Atrial Fibrillation

AF

Atrial fibrillation is a clinical condition characterized by a rapid and irregularly regular atrial rhythm of the heart. This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.

RapidAFib150 (cropped)

RapidAFib150 (cropped), CC BY-SA 3.0

Presentation

Majority of patients will not present with any symptoms at all. Only mild palpitations, chest discomfort, light headedness, dyspnea, and generalized weakness are subjectively felt by the patients. Upon physical examinations, pulses and auscultatory findings will reveal an irregularly regular rhythm. Pulses may not coincide with ventricular rates because the pumping may not generate sufficient blood or force to produce peripheral pressure.

Respiratoric

Dyspnea

This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
He denies dizziness, dyspnea, and chest pain, and says he sleeps comfortably on one pillow each night. His history is significant for diabetes mellitus type 2, hyperlipidemia, and hypertension.[medbullets.com]
Although up to 90% of AF episodes may not cause symptoms, [ 47 ] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure.[emedicine.medscape.com]
More often, however, patients report nonspecific symptoms such as fatigue, dyspnea, dizziness, and diaphoresis. Palpitations are a common feature.[clevelandclinicmeded.com]

Entire body system

Fatigue

Because the ventricles no longer receive rapid signals from the atria, they don't have to work as hard and the symptoms of breathlessness and fatigue go away.[strokeassociation.org]
But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
The primary symptoms of atrial fibrillation include racing heart rates, an irregular feeling of heart beats, fatigue, shortness of breath, mild chest tightness, and lightheadedness.[pathnetwork.org]
[…] fluttering, or a racing feeling in the chest) Lack of energy Lightheadedness Confusion Chest discomfort Shortness of breath, even at rest Risk factors High blood pressure Overactive thyroid Smoking Heavy alcohol or caffeine consumption Extreme stress or fatigue[lifelinescreening.com]

Coronary Artery Disease

Coronary Artery Disease Coronary artery disease (CAD) refers to the narrowing or blockage of arteries in the heart. It is the most common cause of death among men and women in the United States.[activebeat.com]
artery disease, and peripheral artery disease (PAD).[ncbi.nlm.nih.gov]
Arial fibrillation is strongly associated with cardiovascular diseases like coronary artery diseases (CAD), congestive heart failure (CHF) and diabetes mellitus.[symptoma.com]
The major factors that increase the risk of atrial fibrillation are: Age Coronary artery disease Rheumatic heart disease High blood pressure Diabetes An excess of thyroid hormones Symptoms Atrial fibrillation often doesn't cause any symptoms.[drugs.com]
Possible causes of atrial fibrillation include: High blood pressure Heart attacks Coronary artery disease Abnormal heart valves Heart defects you're born with (congenital) An overactive thyroid gland or other metabolic imbalance Exposure to stimulants[mayoclinic.org]

Weakness

This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
This is particularly true if a person is having bothersome symptoms (like shortness of breath or weakness) from atrial fibrillation.[drugs.com]
Your current location is: Change location Change location Enter Street, City, State and/or Zip: Atrial fibrillation (also called AFib or AF) is an irregular, weak heartbeat that increases the risk of heart disease and stroke .[mercy.net]
When symptoms do occur, there may be palpitations (awareness of a rapid heartbeat), fainting, dizziness, weakness, shortness of breath and angina pectoris (chest pain caused by a reduced blood supply to the heart muscle).[hopkinsmedicine.org]

Hypothermia

Causes of ‘slow’ AF include hypothermia , digoxin toxicity , medications, and sinus node dysfunction .[lifeinthefastlane.com]
Noncardiovascular respiratory causes Pulmonary embolism , pneumonia, lung cancer, and hypothermia have been associated with AF. Drug and alcohol use Stimulants, alcohol, and cocaine can trigger AF.[emedicine.medscape.com]

Turkish

[…] markers for the risk of incident AF.A score of age-controlled anthropometric, lipid, and nonlipid variables was compared in participants with recorded nonvalvular persistent/permanent AF (n 110) to those of a nested cohort sample (n 1126) of the Turkish[ncbi.nlm.nih.gov]

Gastrointestinal

Nausea

Some include: palpitations (a sensation of rapid and irregular heart beat), dizziness or lightheadedness, weak feeling, shortness of breath, chest pain and/or angina , nausea .[emedicinehealth.com]

