Patient details

Name
Address
Postcode
Tel. no
Date of Birth
Social Security #

Referring GP / Consultant

Name
Address
Tel. no
Fax no

Patients GP (if not detailed above)

Name
Address
Tel. no
Fax no

ScreenLink Report

Guidelines results

SOURCE OF REFERRAL

BRIEF PRESENTING HISTORY:

CLINICAL FINDINGS:

MEDICATION:

• NYHA I

  No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea

• NYHA II

  Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea

• NYHA III

  Marked limitation of physical activity. Comfortable at rest but less than ordinary activity results in fatigue, palpitation or dyspnea

• NYHA IV

  Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased

SYMPTOMS DURING ATRIAL FIBRILLATION



• EHRA I

  ‘No symptoms’

• EHRA II

  ‘Mild symptoms’; normal daily activity not affected

• EHRA III

  ‘Severe symptoms’; normal daily activity affected

• EHRA IV

  ‘Disabling symptoms’; normal daily activity discontinued

Source: 2010 ESC Guidelines for the management of atrial Fibrillation (European Heart Journal doi:10.1093/eurheartj/ehq278)

• First diagnosed episode of atrial fibrillation

• Paroxysmal
  (usually ≤ 48h)

• Persistent
  (>7 daysor requires CV)

• Long-standing Persistent
  (>1 year)

• Permanent
  (accepted)

Different types of AF. AF = atrial fibrillation; CV =cardioversion.
The arrhythmia tends to progress from paroxysmal (self-terminating, usually <48h) to persistent [non-self-terminating or requiring cardioversion (CV)], long-standing persistent (lasting longer than 1 year) and eventually to permanent (accepted) AF.
First-onset AF may be the first of recurrent attacks or already be deemed permanent.
Source:2010 ESC Guidelines for the management of atrial Fibrillation (European Heart Journal doi:10.1093/eurheartj/ehq278)