Guide to Atrial Fibrillation: Causes, Treatments, Stroke Prevention, and Monitoring

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

Take your pulse and prevent a stroke

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:

  1. AliveCor’s Kardia

Using a Smart Phone Device and App To Monitor Your Pulse for Atrial Fibrillation (AliveCor)

AliveCor Is Now Kardia and It Works Well At Identifying Atrial Fibrillation At Home And In Office

    2. Apple Watch 4 and higher

           Apple Watch posts (here, here and here)

Devices/Apps to avoid for AF detection

Do NOT Rely on AF Detect Smartphone App To Diagnose Atrial fibrillation

Sonohealth’s EKGraph 

Emay

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

        Lifestyle Changes

Eight Lifestyle Changes to Prevent Atrial Fibrillation

-Obesity.

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 

-Alcohol.

Acute and Chronic Influences of Alcohol on Atrial Fibrillation

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.

-Exercise.

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

An accompanying editorial provides this graphic on the benefits of exercise training in AF

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.

The most recent study supporting drug therapy for suppressing atrial fibrillation, EAST-NET AF

My three-part series on “enlightened medical management of AF”:

Part I: Amiodarone. Kardia and Cardioversions

Part II: The Pill-in-Pocket Approach

Part III: Flecainide for Chronic AF Suppression

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.

Cardioversion: How Many Times Can You Shock The Heart?

Ablation: Cautionary Words From Dr. John Mandrola and The Wisdom of a Team Approach

Catheter Ablation of Atrial Fibrillation: Will it Reduce Your Risk of Death, Serious Bleeding or Stroke? 

Ablation For Atrial Fibrillation: One Patient’s Experience

Miscellaneous

What Happens If You Go Into Atrial Fibrillation On A Cruise?

Apple watch versus Kardia to monitor atrial fibrillation from home: A case study

Antifibrillatorily Yours,

-ACP

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10 thoughts on “Guide to Atrial Fibrillation: Causes, Treatments, Stroke Prevention, and Monitoring”

  1. Hi, I would like to add another device that is excellent vis a vis afib/arrhythmias.
    It is the Frontier X chest strap HR monitor. It can be used alone, with other monitors, watches etc and/or a smartphone. It produces a ECG trace and well as other data, heartrate, breath/min, and some created values, heart strain, HRV etc.
    I would say it tends to be more athletically focused. It’s expensive $650.00 cdn.
    I had an ablation and used it to see if increasing my exercise was causing any return of afib (I had an ablation in Aug 2022. https://fourthfrontier.com/
    cheers

    Reply
    • Ian,
      Agree. I’ve used the Frontier with exercise and it provided an amazingly high quality ECG trace at high heart rates.
      I plan to write about it soon.
      Dr. P

      Reply
  2. I’m a very athletic 64 yr old woman. with an intermittent Afib that began in 2012 at approximately the same time as my GERD. Never had either before.Been healthy weight and very active all my life until I was in my 40’s, gained 50 lbs of meno weight. Got it off in 10 months in 2015 and kept it off easily for 2 plus years. Last summer started to regain despite no lifestyle changes. am now 12-15 lbs heavier but still jogging 2 miles a day, 5 days a week, plus strenuous hiking 1-2 days a week. Had extensive thyroid work done, all shows ‘normal’ despite some ‘low normal’ readings. Doctors have been less than helpful or caring. Primary didn’t put a stethascope on my for 3 years..
    My Afib was ‘timed’ for years, 7-15 days apart, lasted about 18-24 hours if I did nothing. I found quite accidentally that jogging would restore rhythm. Also I suspect it’s a vagal Afib, and my resting heart rate does not accelerate much at all, going from a normal of 60 to 75-80. I do have significant discomfort, loss of stamina (although I can still jog, just doesn’t feel good), some indigestion, and lately, pressure at the base of my throat, and sometimes chest pressure, upper right quadrant. Also a bit tight with breathing OUT.
    March 2019 timing changed, more frequent, and two episodes of every two days. Went to cardio with my concerns. She found a heart murmur and suggested a portable ECG, which I bought. Put me on 25 mg of metoprolol. Also scheduled me for an echo and non chem stress test for June. Portable meter is the Emay. I sent the first two, a normal and an Arib to them in early May. Can’t seem to get anyone to respond from their clinic. The medication made my heart rate (not in Afib) to drop below 55 bpm, I was alarmed and asked them about it. No response. I was then told after two emails to the nurse that the doctor would be back in touch and that was 10 days ago.
    I stopped the medication on my own due to the dropped heart rate. And it didn’t seem to do anything to extend my episodes. After stopping it, I went 9 days without an episode. Then 8 days. But now have had two in three days, this last with much discomfort in my chest. Some readings are showing a range in heart rate of 55-80 per 30 sec test.
    Frankly I’m getting frightened and don’t understand the lack of interest from the cardiologist. Any thoughts that could direct me to getting this handled? Also have rotten insurance that requires I pay for everything up to $6500, could that be the reason I am basically being ignored? I need some help.

    Reply
  3. I live in an area where cardiologists are few and far between. The two I’ve seen do not take me seriously when I describe my heart issues and don’t do the halter monitoring. So I bought a Kardia finger pad and app and I have readings that come up possible atrial fibrillation. I showed them to the docs and neither of them gave them any credence because they couldn’t replicate it on their machines & they don’t know anything about Kardia. I am concerned. I tried to attach the most recent here but it will not take the document. Should I be worried?

    Reply
  4. anti-coagulants reduce risk of stroke…okay…but how much? What percentage and what proof? I can’t find hard evidence try as I have.

    Reply
  5. What about paroxysmal atrial fib, normal heart, liw cholesterol of 150, low bp 100/68, no diabetes. Not obese. Women of 66 with L-thyroxine treated hypothyroidism. Walks two miles a day. Normal echocardiogram
    Recent dx of ductal carcinoma insitu and lumpectomy.
    She is in Eliquis.
    What next? Is there a non drug way? The EP cardiologist wants to add Flecainide.

    Reply
    • Teepu,
      I hope soon to publish my post on maintaining normal rhythm for afibbers. It is a complicated topic.
      A common question is “is there anything I can do?”
      Recent evidence suggests that if you are overweight, losing 10% of body weight helps lower recurrence of AF.
      If drinking more than 1 alcoholic beverage today you should cut down. Make sure your thyroid levels are normal, your potassium is >4 and your magnesium >1.9
      Be aware of personal triggers: most of the time afib begins randomly but for some a specific good, or caffeinated beverage or a very stressful experience will set off AF.
      If episodes begin during sleep, consider testing for sleep apnea.
      If considering drug therapy, flecainide is a good choice for you as your heart is structurally normal. Well tolerated, no long term side effects and reasonably effective. You should get some assessment for coronary artery disease prior to starting.

      Reply

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Anthony C. Pearson M.D., F.A.C.C. is a cardiologist, musician, writer and a regular columnist at MedPage Today

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