Atrial Fibrillation

You may or may not notice atrial fibrillation. It can occur with no symptoms. If you do have symptoms, you may only notice them occasionally, or your symptoms may be frequent depending on the overall burden of AFib you have. If you already have heart disease, you are more likely to notice symptoms. Symptoms also may increase if your heart disease gets worse. Atrial fibrillation that goes undiagnosed or is left untreated can cause serious and even life-threatening complications, including stroke and heart failure.

The most common symptoms of atrial fibrillation are heart palpitations or the feeling that your heart is skipping, fluttering, racing or pounding. Other symptoms include:

• Fatigue, or extreme tiredness.
• Low blood pressure
• Difficulty breathing, especially when lying down or when exercising
• Chest pain
• Dizziness or fainting

Keep track of when and how often your symptoms occur and what you feel and note whether these things change over time. They are all important clues to help your healthcare providers diagnose and treat atrial fibrillation. 

Atrial fibrillation is most often caused by changes to the heart’s tissue or the electrical signaling that helps the heartbeat. To better understand atrial fibrillation, it helps to first understand what causes it. Typically, the electrical signals that make the heart pump start in the sinoatrial node, a special area of the upper right chamber of the heart that regulates the rate of the lower heart chambers. The lower chambers pump blood to all the organs of your body.

In atrial fibrillation, unusual and chaotic electrical signals in the upper chambers interrupt this typical process. These signals cause the upper chambers of the heart to contract irregularly, which makes your heart’s upper and lower chambers unable to work together effectively, which then leads to inefficient flow of blood to the body.

When this occurs the pumping of the heart muscle becomes irregular and typically too fast. This can occur in someone with a completely normal heart or be a result of underlying heart disease as well as other medical conditions and blood abnormalities. Treatment strategies are best determined after thorough evaluation for the root cause of atrial fibrillation in each patient.

Changes In Heart Tissue – Factors such as aging, heart disease, infection or genetics can affect heart tissue and keep the heart cells from contracting in rhythm. Tissue changes that impact your heart’s ability to contract in rhythm may include fibrosis; inflammation; stretching, thinning, or thickening of the heart walls; reduced blood flow to the heart; or a buildup of protein, cells or minerals in heart tissue.

Age, family history and genetics, lifestyle, heart disease or other medical conditions, race, and surgical history can all raise your risk of developing the structural and electrical issues that lead to atrial fibrillation. Even in a healthy heart, a fast or slow heart rate — from exercising or sleeping, for example — can trigger atrial fibrillation. Sometimes, though, atrial fibrillation happens for no obvious reason.

Age, family history & genetics 

Age: The risk of atrial fibrillation increases as you get older, especially when you are over age 65. Atrial fibrillation is rare in children.

Family history: If someone in your family has had atrial fibrillation, you have a higher risk of developing atrial fibrillation, too. Scientists have found some genes with mutations that raise the risk of atrial fibrillation. Some of these genes influence fetal organ development or cells in the heart that regulate heart rhythm. Sometimes these genetic patterns are also linked to heart disease which can then contribute to developing atrial fibrillation.

Race: In the United States, atrial fibrillation is more common among white people than among Black or African American, Hispanic, or Asian people. Although people of European ancestry are more likely to develop the condition, Black or African American people with atrial fibrillation are more likely to have serious complications such as stroke, heart failure or heart disease.

Lifestyle Factors 

Some lifestyle choices can raise or lower your risk of atrial fibrillation.

• Physical activity, for example, participating in endurance sports or physically working hard, may lead to a higher risk of atrial fibrillation for some people, especially competitive athletes and men. At the same time, moderate physical activity can have a protective effect that can lower your risk of atrial fibrillation, as well as other heart diseases.
• Stress: Stressful situations, panic disorders, sleep disorders and other types of emotional stress may be linked to a higher risk of atrial fibrillation.
• Caffeine and sugars: Ingestion of large amounts of caffeinated beverages or food high in unrefined sugars and chocolate can increase the risk of atrial fibrillation.
• Alcohol consumption in large amounts, especially binge drinking, raises your risk of atrial fibrillation. Even modest amounts of alcohol can trigger atrial fibrillation in some people.
• Smoking increases the risk of atrial fibrillation. The risk appears to be higher the longer you smoke and decreases if you quit.
• Exposure to secondhand smoke, even in the womb, can increase a child’s risk of developing atrial fibrillation.
• Illegal drugs, such as cocaine and other street drugs, can trigger atrial fibrillation or make it worse.

