Additional tests as clinically warranted. Review of the presence of any indwelling cardiac devices. Pneumonia, COPD, hypoxemia, hypercapnia. Primary neurologic disorders (e.g., intracranial hemorrhage, ischemic stroke). 
Beta-agonists (norepinephrine, epinephrine, dobutamine, etc.). Substance use (especially cocaine, amphetamine, methamphetamine). Electrolyte abnormalities (especially hypokalemia and hypomagnesemia). Be careful when cardioverting patients with a heart rate <100, as there may be an increased risk of bradycardia. If the heart rate is <100, conduction disease is likely. If the heart rate is >200, consider the possibility of an accessory tract (AF plus Wolff Parkinson White). For most patients who aren't on medications that suppress the AV node, AF will have a heart rate of ~120-180. (One exception to these criteria is that if AF is combined with heart block, then the ventricular response may be regular.). Also consider comparison to P wave morphology in prior EKGs (if the patient previously had large, well-defined P-waves and now they're gone, then this supports an AF diagnosis). If it is unclear whether there are P waves or fibrillation waves, consider obtaining a Lewis Lead EKG. In some patients, fibrillation waves may be small and difficult to distinguish from artifact. 
Fibrillation waves may be best seen in the inferior and right-sided precordial leads.
No P waves are seen instead these may be replaced by fibrillation waves.When in doubt, calipers may help determine whether there is any regularity.At very high rates, the heart rate may appear to be regular (“pseudo-regularization”).
DOES ATRIAL FLUTTER ALWAYS TURN INTO AFIB FLUTTER FULL
AF diagnosis should always be confirmed with a full 12-lead EKG.AF may be suspected on the basis of an irregularly irregular heart rate (either on clinical examination or telemetry).
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