This is an updated version of my summary page on atrial fibrillation. Use this as a starting point if you are trying to navigate the massive amount of information available on the topic in order to make more informed decisions on the treatment options you will be offered.
Atrial fibrillation occurs when the normal, regular, synchronous action of the upper chambers of the heart becomes chaotic, rapid, and inefficient.
Some who go into atrial fibrillation know it right away because they feel bad-they feel what we doctors term palpitations: a sensation that their heart is beating rapidly or irregularly (like a fluttering.) They may have other symptoms associated with this such as dizziness, chest pain, anxiousness or shortness of breath.
Many, however, go into atrial fibrillation and are not aware of it (aka asymptomatic.)
For those who are asymptomatic, the first symptom felt may be due to a stroke from a clot developing in the (now dysfunctional) left atrium, or upper chamber of the heart, dislodging and going down an artery to the brain. For others, especially if the heart rate is high, heart failure may develop, cause shortness of breath and prompt medical evaluation.
It is natural to wonder “Why Did I Go Into Atrial Fibrillation?” For some individual cases, specific triggers can be identified but for many we never identify a particular cause.
For most patients who are persistently in atrial fibrillation I recommend utilizing a combination of medications and cardioversions to restore the normal rhythm (normal sinus rhythm.) This is termed a “rhythm” management strategy. For decades we did not have solid evidence supporting this strategy over a “rate” strategy.” A rate strategy is a conservative approach in which the patient is left to permanently be in atrial fibrillation but rate and stroke risk are controlled by medications.
I discussed in detail why I recommended the rhythm strategy in “Why I Favor The Restoration and Maintenance of Sinus Rhythm For Most Patients With Atrial Fibrillation.” Since I wrote that strong evidence has emerged supporting this position beginning with the 2020 Eastnet-AF trial I discuss below.
Whether you choose a rhythm or a rate strategy, a second major discussion and decision for AF patients is whether to take a blood thinner or anticoagulant to reduce the risk of atrial clot formation and resulting stroke.
Diagnosing Atrial fibrillation
TIAs and silent atrial fibrillation. Sometimes strokes present in unusual ways, like the inability to differentiate a spade from a diamond when playing bridge and afib can be the cause.
Using Personal ECG Devices To Diagnose Atrial Fibrillation
I’ve written extensively on the value of personal ECG devices to detect and monitor atrial fibrillation. There are two that I have considerable patient experience with and highly recommend:
- AliveCor’s Kardia
2. Apple Watch 4 and higher
Devices/Apps to avoid for AF detection
Stroke Risk and Stroke Prevention
The most serious adverse consequence of having atrial fibrillation is stroke. Since we have safe and effective ways of preventing afib-related stroke with oral anticoagulant drugs (blood thinners), a major decision for the newly diagnosed patient with atrial fibrillation is “should I take a blood thinner?”
To answer this question the afibber should engage in a lengthy discussion with his/her health-care provider which results in a shared and informed decision. Such discussion must cover your risk of stroke, the benefits of blood thinners in preventing stroke, the bleeding risks of blood thinners and the pros and cons of the five oral anticoagulants available to prevent stroke.
As background for these physician discussions I highly recommend reading my post on “Which Patients Should Take Blood Thinners” which discusses stroke risk, anticoagulant risk and the lack of efficacy of aspirin in this area.
Estimating Stroke Risk in Patients With Atrial Fibrillation You can estimate your stroke risk using an app that utilizes the CHAD2DS2-VASc score. I prefer to call the Lip score. This post was written in 2015 but the CHADS2 score is still the primary tool for assessing afib related stroke risk.
Why Does the TV Tell Me Xarelto Is A BAD Drug? Anticoagulant drugs that prevent the bad clots that cause stroke also increase bleeding risk. A bleeding complication is not a valid reason to sue the manufacturer. The lawsuits are strictly a money-making tactic for sleazy lawyers.
All patients with afib do not need anticoagulant therapy chronically. For some, we offer a pill in the pocket approach, something I’ve touched on a few times.
Procedural alternatives to anticoagulant therapy have been developed including closure or obliteration of the left atrial appendage at the time of open heart surgery and closure using a catheter-based technology without surgery (left atrial appendage occlusion.) I have only referred rare patients for the FDA approved catheter-based closure devices. For a good discussion on this area see Dr. Mandrola’s article entitled “Left atrial appendage occlusion should be offered only to select atrial fibrillation patients.“
Treatment Of Atrial Fibrillation
How Obesity Causes Atrial Fibrillation in Fat Sheep and how Losing Weight can reduce the recurrence of atrial fibrillation.
More recently we have solid evidence that sustained weight reduction can significantly reduce the recurrence of AF from the Australian LEGACY study
The alcohol AF trial published in NEJM showed abstinence from alcohol significantly reduced symptomatic episodes and hospitalizations for AF
-Fish Oil Supplements
Omega-3 Fatty Acids, Fish Oil Supplements and the Risk of Atrial Fibrillation discussed evidence that high dose omega-3 supplements may cause atrial fibrillation.
The most compelling evidence for the independent role of exercise in reducing AF comes from a Norwegian study of 51 patients with AF who were randomized either to aerobic interval training (AIT) or to their regular exercise habits. The exercise arm had a lower burden of Afib
Drug Therapy: Rate Control and Anticoagulation
Foxglove Equipoise. When William Withering began treating patients suffering from dropsy in 1775 with various preparations of the foxglove plant he wasn’t sure if he would help or hurt them. After 240 years of treatment, we are still unsure if the drug obtained from foxglove is useful.
Should Digoxin Still Be Used in Atrial Fibrillation? The answer is it still has a minimal role in chronic outpatient therapy. In hospitalized patients we use it frequently intravenously to aid in slowing heart rate in hypotensive patients with rapid afib.
Drug Therapy: Antiarrhythmic Drugs for Maintenance of Sinus Rhythm
If lifestyle changes alone can’t control atrial fibrillation, I am an advocate of enlightened use of medications (antiarrhythmic medications or AADs) that can safely restore and maintain the normal sinus rhythm long term.
My three-part series on “enlightened medical management of AF”:
There are other medications one can utilize for maintenance of sinus rhythm but i utilize them much less commonly than amiodarone and flecainide.
I discuss sotalol (Betapace) and beta-blockers here. Dofedilide (Tikosyn) is another alternative for suppression of atrial fibrillation. Both of these drugs should be started in the hospital with the patient on an ECG monitor for 72 hours to monitor for ventricular tachycardia and QT prolongation.
I don’t recommend Multaq (aka amiodarone light) and have a post pending on this topic.
Cardioversion and Ablation
We can shock (cardiovert) the heart back to normal rhythm with little risk and a very high success rate when performed by experienced and enlightened cardiologists. Keeping the rhythm normal after successful cardioversion is a bigger challenge (see above) and when medications and lifestyle changes fail an invasive procedure (ablation) is an option for some patients. Ablation should not be considered a cure for AF as recurrence is common and successful ablation has not been shown to lower stroke risk thus anticoagulants are still recommended lifelong after the procedure.