Cardiovascular

Heart Failure

In some cases, this means the heart can’t pump enough blood to the body, causing heart failure. A rapid heart rate in AFib, left untreated, will increase the risk of heart failure.[cedars-sinai.edu]
Patients with chest pain, ischemia, congestive heart failure, mitral stenosis or hypotension may require intravenous verapamil, digoxin or a combination to quickly control the ventricular rate.[rnceus.com]
Heart failure. Atrial fibrillation, especially if not controlled, may weaken the heart and lead to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.[mayoclinic.org]
Though there was considerable heterogeneity (I 2 78%, P Congestive heart failure Six studies 2 42 71 101 117 118 involving 82 476 patients examined incident congestive heart failure as an outcome.[bmj.com]

Heart Disease

In fact, women are at a higher risk for heart disease in general, and AF is believed to be one effect of heart disease.[draxe.com]
Ischaemic heart disease and sudden cardiac death Sixteen studies 2 8 13 14 42 48 52 54 61 66 68 78 82 85 88 101 involving 395 957 patients examined ischaemic heart disease as an outcome (figs 2 and 6 ).[bmj.com]
The active prevention of heart diseases through a heart friendly diet, exercise, and lifestyle may prevent occurrence of an acquired atrial fibrillation.[symptoma.com]
Heart disease. Anyone with heart disease — such as heart valve problems, congenital heart disease, congestive heart failure, coronary artery disease, or a history of heart attack or heart surgery — has an increased risk of atrial fibrillation.[mayoclinic.org]

Palpitations

TOPIC Editors' Choice of Best Available Content This collection features the best content from AFP , as identified by the AFP editors, on atrial fibrillation and related issues, including anticoagulation therapy, antiplatelet therapy, arrhythmias, and palpitations[aafp.org]
This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
Symptoms of atrial fibrillation include shortness of breath, heart palpitations, chest discomfort, dizziness and even fainting. People of all ages have atrial fibrillation, but it is a more common condition in people over 65.[advocatehealth.com]
Medical Dictionary : very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat If you're experiencing chest pain, palpitations, lightheadedness or shortness of breath, you could[merriam-webster.com]
But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]

Chest Pain

In many patients, it can also cause chest pain, heart attack , or heart failure .[medlineplus.gov]
If you already have chest pains (angina) , the chest pains may become worse if you have AF. AF can also reduce the amount of exercise you're able to do.[patient.info]
Medical Dictionary : very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat If you're experiencing chest pain, palpitations, lightheadedness or shortness of breath, you could[merriam-webster.com]
If you have chest pain, seek emergency medical assistance immediately. Chest pain could signal that you're having a heart attack.[mayoclinic.org]

Hypertension

[…] or systemic embolic event (SEE) prevention for any of the DOACs in the patient subgroups, including patients with advanced age, impaired renal function, diabetes, prior stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension[ncbi.nlm.nih.gov]
Similarly, mapping of the TNF signaling pathway indicated significant association with genetic traits of ischemic heart disease, hypertension, and diabetes comorbidity.[ncbi.nlm.nih.gov]
Medical history is significant for hypertension being treated with hydrochlorothiazide. On physical exam, the patient appears uncomfortable. There is an irregularly irregular pulse when palpating the radial artery.[medbullets.com]
For atrial fibrillation, the major risk factors are increased age (over 50), obesity, family history, hypertension , diabetes and thyrotoxicosis (an excess of thyroid hormones).[hopkinsmedicine.org]
[…] atrial fibrillation Atrial fibrillation pattern Atrial fibrillation types reflecting different causes of the arrhythmia Symptom burden in atrial fibrillation Detection and management of risk factors and concomitant cardiovascular diseases Heart failure Hypertension[escardio.org]

Neurologic

Stroke

stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD).[ncbi.nlm.nih.gov]
Atrial fibrillation is a major risk factor for ischemic stroke, increasing risk of stroke by as much as 5-fold.[ncbi.nlm.nih.gov]
To help raise awareness about the association between AFib and the increased risk of stroke, National Stroke Association has developed the AFib-Stroke Connection .[stroke.org]
Atrial fibrillation is the most common arrhythmia and increases the risk of stroke.[ncbi.nlm.nih.gov]
[…] and stroke-related complications and costs.[ncbi.nlm.nih.gov]