Other Medical Conditions

Many other medical conditions, including heart, lung, and sleep disorders, can raise your risk of atrial fibrillation. Common conditions that increase your risk include:

• Chronic kidney disease
• COPD and other lung problems, especially pneumonia
• Diabetes
• Heart failure
• Heart valve diseases
• High blood pressure
• Hyperthyroidism
• Overweight and obesity
• Sick sinus syndrome, a conduction disorder
• Sleep apnea and other sleep problems
• Viral infections

Surgery & medications

Medications: Many medicines, including over-the-counter ones and stimulants, may also increase your risk, especially if you have other risk factors for atrial fibrillation.

Surgery: You may be at risk of atrial fibrillation in the early days and weeks after surgery on your heart, lungs or esophagus. For example, atrial fibrillation occurs commonly (up to 40% by some estimates) in patients who undergo any type of open-heart surgery. Most patients respond to treatment and can get back to normal rhythm within days to weeks after surgery. Some have recurrent AFib or even develop permanent AFib, however. After childhood surgery (to correct congenital disorders of the heart) the risk of AFib remains high for years. 

A healthcare provider will diagnose atrial fibrillation based on your medical and family history, a physical exam, the results from an electrocardiogram (EKG) and possibly other tests and procedures. If you have atrial fibrillation, your provider will also look for any disease that may be causing it and assess your risk of developing dangerous blood clots. This will help in planning the best way to treat you.

Medical History – Your provider will ask about your eating and physical activity habits, family history and other risk factors for atrial fibrillation and heart disease. You may also be asked whether you have any other symptoms. This information can help your provider determine whether you have other conditions that may be causing you to have atrial fibrillation.

Screening Methods – Screening, or checking for symptoms and risk factors, helps healthcare providers decide whether you truly have atrial fibrillation and whether diagnostic testing is needed. Your healthcare provider may screen you for atrial fibrillation only when you have risk factors. However, they may also check for symptoms of atrial fibrillation as part of your regular medical care. Screening steps may be part of your regular care if you are 65 or older or if you have other risk factors. Your provider may also recommend healthy lifestyle changes to help you lower your risk of developing atrial fibrillation.

If you had a stroke and there is no clear cause, your provider may recommend more detailed screening for atrial fibrillation. This can be done by having you wear different types of monitoring devices. These devices are now available to detect and record your heart rhythm for long periods of time during normal activities to allow your physician to make an accurate diagnosis.

Physical Examination – Your provider will do a complete physical examination, paying close attention to your heart and lungs. During this examination, they will:

• Check your pulse to find out how fast your heart is beating
• Listen to the rhythm of your heartbeat
• Listen to your lungs to check for signs of heart failure or infection
• Check for swelling in your legs, ankles or feet, which could be a sign of heart failure
• Check for signs of too much thyroid hormone, such as tremors, weight loss, sweatiness and a thyroid gland that is larger than normal

Atrial fibrillation diagnostic tests  

To diagnose atrial fibrillation, your provider will likely do one or more tests of your heart

• Electrocardiograms, or EKGs, record your heart’s electrical activity. Data from your pacemaker or implanted defibrillator, if you have one, may also be helpful. If the diagnosis is unclear from the EKG or if more information is needed, your provider may order additional testing.
• Holter and event monitors record your heart’s electrical activity over long periods of time while you do normal, day-to-day activities. These portable EKG monitors can help assess the cause of symptoms, like palpitations or dizziness, that happen outside the healthcare provider’s office. Most portable monitors will send data directly to your provider.
• A loop recorder is a type of long-term monitoring device that records the heart’s electrical activity. Some loop recorder models are worn outside the body, and some require minor surgery to place the device under the skin in the chest area. Implanted devices can record data for months to even a few years and are used to detect patterns in abnormal heart rhythms that do not happen very often or that are suspected in high-risk patients such as those with a stroke of unknown cause.
• Echocardiography (ultrasound) uses sound waves to look directly at the structure and function of your heart, including the heart valves, the various chambers of your heart and heart pumping function. This test may show heart valve diseases, areas of heart muscle that are not pumping normally, and any previous injury to the heart muscle. It may also identify potentially dangerous blood clots in the heart’s chambers.
• Transesophageal echocardiography checks for blood clots that may be forming in the heart’s upper chambers because of atrial fibrillation. It uses sound waves to take pictures of your heart through the esophagus.
• MRI or CT scan: Other non-invasive imaging techniques that may be recommended include cardiac magnetic resonance imaging (MRI) or CT Scanning. These tests are used occasionally to look for abnormalities in the heart that can be difficult to diagnose and that may not be seen on echocardiography or catheterization.
• A stress test may be ordered to evaluate whether your AFib is directly related to changes that occur when your heart rate increases after exercise. These changes can involve just the electrical system or the blood supply to your heart, or both. If you cannot exercise, your provider may give you medicine to make your heart work hard and beat fast.
• Cardiac catheterization: Depending on your symptoms and other factors, invasive evaluation with cardiac catheterization may be recommended to see if blocked arteries, valve abnormalities or changes in heart structure and function could be the underlying cause or contributing significantly to your atrial fibrillation.
• In some cases, the specific diagnosis of atrial fibrillation (to distinguish it from other types of arrhythmias) can be difficult and require more invasive and sophisticated testing, referred to electrophysiology. An electrophysiology study records your heart’s electrical signals precisely to diagnose the problem accurately and to map out exact locations and type of electrical problems that will help determine the best treatment strategy for you.

