Applied Evidence

Is pulse palpation helpful in detecting atrial fibrillation? A systematic review

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Particular high-risk patients may benefit from repeated testing.


 

References

Practice recommendations
  • Pulse palpation is a good test for ruling out atrial fibrillation (C).
  • Patients with an irregular pulse should be followed up with an ECG.
Abstract
  • Background: Atrial fibrillation in the elderly is common and potentially life threatening. The classical sign of atrial fibrillation is an irregularly irregular pulse.
  • Objective: The objective of this research was to determine the accuracy of pulse palpation to detect atrial fibrillation.
  • Methods: We searched Medline, EMBASE, and the reference lists of review articles for studies that compared pulse palpation with the electrocardiogram (ECG) diagnosis of atrial fibrillation. Two reviewers independently assessed the search results to determine the eligibility of studies, extracted data, and assessed the quality of the studies.
  • Results: We identified 3 studies (2385 patients) that compared pulse palpation with ECG. The estimated sensitivity of pulse palpation ranged from 91% to 100%, while specificity ranged from 70% to 77%. Pooled sensitivity was 94% (95% confidence interval [CI], 84%–97%) and pooled specificity was 72% (95% CI, 69%–75%). The pooled positive likelihood ratio was 3.39, while the pooled negative likelihood ratio was 0.10.
  • Conclusions: Pulse palpation has a high sensitivity but relatively low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may also be a useful screen to apply opportunistically for previously undetected atrial fibrillation. Assuming a prevalence of 3% for undetected atrial fibrillation in patients older than 65 years, and given the test’s sensitivity and specificity, opportunistic pulse palpation in this age group would detect an irregular pulse in 30% of screened patients, requiring further testing with ECG. Among screened patients, 0.2% would have atrial fibrillation undetected with pulse palpation.

The objective of this review was to determine how well pulse palpation detects the classical sign of atrial fibrillation—an irregularly irregular pulse—and to estimate the test’s false-positive and false-negative rates. You may want to consider using pulse palpation opportunistically with certain high-risk patients identified in this article.

The scope of the problem. Atrial fibrillation in the elderly is common and potentially life-threatening. Its prevalence increases from 2% in the 65- to 69-year-old age group to 8% among those older than 85 years.1

Atrial fibrillation is an independent risk factor for stroke, increasing a person’s risk 3- to 5-fold. While other major risk factors for stroke, such as hypertension, become less important with age, the risk of stroke from atrial fibrillation increases with age.

Stroke attributable to atrial fibrillation increases from 1.5% among patients 50 to 59 years to 23.5% for those aged 80 to 89.2 Furthermore, stroke in the presence of atrial fibrillation is almost twice as likely to be fatal, results in more functional impairment among survivors, and recurs frequently.3

Stroke due to atrial fibrillation results in considerable mortality and morbidity, but treatment of atrial fibrillation reduces the risk. Warfarin reduces the risk of stroke in non-rheumatic atrial fibrillation by about 70%, an annual absolute risk reduction of 3% (number needed to treat: 30), though the benefits are somewhat offset by the risk of bleeding (annual risk of 0.6%).4

Methods

Search strategy and study selection

We searched the Medline and EMBASE electronic databases from 1966 to June 2005 for all studies comparing pulse palpation with ECG diagnosis. There was no restriction on the language of publication.

The search strategy (see Search strategy and inclusion criteria) included terms for pulse, atrial fibrillation, and a search filter for studies of diagnostic accuracy developed by Van der Weijden et al5 that is highly sensitive and precise.6 We also searched the reference lists of all possibly relevant studies, including review articles. We included all studies that tested patients with both pulse palpation and ECG, and that provided data suitable for calculating sensitivity or specificity (or could be provided by the study authors).

Two reviewers (GC and JD) independently screened the electronic lists of citations. We obtained full-text documents of relevant papers and the 2 reviewers independently reviewed the full-text articles for inclusion according to predetermined criteria (see Search strategy and inclusion criteria). The reviewers agreed on all inclusions.

Search strategy and inclusion criteria

The authors of this study searched Medline, EMBASE, and the reference lists of review articles for studies using the following criteria.

(pulse) OR (‘Pulse’/all subheadings in MIME,MJ ME))

AND ((atrial fibrillation) OR (‘Atrial-Fibrillation’/all subheadings in MIME,MJME))

AND ((‘sensitivity-and-specificity’/all subheadings in MIME,MJME) OR (sensitivity) OR (specificity) OR (‘Diagnosis-Differential’/all subheadings in MIME,MJME) OR (‘False-Negative-Reactions’/all subheadings in MIME,MJME) OR (‘False-Positive-Reactions’/all subheadings in MIME,MJME) OR (‘Mass-Screening’/all subheadings in MIME,MJME) OR (diagnos*) OR (predictive value*) OR (reference value*) OR (ROC*) OR (Likelihood ratio) OR (monitoring) OR (‘Reference-Values’/all subheadings in MIME,MJME)) OR (atrial fibrillation and (SH=diagnosis))

Two reviewers then independently assessed the search results to determine the eligibility of studies, extracted data, and assessed the quality of the studies.

Inclusion criteria

  • Does the study compare pulse palpation to ECG diagnosis of atrial fibrillation?
  • Do all the participants receive both tests?
  • Are the sensitivity and specificity provided, or calculable from the data provided?

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