Dizziness

Symptoms of atrial fibrillation include shortness of breath, heart palpitations, chest discomfort, dizziness and even fainting. People of all ages have atrial fibrillation, but it is a more common condition in people over 65.[advocatehealth.com]
But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
This can cause problems including dizziness , shortness of breath and tiredness.[nhs.uk]
This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
When symptoms do occur, there may be palpitations (awareness of a rapid heartbeat), fainting, dizziness, weakness, shortness of breath and angina pectoris (chest pain caused by a reduced blood supply to the heart muscle).[hopkinsmedicine.org]

Confusion

But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
[…] turtleneck Warning signs Even though not everybody with atrial fibrillation experiences symptoms, these warning signs may indicate heart issues: Heart palpitations (sudden pounding, fluttering, or a racing feeling in the chest) Lack of energy Lightheadedness Confusion[lifelinescreening.com]
Others experience: Palpitations: uncomfortable feeling that the heart is racing, beating irregularly or fluttering Fatigue Dizziness Shortness of breath Weakness Lightheadedness Confusion Problems exercising Sweating Chest pain or pressure (a medical[umm.edu]
However, those with symptoms may experience: Palpitations, or feelings of a rapid, uncomfortable, irregular heartbeat or a flopping in your chest Low blood pressure Weakness Shortness of breath Chest pain Lightheadedness Confusion Fatigue If you have[bidmc.org]

Workup

Atrial fibrillations are effectively diagnosed by an accurate medical history and a thorough physical examination. The following diagnostic methods and tests may be implored in patients presenting signs and symptoms of atrial fibrillations:

Electrocardiogram (ECG) is considered the primary tool in diagnosing atrial fibrillations.
Holter monitor monitors a 24 hour period of cardiac electrical activity to detect intermittent AF cases.
Event recorder will record cardiac activities in a period of weeks to months. It comes with an access button that the patient could easily press during an event or period of chest discomfort or irregularity for real time recording of the dysrhythmia.
Echocardiography elucidates the heart structures and clot formations during atrial fibrillation events [9].
Blood tests will determine the presence of electrolyte imbalance and hormonal hyperactivity like hyperthyroidism that can cause clinical dysrhythmias like AF.
Chest radiography will demonstrate other anatomic pathology of the heart, pericardium, and the lungs that may induce atrial fibrillation.

Jugular Venous Pressure

Absent A-Waves

P waves if arrhythmia is not captured on ECG then Holter monitoring in the outpatient setting these patients are hemodynamically stable telemitry in the inpatient setting Transthoracic echocardiogram (TTE) can assess atrial size and ventricular function[medbullets.com]

Treatment

The general treatment goals involved in the control of atrial fibrillation include the resetting of the heart rate and rhythm, and the active prevention of blood clot formation. Conservative approaches to atrial fibrillation using medications to control rhythm is primarily sought before invasive procedures are implored. Some patients presenting with an organic disease like hyperthyroidism that induces atrial fibrillation may be treated accordingly to relieve the heart of these unnecessary stresses.

To reset the heart to normal rhythm, physicians often resort to cardioversion of the heart which may done by either electrical means (Electrical cardioversion), and by medical cardioversion. When the abnormal rhythm is normalized after electrical cardioversion, patients are often given antiarrhythmic drugs like flecainide, propafenone, dofetilide, and amiodarone to prevent the recurrence of the atrial dysrhythmia. Medications to control resting heart rate may be given like digoxin, beta blockers, and calcium channel blockers although proper precautions must be made to prevent hypotension [10].

In cases, where medical cardioversion fails to achieve its goals, surgical approaches like cardiac catheter ablation, atrio-ventricular node (AV node) ablation, and surgical maze procedures may be the only options left. Patients with atrial fibrillation are at high risk for the development of thrombi and embolus from blood clots; thus, anticoagulation therapy like warfarin, dabigatran, rivaroxaban, and apixaban may be given as a preventive measure.

Prognosis

Atrial fibrillation is closely associated with thromboembolic events that is why patients with AF have up to 1.9 fold risk of death compared to those who don’t suffer from it [6]. Mild asymptomatic AF has a good long term prognosis. The administration of maintenance medications like rate control and anticoagulants does not increase the survival rating of AF patients that are asymptomatic [7].

The risk of a thromboembolic stroke among AF patients beyond 75 years of age is staggering; thus, anticoagulant therapy is perpetually given unless other contraindications are identified. Meta-analysis data revealed that patients who were brought to the emergency room with myocardial infarction presenting with AF have a 40% increase in mortality rate [8].

