Atrial fibrillation (AF) — irregular heartbeat
Atrial fibrillation is chaotic electrical activity in the atria (upper heart chambers) — ** ineffective atrial contraction** — ** irregular ventricular response** — often fast.
Most common sustained arrhythmia — UK ~1.4 million — 1 in 10 over 65.
Stroke prevention is central — AF causes ~20% of UK strokes.
Symptoms
- palpitations — irregular irregular
- fatigue
- breathlessness
- dizziness, presyncope
- chest discomfort
- polyuria — ANP release
Asymptomatic AF — opportunistic pulse check in ≥65 — NHS recommendation.
Types
| Type | Pattern |
|---|---|
| Paroxysmal | Episodes <7 days, self-terminating |
| Persistent | >7 days — needs cardioversion/drugs |
| Permanent | Accepted — rate control |
Diagnosis
12-lead ECG — no P waves, ** irregularly irregular RR**, ** fibrillatory baseline**
Ambulatory monitor if paroxysmal — symptom loop recorder
Blood tests — TFTs, FBC, U&E, LFTs — exclude triggers
Echocardiogram — structure, valve disease, LA size
Stroke risk — CHA2DS2-VASc
Score components:
- C — CHF
- H — Hypertension
- A2 — Age ≥75 (2 points)
- D — Diabetes
- S2 — prior Stroke/TIA (2 points)
- V — Vascular disease
- A — Age 65–74
- Sc — Sex category female
Men ≥2, Women ≥3 — offer anticoagulation (NICE)
HAS-BLED — bleeding risk — not reason alone to withhold if high stroke risk — manage modifiable bleeds.
Anticoagulation
DOACs first-line non-valvular AF:
- apixaban
- rivaroxaban
- edoxaban
- dabigatran
Warfarin — mechanical valve, moderate-severe mitral stenosis
Aspirin alone — not adequate stroke prevention in AF.
See stroke prevention context.
Rate vs rhythm control
Rate control — first-line many especially >80 years:
- bisoprolol
- diltiazem (avoid if reduced EF)
- digoxin — sedentary elderly
Rhythm control:
- electrical cardioversion — sedated shock — anticoagulate ≥3 weeks before or TOE-guided
- flecainide, amiodarone
- catheter ablation — symptomatic paroxysmal — pulmonary vein isolation
Triggers and comorbidity
- hypertension — treat
- alcohol — ” holiday heart”
- hyperthyroidism — see overactive thyroid
- sleep apnoea — sleep apnoea treatment reduces AF burden
- obesity, diabetes
- post-surgery, sepsis — reactive AF may revert
Living with AF
- learn pulse check
- MedicAlert if on anticoagulant
- limit alcohol
- exercise as tolerated
- AF Association — support
New palpitations — GP ECG same week — AF diagnosed is stroke risk managed, not just ” irregular heartbeat tolerated”.
Common questions about atrial fibrillation
- What does atrial fibrillation feel like?
- Palpitations — fluttering or pounding heartbeat, irregular pulse, tiredness, breathlessness on exertion, dizziness, reduced exercise tolerance. Paroxysmal AF comes and goes; persistent AF continuous until treated. Some people — especially elderly — have no symptoms — found on routine pulse check.
- Is atrial fibrillation dangerous?
- Not immediately fatal itself but increases stroke risk significantly — blood pools in atria forming clots. Also heart failure risk if uncontrolled fast rate long term. Anticoagulation reduces stroke by about two-thirds in eligible patients.
- How is atrial fibrillation treated?
- Rate control — beta-blockers (bisoprolol), rate-limiting calcium channel blockers (diltiazem), digoxin selected cases. Rhythm control — cardioversion, flecainide, amiodarone, catheter ablation in selected patients. Anticoagulation — DOAC if CHA2DS2-VASc score indicates — balances stroke vs bleeding risk.
- What is the difference between warfarin and DOACs for AF?
- DOACs (direct oral anticoagulants) — apixaban, rivaroxaban, edoxaban, dabigatran — fixed doses, no routine INR monitoring, fewer food interactions — preferred for non-valvular AF. Warfarin still used if mechanical heart valve or moderate-severe mitral stenosis.
- Can atrial fibrillation be cured?
- Paroxysmal AF may respond to rhythm control or ablation — pulmonary vein isolation — cure possible in selected younger patients without structural heart disease. Persistent AF often managed long term — rate control plus anticoagulation. Treat triggers — alcohol, thyroid, sleep apnoea.
Sources
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