymptomatic AF can potentially help prevent future thromboembolic events and the onset of symptoms, and reduce AF-related morbidity and hospitalizations.

Case Presentation: Medical Evaluation and History

Frank is a 67-year-old white man who has come in for a routine wellness visit and wants to know about vaccines for the flu and whooping cough because he is expecting a new granddaughter next month. His height is 5’9” and his weight is 220 lb; his BMI is 32.5 kg/m2. His blood pressure is 124/80 mm Hg, and his pulse is 115 bpm. Frank was diagnosed with hyperlipidemia 8 years ago and hypertension 5 years ago. He currently takes atorvastatin 10 mg/d and lisinopril 10 mg/d.

Frank owns and manages a local restaurant. He has never smoked and consumes alcoholic beverages only on special occasions. His age and history of hypertension suggest he might be at risk for AF. During the physical exam, his heart rate is 120 bpm with an irregular rhythm. He denies experiencing fatigue, dizziness, palpitations, shortness of breath, or chest pains. Other physical examination findings include: lungs = normal; abdomen = obese, no tenderness or masses; neck = negative for thyromegaly; vision = normal; neurologic = normal reflexes and coordination. An electrocardiogram is performed and shows AF with rapid ventricular response.

What is the best next step in the care of Frank?

  • Obtain an echocardiogram
  • Refer for cardiac stress testing
  • Initiate anticoagulation therapy
  • Start aspirin