Presentation and initial management of atrial fibrillation

In untreated patients with a normal atrioventricular (AV) node, atrial fibrillation usually presents with an irregular ventricular rate of around 160 to 180 beats per minute. Approximately 50% of atrial fibrillation episodes spontaneously terminate within 24 hours. Patients can present with symptoms such as palpitations, shortness of breath and fatigue, but many patients are asymptomaticHindricks, 2021; this highlights the importance of opportunistic screening for atrial fibrillation (eg when taking a blood pressure measurement)Royal Australian College of General Practitioners (RACGP), 2021.

Note: Many patients with atrial fibrillation are asymptomatic; consider opportunistic screening for atrial fibrillation (eg when taking a blood pressure measurement).

Patients commonly present to general practitioners (GPs) or to emergency departments with atrial fibrillation. Many of these patients (eg those with a controlled ventricular rate and no other significant heart disease) can be safely managed by the GP initially, with cardiologist consultation if required.

Refer patients with the following features for immediate management (eg to an emergency department):

haemodynamic instability
chest pain
acute heart failure
syncope or presyncope
sustained and symptomatic tachycardia
known pre-excitation syndromes (eg Wolff–Parkinson–White syndrome)
significant or serious underlying cause suspected (eg sepsis, surgery).

Atrial fibrillation can also frequently occur in hospitalised patients.

For more information on recognising and diagnosing tachyarrhythmias, see Initial assessment and management of an acute tachyarrhythmia.