Etiology

Atrial fibrillation may be induced by any of these conditions:

Coronary artery disease (CAD)
History of heart surgery
Viral endocarditis
Sick sinus syndrome
Sleep apnea
Pneumonia and other lung diseases
Stimulants like coffee, tobacco, alcohol and medications
Hyperthyroidism
Electrolyte imbalance
Heart valve abnormalities
Congenital heart disease
Neurologic disorders
Carditis and pericarditis
Genetic factors

Epidemiology

In the United States alone, more than 2.2 million Americans are suffering from atrial fibrillation. This cardiac dysfunction is primarily age related, because a fourth of the patients beyond 40 years old are at risk of developing atrial fibrillation in their remaining lifetime [2].

The increasing prevalence of atrial fibrillation among the elderly population is expected to double by 2050 in the US. Atrial fibrillation is relatively rare in infants and childhood, except for those who have undergone prior cardiac surgery [3]. Atrial fibrillation is more common among males than in females, and it is commonly seen in the white race than the black. Patients reaching the seventh decade the prevalence doubles per 10 year increment [4].

Sex distribution

Age distribution

Pathophysiology

Arial fibrillation is strongly associated with cardiovascular diseases like coronary artery diseases (CAD), congestive heart failure (CHF) and diabetes mellitus [5]. Although the exact mechanism is inconclusively elaborated, theories abound that excessive catecholamine, hemodynamic stress and cardiac inflammation causes the AF phenomenon. There are theories of the occurrence of an automatic focus of electrical conduction from sources other than the AV node like some focal regions in the pulmonary vein can cause the unsynchronized impulses that gives rise to AF.

Prevention

The active prevention of heart diseases through a heart friendly diet, exercise, and lifestyle may prevent occurrence of an acquired atrial fibrillation. A healthy lifestyle connotes the willful avoidance of stimulants like caffeine, alcohol and tobacco. Regular exercises and physical activity to maintain ideal body weight is also paramount in the prevention of heart diseases. Patients must understand that severe anger and stress can directly cause heart rhythm dysfunction on a long term basis.

Summary

Atrial fibrillation (AF) is clinically defined as a fast and irregular heart rate that reduces blood flow all over the body. Although atrial fibrillation is not considered life-threatening, persistent symptoms may require immediate treatment to prevent serious complications.

The desynchronized atrial contraction in atrial fibrillation may lead to thrombi or emboli formation that can functionally obstruct blood flow in multiple distant organs and cause ischemia. Atrial fibrillation is often times approached by interventions and medications to normalize the cardiac electrical activities. Atrial fibrillation is classified into three patterns: Paroxysmal AF, persistent AF, and permanent AF [1].

Patient Information

Definition

Atrial fibrillation is clinically defined as a fast and irregular heart rate that reduces blood flow all over the body.

Cause

Atrial fibrillation may be triggered by an ongoing heart disease, metabolic disease, neurologic disorders, and the intake of stimulants.

Symptoms

Patients may be asymptomatic, or may complain of palpitation, dizziness and weakness.

Diagnosis

Electrocardiography, echocardiography, Holter monitoring, blood tests and a chest X-ray may be used to diagnose the condition.

Treatment and follow-up

Medical and electrical cardioversion, and cardiac surgery ablation are the most common treatment options.

References

Article

Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation. Oct 23 2001; 104(17):2118-50.
Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. Aug 31 2004; 110(9):1042-6.
Abdel Latif A, Messinger-Rapport BJ. Should nursing home residents with atrial fibrillation be ant coagulated? Cleve Clin J Med. Jan 2004; 71(1):40-4.
Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ, et al. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation. Mar 7 2000; 101(9):969-74.
Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. Oct 16 1998; 82(8A):2N-9N.
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. Aug 1991; 22(8):983-8.
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. Dec 5 2002; 347(23):1825-33.
Jabre P, Roger VL, Murad MH, et al. Mortality associated with atrial fibrillation in patients with myocardial infarction: a systematic review and meta-analysis. Circulation. Apr 19 2011; 123(15):1587-93.
Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. May 10 2001; 344(19):1411-20.
Hagens VE, Ranchor AV, Van Sonderen E, Bosker HA, Kamp O, Tijssen JG, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol. Jan 21 2004; 43(2):241-7.

Symptoms

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