Other Tests

Your healthcare provider may order other tests to look for other specific conditions that can lead to atrial fibrillation.

• Abnormalities in function of your other organs such as the kidney, liver and thyroid can lead to abnormalities in blood content of many different substances that can then lead to atrial fibrillation. Most of these abnormalities, such as high levels of potassium or thyroid hormone can be detected with simple blood tests which your doctor may order.
• Chest X-rays can diagnose pneumonias or other abnormalities of the lungs which can then lead to atrial fibrillation. In addition, these can look for signs of complications from atrial fibrillation, such as fluid buildup in the lungs or a heart that is larger than normal.
• Patients who suffer from sleep apnea are at very high risk of developing atrial fibrillation. A sleep study can determine whether you may have sleep apnea or other important sleep disorders that might be causing your symptoms. 

Your provider may recommend that you take steps to help lower your risk of atrial fibrillation.

Adopt heart-healthy lifestyle changes, including aiming for a healthy weight, being physically active, controlling your blood sugar, limiting alcohol, lowering your blood pressure, managing stress and quitting smoking.

You may be asked to take specific medicines if you are having heart surgery.

Your provider also may recommend other treatments to maintain or supplement electrolytes levels during or after the procedure.

Avoid illegal drugs, such as cocaine, or stimulants such as amphetamines, which can trigger atrial fibrillation or make it worse. If you use illegal or street drugs, ask your provider how to get help to stop. You can also call the Substance Abuse and Mental Health Services Administration’s National Helpline at 1‑800‑662‑HELP (1-800-662-4357).

If you have been diagnosed with atrial fibrillation, it is important you continue your treatment. With follow-up care your healthcare provider can check your condition, talk to you about how to prevent repeat events, and give you instructions about what to do in an emergency.

Sometimes, atrial fibrillation returns to a normal heart rhythm without treatment. If undetected or untreated, atrial fibrillation can lead to serious complications. This is an especially important point for people who are Black or African American. Even though white Americans have atrial fibrillation at higher rates, research has found that many of the complications — including stroke, heart disease and heart failure — are more common for Black and African American people.

Other complications include:

• Stroke may occur if a blood clot that develops in the heart as a result of atrial fibrillation travels to and blocks a blood vessel that supplies the brain. For some people, atrial fibrillation has no symptoms, and a stroke may be the first sign of the condition. If you are a woman who has atrial fibrillation, the risk of a stroke is higher than it is for men.
• Blood clots to parts of the body other than the brain can also occur to as a complication of atrial fibrillation. Clots can break off and travel to organs such as the lungs, intestines, spleen or kidneys and lead to serious and even life-threatening conditions.
• Heart failure risk is higher if you have atrial fibrillation because the heart is beating quickly and unevenly. The heart’s chambers do not fill and move blood efficiently thus cannot pump enough blood out of the lungs to the rest of the body. Atrial fibrillation may also make existing heart failure symptoms worse.
• Cardiac arrest (when the heart suddenly and unexpectedly stops beating) is extremely rare but can occur if you have atrial fibrillation and another serious heart condition.

Routine Follow-Up Care

How often you need to visit your provider for follow-up care will depend on your symptoms and treatment. Be sure to attend all of your follow-up appointments as recommended by your healthcare provider. You can make these visits, and any other visits with a provider, more efficient and productive by taking these steps:

