Definition
Atrial fibrillation is increasingly common with advancing age. During atrial fibrillation, the heart's
two upper chambers (the atria) beat chaotically and irregularly out of coordination with the two
lower chambers (the ventricles) of the heart. The result is an irregular and often rapid heart rate
that causes poor blood flow to the body and symptoms of heart palpitations, shortness of breath
and weakness. Most people with atrial fibrillation have an increased risk of developing blood clots
that may lead to stroke.
Atrial fibrillation is a common heart rhythm problem. More than 2 million Americans have atrial
fibrillation, which can cause palpitations, shortness of breath, fatigue and stroke.
Atrial fibrillation is often caused by changes in your heart that occur as a result of heart disease or
high blood pressure. Episodes of atrial fibrillation can come and go, or you may have chronic
atrial fibrillation.
Although atrial fibrillation usually isn't life-threatening, it can lead to complications. Treatments for
atrial fibrillation may include medications and other interventions to try to alter the heart's
electrical system.
Symptoms
A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump an adequate
amount of blood out to your body with each heartbeat, causing a drop in your blood pressure.
Some people with atrial fibrillation have no symptoms and are unaware of their condition until
their doctor discovers it during a physical examination. Those who do have symptoms may
experience:
Chronic. With chronic atrial fibrillation, symptoms may last until they're
treated.
Causes
Normal heartbeat
A normal heartbeat begins when a tiny cluster of cells called the sinus node sends
an electrical signal (1). The signal then travels through the atria and passes
through another group of cells called the atrioventricular node (2). From the
atrioventricular node, the signal travels through the ventricles (3), causing them to
contract and pump out blood. After this, the process starts over (4).
Atrial fibrillation
Electrical signals fire from multiple locations in the atria, causing abnormal
quivering of the atria. (1). The atrioventricular node your heart's natural
pacemaker is unable to prevent all of these chaotic signals from entering the
ventricles (2). Your ventricles respond to these extra, chaotic signals by beating
faster than normal. (3).
To pump blood, your heart muscles must contract and relax in a coordinated rhythm. Contraction
and relaxation are controlled by electrical signals that travel through your heart muscles.
Your heart consists of four chambers two upper chambers (atria) and two lower chambers
(ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called
the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that
starts each heartbeat.
Normally, the impulse travels first through the atria, then through a connecting pathway between
the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal
passes through the atria, they contract, pumping blood from your atria into the ventricles below. A
split second later, as the signal passes through the AV node through the right and left bundle
branches to the ventricles, the ventricles contract, pumping blood out to your body.
In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals.
As a result, they quiver. The AV node the electrical connection between the atria and the
ventricles is overloaded with impulses trying to get through to the ventricles. The ventricles
also beat rapidly, but not as rapidly as the atria. The reason is because the AV node is like a
highway on-ramp only so many cars can get on at one time. The result is an irregular and fast
heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The
normal range for a heart rate is 60 to 100 beats a minute.
Possible causes
Abnormalities or damage to the heart's structure is the most common cause of atrial fibrillation.
Diseases affecting the heart's valves or pumping system are common causes, as is long-term
high blood pressure. However, some people who have atrial fibrillation don't have underlying
structural heart disease, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause
is often unclear. Serious complications are usually rare in lone atrial fibrillation.
Possible causes of atrial fibrillation include:
Risk factors
Age. The older you are, the greater your risk of developing atrial
fibrillation. As you age, the electrical and structural properties of the atria
can change. This may lead to the breakdown of the normal atrial rhythm.
Blood tests. These help your doctor rule out thyroid problems or blood
chemistry abnormalities that may lead to atrial fibrillation.
Complications
Sometimes, atrial fibrillation can lead to the following complications:
Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to pool in
your atria and form clots. If a blood clot forms, it could dislodge from your
heart and travel to your brain. There it might block arterial blood flow,
causing a stroke. The risk of stroke in atrial fibrillation depends on your
age (you have a higher risk as you age) and on whether you have high
blood pressure or a history of heart failure or previous stroke, and other
factors. Most people with atrial fibrillation have a much greater risk of
stroke than do those who don't have atrial fibrillation. Medications such as
blood thinners can greatly lower your risk of stroke or damage to other
organs caused by blood clots.
