Case Study : Respiratory

166. Atrial fibrillation

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Breathlessness of 2 months duration

Presentation : At the end of a consultation for a separate unrelated matter, a 71-year-old man mentions that he has been experiencing breathlessness for the last 2 months.

He denies any cough, phlegm, tiredness, or weight change.

A quick check of his pulse reveals that it is irregularly irregular and the same rate (108 beats per minute [bpm]) as the heartbeat. Heart sounds were normal.


The IMPRESS algorithm is designed to assist clinicians during the initial assessment of a patient presenting with acute or chronic breathlessness and is intentionally broad-based because of the large number of possible diagnoses.(1) 

These algorithms reflect that a patient may well have more than one condition contributing to the symptom of breathlessness and the existence of terms such as ‘cardiac asthma’ demonstrates that it is very easy to be led astray by symptoms more typical of other causes.

Important aspects of a clinical assessment of breathlessness

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The patient’s irregular pulse suggests that he may have atrial fibrillation. An electrocardiogram (ECG) should be performed for people in whom atrial fibrillation is suspected because an irregular pulse has been detected, to give additional information about the nature and the irregularity of the pulse.(2)

Consider the reversible causes of atrial fibrillation, such as hyperthyroidism and excessive alcohol intake, as well as being alert to co-existent valvular heart disease in any patient with a cardiovascular abnormality.


Rate control should be offered to people with atrial fibrillation who need drug treatment; either a standard beta-blocker (i.e. a beta-blocker other than sotalol) or a rate-limiting calcium channel blocker should be offered as initial monotherapy.(2)


Stroke risk should be assessed using CHA2DS2-VASc and anticoagulation should be discussed and initiated where appropriate (2)(7)


Patient decision aids are available to assist the patient in making an informed decision about treatment.(3) 


For most people, the benefit of anticoagulation outweighs the risk of bleeding.(2)

Clinical outcome

The patient’s pulse rate and symptoms responded to a dose of 3.75 mg bisoprolol fumarate and he was referred to the local anticoagulation service.


After consideration of the patient’s medical history and his medication preference, warfarin was initiated as, in this case, it was straightforward to retain the international normalised ratio (INR) readings within the therapeutic range.


1. Acute breathlessness assessment

Improving and Integrating Respiratory Services in the NHS (IMPRESS).

The Health Foundation,




2. Atrial fibrillation: management.

NICE Clinical Guideline CG180.

Published June 2014. 

Last Updated August 2014


3.  Atrial fibrillation: medicines to help reduce your risk of a stroke—what are the options?

NICE Clinical Guideline CG180 tools and resources.

June 2014.


Breathlessness: what's the diagnosis?

Dr Chris Cooper

Guidelines in practice

October 2017


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