• Bring a list of all the medicines you are taking. Do this for every provider and emergency room visit. This will help any healthcare provider know exactly what medicines you are taking and therefore make better treatment decisions.
• Take your medicines as prescribed. If you are taking medicines to treat atrial fibrillation, your provider will check the dose of the medicines as well as their possible effects on your body’s electrolytes levels and how they affect other organs.
• Tell your provider if your medicines are causing side effects, if your symptoms are getting worse or if you have new symptoms.
• Check with your provider before taking over-the-counter medicines, nutritional supplements, or cold and allergy medicines. Some of these products can trigger rapid heart rhythms or interact poorly with other medicines you may be taking. In addition, medicines to treat arrhythmia can make the effect of blood thinners stronger.
• Ask your provider about recommended physical activity levels, weight control and alcohol use.
• If you use illegal or street drugs, ask your provider how to get help to stop.
• If you have had an ablation or an electrical cardioversion, your provider may want to see you regularly to check for any new or additional atrial fibrillation episodes and to adjust blood thinning medicines as needed.
• Report any lasting pain — for example, at the site of an incision — or any other signs of a complication. Your provider may also want to see you at least once a year after the initial follow-up period.
• If you are taking a blood thinning medicine, talk to your provider about any other instructions you need to follow.
  • You may need to avoid certain other medicines and watch what you eat.
  • If you are taking a blood thinner and need a dental or medical procedure, you will need to talk to your doctor first to see if you need to temporarily hold or adjust your blood thinner dose or schedule.
  • For blood thinners like warfarin, your provider will do blood tests every week at first, then monthly once the level has stabilized.
  • Blood thinners called DOACs, which are very effective and safe alternatives to warfarin, are now very commonly used and do not require monitoring of drug levels or blood thinning effect.

Monitor Your Condition

Regular visits to the clinic give your provider a chance to learn how well medicines are controlling your atrial fibrillation, keep track of your ongoing risks of clotting or bleeding, and check how well you are healing from any procedures.

• Electrocardiogram (EKG) monitoring can help detect a repeat atrial fibrillation event or assess your response to medicine and dose changes. You may record an EKG during your regular visits, or you may wear a portable monitor, sometimes called Holter or event monitor.
• Blood tests check the effects of certain heart rhythm medicines on your thyroid, kidneys or liver. The blood thinner warfarin also requires regular blood testing to make sure the dose is correct. In some cases, your provider may talk to you about devices available to monitor your blood thinning medicines at home. Blood thinners may be stopped or adjusted if you are going to have surgery.

Preventing Repeat Atrial Fibrillation

To help prevent a repeat episode of atrial fibrillation, your provider may recommend some specific actions.

• Make heart-healthy lifestyle changes, including aiming for a healthy weight. Combining weight loss with physical activity and managing other risk factors such as high blood pressure, diabetes, alcohol use and smoking can improve symptoms more than weight loss alone.
• Take medicine at home as needed to correct your heart rhythm. Before giving you medicine, your provider will ask you to take a dose and then try to trigger an event to see if the medicine works to prevent the event. Your provider can then determine how much medicine you need to manage your condition.
• Work closely with your physicians to treat any of your underlying conditions, such as sleep apnea, high blood pressure or diabetes.

Warning Signs of Serious Complications

Atrial fibrillation can lead to serious complications, especially if it is untreated or undiagnosed. There are also some risks of treatment with blood thinners, including the possibility of severe bleeding. 

If you see any signs or symptoms of the following conditions in yourself or someone else, call 9-1-1 immediately.

• If you think you recognize the signs of a stroke, such as sudden weakness, sudden trouble speaking, walking, or seeing, or sudden headache, call 9-1-1 immediately. Every minute matters.
• Bleeding in the brain, digestive system, or urinary tract can occur if you take blood-thinning medicines, especially if you have inadvertently taken a dose that is too high. Symptoms may include bright red vomit; bright red blood in your stool or black, tarry stools; blood in your urine; severe pain in the abdomen or head; sudden, severe changes in your vision or ability to move your arms or legs; or memory loss.
• Excessive bleeding after a fall or injury or easy bruising or bleeding may mean that your blood is too thin. Excessive bleeding is defined as bleeding that will not stop after you apply pressure to a wound for 10 minutes.
• Atrial fibrillation can be associated with a heart attack in some cases. Heart attacks can include mild or severe chest pain or discomfort in the chest or upper abdomen that lasts for more than a few minutes or goes away and comes back. It can feel like pressure, squeezing, fullness, heartburn or indigestion. There may also be pain down the left arm shortness of breath, nausea, vomiting, unusual tiredness, and pain in the back, shoulders or jaw. Women may have are more likely to have less typical symptoms with different characteristics to their chest pain and other associated symptoms.
• Cardiac arrest is a possible explanation if someone suddenly faints. At the same time, there will be no heartbeat. Just before they faint, some people may have a racing heartbeat or feel dizzy or light-headed. Within an hour before cardiac arrest, some people have chest pain, shortness of breath, nausea or vomiting. Call 9-1-1 right away if someone has symptoms of cardiac arrest. Look for a defibrillator nearby and follow the instructions.