Sometimes atrial fibrillation will correct or "reset" itself. In some people, a specific event or an
underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. If the condition that
triggered your atrial fibrillation can be treated, you might not have any more heart rhythm
problems or at least not for quite some time. If your symptoms are bothersome or if this is your
first episode of atrial fibrillation, your doctor may attempt to reset the rhythm. Or it may be best to
simply take medications to control the heart rate and prevent blood clots.
The best strategy for you depends on many factors, including whether you have other problems
with your heart and how well you tolerate the medications available to treat atrial fibrillation or
control the rate. In some cases, you may need a more invasive treatment, such as catheter or
surgical techniques.
Resetting the rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. This can be
accomplished in some cases, depending on the underlying cause of atrial fibrillation and how long
you've had it. To correct atrial fibrillation, doctors may be able to reset your heart to its regular
rhythm (sinus rhythm) using a procedure called cardioversion. Cardioversion can be done in two
ways:
Before undergoing cardioversion, you may be given a blood-thinning medication, such as warfarin
(Coumadin), for several weeks to reduce the risk of blood clots and stroke. Alternatively, you may
undergo transesophageal echocardiography a test to exclude the presence of a blood clot
Surgical maze procedure. The maze procedure is often done during an open-heart
surgery. Using a scalpel, doctors create several precise incisions in the atria to create a
pattern or maze of scar tissue. Because scar tissue doesn't carry electricity, it interferes
with stray electrical impulses that cause atrial fibrillation. Radio frequency or cryotherapy
can also be used, and there are several variations of the surgical maze technique. The
procedure has a high success rate, but because it usually requires open-heart surgery,
it's generally reserved for people who don't respond to other treatments or when it can be
done during other necessary heart surgery, such as coronary artery bypass surgery or
heart valve repair. Some people require a pacemaker after the procedure.
Newer and less invasive techniques are being developed to create the atrial scar tissue.
Doctors at some centers use radio frequency or cryotherapy applied to the outside
surface of the heart through a small chest incision or through a scope placed into the
chest cavity (thorascopic approach). Microwave, laser and ultrasound energy are also
being studied as options to perform the maze procedure.
You may need to make lifestyle changes that improve the overall health of your heart, especially
to prevent or treat conditions such as high blood pressure. Your doctor may advise that you:
Reduce your salt intake, which can help lower blood pressure
Increase your physical activity
Quit smoking
Avoid alcohol
Atrial Fibrillation
Atrial Fibrillation Overview
Atrial fibrillation describes an irregular and often rapid heart rhythm. The irregular rhythm, or
arrhythmia, results from abnormal electrical impulses in the heart. The irregularity can be
continuous, or it can come and go.
Normal heart contractions begin as an electrical impulse in the right atrium. This impulse comes
from an area of the atrium called the sinoatrial (SA) or sinus node, the "natural pacemaker."
The impulse reaches the atrioventricular (AV) node in the muscle wall between
the 2 ventricles. There, it pauses, giving blood from the atria time to enter the
ventricles.
The impulse then continues into the ventricles, causing ventricular contraction
that pushes the blood out of the heart, completing a single heartbeat.
In a person with a normal heart rate and rhythm the heart beats 50-100 times per minute.
If the heart beats more than 100 times per minute, the heart rate is considered fast
(tachycardia).
If the heart beats less than 50 times per minute, the heart rate is considered slow
(bradycardia).
In atrial fibrillation, multiple impulses travel through the atria at the same time.
These irregular impulses reach the AV node in rapid succession, but not all of
them make it past the AV node. Therefore, the ventricles beat slower, often at
rates of 110-180 beats per minute in an irregular rhythm.
The resulting rapid, irregular heartbeat causes an irregular pulse and sometimes a
sensation of fluttering in the chest.
10
Persistent: Atrial fibrillation occurs in episodes, but the arrhythmia does not
convert back to sinus rhythm spontaneously. Medical treatment is required to end
the episode.
Atrial fibrillation, often called A Fib, is a very common heart rhythm disorder.
