American College of Cardiology/American Heart Association Clinical Practice Guidelines: Part II

C ase Presentation:A 50-year-old male presents to your office for evaluation of a recent episode of atrial fibrillation.The patient had no prior history of atrial fibrillation until 3 days ago.At that time, he was working in his home woodworking shop on a large cabinet.The cabinet slipped out of the clamps holding it and fell on his right great toe.The patient was having moderate to severe toe pain when he noticed that his heart was beating rapidly and irregularly.His palpitations were not associated with any chest pain, shortness of breath, or lightheadedness.He went to his local emergency room.His blood pressure was 135/80, and his pulse was rapid and irregularly irregular.An ECG showed that he was in atrial fibrillation with a ventricular response rate of 160.There were no ST segment changes.Before the patient received any therapy, he converted to normal sinus rhythm.The total duration of his episode of atrial fibrillation was Ϸ2 hours.A subsequent ECG was entirely normal.X-rays of his right foot did not show any fracture.He was discharged from the local emergency room and advised to see you.The patient is physically active.He denies any history of chest pain or chest pressure.He has no history of hypertension, diabetes, or tobacco use.His only other medical problem is mild asthma, treated with occasional inhalers.Both his mother and father lived into their late 80s and died of cancer.His two siblings are both alive and well without any cardiovascular disease.On physical examination, his blood pressure is 120/ 80 mm Hg.His heart rate is 70 bpm and regular.His cardiac examination is normal.On lung examination, there are rare wheezes over both lung fields.His right great toe is badly bruised.His ECG from the local emergency room is available and is normal.What are the appropriate next steps in the evaluation of this patient, as outlined in the American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) Guidelines for the Management of Patients With Atrial Fibrillation? 1 Appropriate clinical evaluation is shown in Table 1.This patient merits a chest x-ray (to evaluate his rare wheezes), a transthoracic echocardiogram, and blood tests of thyroid function.None of the additional tests listed, ie, exercise testing, Holter monitoring, transesophageal echocardiography, or electrophysiological study, are appropriate at this time.