Explain ECG — newly diagnosed atrial fibrillation

PLAB 2 & PRES 3 · cardiology · medium · 8 minutes

Candidate brief

You are a doctor in a GP practice. Mr David Thompson, 68, attended because of intermittent palpitations and mild breathlessness. A 12-lead ECG has shown atrial fibrillation with a ventricular rate of 112 beats/min. Explain the ECG result, assess relevant symptoms and risks, and discuss the initial management plan. No physical examination is required, but verbalise any assessment or investigations you would perform.

What examiners look for

Atrial fibrillation produces an irregularly irregular rhythm without consistent P waves. Always assess clinical stability before giving a routine explanation. Emergency features include shock, ongoing chest pain or myocardial ischaemia, pulmonary oedema, syncope and stroke symptoms. Unstable AF requires immediate escalation and synchronised electrical cardioversion. Explain that AF is treatable but increases the risks of blood clots, stroke and heart failure. Assess the duration of AF, symptoms, reversible causes, comorbidities and stroke and bleeding risks. UK mode uses CHA2DS2-VASc for stroke risk and ORBIT for bleeding risk. This patient’s age and hypertension give a CHA2DS2-VASc score supporting anticoagulation. Aspirin alone is not an alternative. Rate and rhythm control are separate from stroke prevention. Restoring sinus rhythm does not automatically remove the need for anticoagulation. Do not arrange elective cardioversion when AF has lasted more than 48 hours or its duration is uncertain without an appropriate anticoagulation or TOE-guided plan. Address blood pressure, alcohol, weight, smoking, exercise and possible sleep apnoea, and provide clear emergency safety-netting.

Guideline references

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