It affects about 1% of the population, mostly people older than 50 years. This
amounts to more than 2 million people.
For many people, atrial fibrillation may cause symptoms but does no harm.
Pneumonia
Most commonly, atrial fibrillation occurs as a result of some other cardiac condition
(secondary atrial fibrillation).
11
Heart valve disease: This can be something you are born with or be caused by
infection or degeneration/calcification of valves with age.
Coronary heart disease (or coronary artery disease): This results from
atherosclerosis, deposits of fatty material inside the arteries that cause blockage or
narrowing of the arteries.
Atrial fibrillation frequently occurs after cardiothoracic (open heart) surgery, but often resolves in a
few days.
For many people with infrequent and brief episodes of atrial fibrillation, the episodes are brought
on by a number of triggers. Because some of these involve excessive alcohol intake, this is
sometimes called holiday heart. Some of these people are able to avoid episodes or have fewer
episodes by avoiding their trigger. Common triggers include alcohol and caffeine in susceptible
individuals.
12
Call if you have persistent atrial fibrillation while you are on medical therapy for the condition or
you note worsening of your symptoms, or new symptoms such as fatigue or mild shortness of
breath.
Call if you have questions about medications and dosages.
Call 911 for emergency medical services when atrial fibrillation occurs with any of the following:
Chest pain
Weakness
Not all heart palpitations are atrial fibrillation, but a continuing feeling of your heart fluttering in
your chest together with a fast or slow pulse should be evaluated by your doctor or at a hospital
emergency department.
Markers for heart injury (enzymes such as troponins and creatine kinase [CK])
Prothrombin time (PT) and international normalized ratio (INR): If you are taking
warfarin (Coumadin) to prevent blood clotting, these tests show how well the
drug is working to lower your risk of a blood clot.
Chest x-ray: This imagery is used to evaluate for complications such as fluid in the lungs or to
estimate heart size
13
This very safe test uses the same technique used to check a fetus in pregnancy.
Ambulatory electrocardiogram (ECG): This test involves wearing a monitor for a period of time
(usually 24-48 hours) to try to document the arrhythmia while you go about your everyday
activities.
An Event monitor is a device that can be worn for 1-2 weeks and records the heart
rhythm when it is activated by the patient.
These tests may be used if your symptoms come and go and your ECGs do not
reveal the arrhythmia.
Self-Care at Home
There is no effective home treatment for atrial fibrillation. If your doctor recommends
lifestyle changes or prescribes medicine, follow his or her recommendations exactly. This
is the only way to see whether the treatment works.
Medical Treatment
Treatment for atrial fibrillation traditionally seeks three goals: to slow down the heart rate, to
restore and maintain normal heart rhythm, and to prevent stroke.
Control rate: The first treatment goal is to slow down the ventricular rate, if it is
fast.
14
Restore and maintain normal rhythm: About half the people with newly diagnosed
atrial fibrillation will convert to normal rhythm spontaneously in 24-48 hours.
However, atrial fibrillation typically returns.
The frequency with which your arrhythmia returns and the symptoms it
causes partly determine whether you receive rhythm-controlling
medication, which is usually called anti-arrhythmia medication.
Most of these medications cause unwanted side effects, which limit their
use. These medications should be discussed with a doctor.
People at lower risk of stroke and those who cannot take warfarin may use
aspirin. Aspirin is not without its own side effects, including bleeding
problems and stomach ulcers.
15
Defibrillation (cardioversion): This technique uses electrical current to "shock" the heart back to
normal sinus rhythm. This is sometimes called DC cardioversion.
Defibrillation works very well; more than 90% of people convert to sinus rhythm.
It is most successful if your atrial fibrillation is new (that is, hours, days, or a few
weeks). For many, however, this is not a permanent solution because the
arrhythmia often comes back.
Defibrillation increases the risk of stroke and thus requires pretreatment with an
anticoagulant medication.
Catheter ablation (radiofrequency [RF] ablation). This technique electrically burns/destroys some
of the abnormal conduction pathways in the atria.
Pacemaker: A pacemaker is an electronic device that prevents slow heartbeats, and may reduce
the likelihood of atrial fibrillation in a small number of patients. The artificial pacemaker takes the
place of the "natural pacemaker," the SA node, supplying electrical impulses to keep the heart
beating in a normal rhythm when the SA node no longer can.
The pacemaker is usually implanted in both the right atrium and right ventricle.
The goal is to override your own atrial fibrillation with a new atrial electrical
pacemaker, and turn off your own, native arrhythmic focus. A minority of patients
are offered this technique currently. This is a more complex technique and device,
and no long-term data regarding success is available yet.
16
Some machines and devices in your surroundings can interfere with the
production of electrical impulses by your pacemaker. For example, airport
security devices can deactivate pacemakers. Be sure you are familiar with which
types of devices may have this effect, and avoid those devices.
Carry an identification card that shows that you have a pacemaker. You will need
to present this identification when going through airport security and ask to be
hand searched as some security machines may inactivate pacemakers. Always tell
any medical or dental personnel that you have a pacemaker.
Medications
The choice of medication depends on the type of atrial fibrillation you have, the underlying cause,
your other medical conditions and overall health, and the other medications you take. Ironically,
many anti-arrhythmia medications may induce abnormal heart rhythms.
Anti-arrhythmia medications
Beta-blockers: These drugs slow the heart rate by decreasing the rate of the SA
node and by slowing conduction through the AV node. Therefore, the heart's
demand for oxygen is decreased, and the blood pressure is stabilized. Examples
include propranolol (Inderal) or metoprolol (Lopressor Toprol XL).
Calcium channel blockers: These drugs also slow heart rate by similar
mechanisms as beta-blockers. Verapamil (Calan, Isoptin) and diltiazem
(Cardizem) are examples of calcium channel blockers.
Other drugs
17
Surgery
Before the development of catheter ablation, open heart surgery was done to interrupt conducting
pathways in both atria. This is called the surgical maze procedure. Maze surgery is usually
considered in patients who need some other type of heart surgery, such as valve repair or
coronary artery bypass surgery.
Follow-up
If you have no heart disease and medications succeed in controlling your heart rate, you can be
sent home from the emergency room. You should follow-up with your health care provider within
48 hours.
If your rhythm does not convert to normal by itself, you may need electrical cardioversion, or
defibrillation.
If you have been in atrial fibrillation longer than 48 hours, you will need three
weeks of treatment with an anticoagulant medication, such as warfarin, before
electric shock and for four weeks after.
Anyone with underlying heart disease or those that do not respond to rate
controlling treatment may require hospital care.
Prevention
If you do not have atrial fibrillation, you can lower your chance of getting this arrhythmia by
reducing your risk factors. This includes risk factors for coronary heart disease and high blood
pressure.
Do not smoke.
Take part in moderately strenuous physical activity for at least 30 minutes every
day.
18
If you have atrial fibrillation, your health care provider may prescribe treatments for the underlying
cause and to prevent future episodes of atrial fibrillation. These treatments might include any of
the following (see Medical treatment for more information).
Medications
Cardio version
Pacemaker
Radiofrequency ablation
Maze surgery
Outlook
The most dangerous complication of atrial fibrillation is stroke.
Someone with atrial fibrillation is about 3-5 times more likely to have a stroke
than someone who does not have atrial fibrillation.
The risk of stroke from atrial fibrillation for people aged 50-59 years is about
1.5%. For those aged 80-89 years, the risk is about 30%.
It is important to know that clinical trial data has shown that you can live just as
long with atrial fibrillation with a controlled heart rate, for example, with
medications, plus Coumadin as in normal sinus rhythm (AFFIRM trial).
In heart failure, the heart no longer contracts and pumps as strongly as it should.
The very rapid contraction of the ventricles in atrial fibrillation can gradually
weaken the muscle walls of the ventricles.
This is uncommon, however, because most people seek treatment for atrial
fibrillation before the heart begins to fail.
For most people with atrial fibrillation, relatively simple treatment dramatically lowers the risk of
serious outcome. People with infrequent and brief episodes of atrial fibrillation may need no
further treatment than learning to avoid the triggers of their episodes, such as caffeine, alcohol, or
overeating.
19