I have been diagnosed with Atrial Fibrillation. What Now?

Information about Atrial Fibrillation and Atrial Flutter 

Atrial Fibrillation and flutter are atrial arrhythmias affecting over a million people in the UK.

By the age of 70 yrs over 10% of people will have the condition.

Please remember that everyone with the condition is different and therefore the information given is provided as a guide rather than a substitute to consulting with an experienced Physician or Cardiologist about the problem.

In this article some of the common questions that crop up are addressed.

What is atrial fibrillation?

Normally the top chambers of the heart (right and left atrium - often described together as ‘the atria’) contract to prime the main pumping chamber (ventricles) before every heart beat or pulse that can be felt in the neck or wrist.  

When atrial fibrillation, flutter or tachycardia occurs this process goes wrong because instead of the atria beating just once prior to each heart beat, they beat uncontrollably at a high rate and out of sequence with the rest of the heart.

Each arrhythmia can be:

  1. transient- so called ‘paroxysmal atrial fibrillation/tachycardia/flutter 
  2. temporary until it can be fixed - this referred to as ‘persistent’ atrial fibrillation
  3. permanent - referred to as  ‘accepted’ or longstanding atrial fibrillation

What is the difference between atrial fibrillation and atrial flutter or tachycardia?

The name of the arrhythmia depends on the cycle/speed of the electrical circuit - in Atrial Fibrillation (AF) both atria quiver without any coordination at approx. 600 cycles per minute whereas atrial flutter and tachycardia the atria are contracting at 380-320 cycles per minute often generating a typical flutter pattern on the electrocardiogram. 

How does atrial fibrillation and flutter affect the heart?

Because the activation of the main pumping chamber (ventricle) occurs via the atria, any atrial rhythm disturbance can lead to fast and/or erratic heart (or pulse) rates. The precise pulse rate varies between individuals ranging between 40 -180 beats per minute - which explains why some people feel it more than others. 

Although many people may not be aware that anything is wrong, most will have symptoms on physical activity  since the loss of the atrial priming function (similar to a turbocharger packing up in a car engine)  causes lower efficiency during work. 

Older people have stiff hearts so are more relient on the priming function of the atria. Loss of atrial function during atrial fibrillation can therefore cause more extreme symptoms including breathlessness at rest. 

How is atrial fibrillation linked to strokes?

The atria normally contract and this movement prevents blood clots from sticking inside- particularily in the area of the left atrial appendage which is confined. During atrial fibrillation or flutter blood pools within the appendage and occasionally coagulates to form a sticky gel like substance called a 'thrombus'. In unlucky individuals part of this gelatenous material detaches and is carried in the blood arterial steam around the body. If it deposits in the head it can block a major cerebral artery causing a stroke see our animation for more detail.

Atrial Fibrillation and clots arising from the heart are thought to be the cause of approx 20% of all stroke cases, and as many as 50% of all major disabling strokes. Clearly it is vital to prevent them!

Is Atrial Fibrillation/Flutter a form of ‘heart disease’?

In some patients the development of atrial fibrillation or flutter can be associated with other conditions that make it seem worse and that may require seperate treatment. These include:

  • Cardiomyopathy - or enlarged heart
  • Heart Failure- with congestion of the lungs
  • Overactive Thyroid gland which affects metabolism (Thyrotoxicosis)
  • Coronary artery Disease (narrowed arteries supplying blood to the heart)
  • Heart Valve defects such as Mitral Regurgitation and Aortic Stenosis.
  • High Blood Pressure or Hypertension

Until each case is assessed by an experienced Physician and/or various tests undertaken it is not always possible to know whether any of these conditions are present.  Once the tests have been undertaken and the heart is shown to be structurally normal, atrial fibrillation will often be referred to as ‘lone atrial fibrillation’, ‘lone atrial flutter’ or ‘atrial arrhythmia without structural heart disease’. 

What medications may be required?

This depends. If the heart is racing too fast thereby creating symptoms of breathless and palpitation your physician will often prescribe medication to slow the pulse such as:

  • Digoxin a drug derivative of the flower ‘Foxglove’ or Digitalis
  • Betablockers (Metoprolol, Bisoprolol, Atenolol)
  • Calcium Channel Blockers (Verapamil, Diltiazem)

However if the heart rate is within normal limits these drugs would not normally be needed. Some patients in atrial fibrillation thus require no medication whatsoever!

Sometimes drugs are given to help get the heart back into its normal rhythm- a treatment referred to as Cardioversion. 

These drugs can include:

  • Flecainide
  • Propafenone
  • Amiodarone

Anticoagulants 

Depending on various factors, including whether there is an intention to restore the normal heart rhythm, blood thinners called Anticoagulants may be started to prevent formation of blood clots within the left atrial appendage (part of the left atrium).  In addition for those patients with ‘accepted atrial fibrillation’ most physicians use a risk scoring system called CHADVASC to help decide whether long term anticoagulants  are needed.     The current thinking is that long term anticoagulants should be considered for patients with non valvular heart disease and atrial fibrillation where the CHADVASC score exceeds '1'.  Exceptions to this rule include all patients with paroxysmal atrial fibrillation where attacks last over 24 hours (who should generally be anti coagulated) and any patient with bleeding tendencies or past cerebral (head) bleeding, where there are contraindications to taking anticoagulants even if there is a high CHADVASC score.

Examples of Anticoagulants are Warfarin, and Novel Oral Anticoagulants (NOACS). 

Should I take an Aspirin to thin my blood?

Aspirin is no longer used to prevent blood clots in atrial fibrillation or flutter- since it can occasionally cause side effects yet has insufficient potency to prevent a clot forming within the atrial appendage.

Can I drive?

Providing you have no major limitations for example have not experienced periods of feeling lightheaded or any blackouts and all the other vital senses (full visual fields, balance and mental capacity) the presence of atrial fibrillation does not automatically exclude driving, but to avoid any doubt you should check with your Doctor.

Can I work normally?

Atrial Fibrillation or flutter once treated or controlled should not normally prevent return to normal work. The exception to this rule is in certain key occupations for example Pilot, HGV driver, working at heights or altitude where your employers occupational health team will need to be contacted.

If your treatment is not fully effective and you continue to experience severe palpitation, breathlessness or dizzy spells you should not return to work until given the go ahead by your Physician especially if this involves a labouring job.

Can I undertake normal physical activity when in AF?

Once treated so that the heart rate is no longer racing at rest or on minimal effort most people should be physically able to undertake light or even moderate physical activities.  If your treatment is not fully effective and you continue to experience severe palpitation, chest pains or tightness, breathlessness or dizzy spells you should not return to physical activities until given the go ahead by your Physician.

What about sex?

Atrial Fibrillation or flutter once treated or controlled should not normally prevent return to physical activities including sex.  Essentially if you can walk up two flights of stairs without feeling lightheaded, overly breathless or dizzy then a normal sex life can be resumed.

If your treatment is not yet fully effective and you continue to experience severe palpitation, breathlessness or dizzy spells on minimal activities then it may be best to wait until  given the go ahead by your Physician.

What lifestyle measures are required?

This will depend on whether there are associated conditions such as high blood pressure or coronary artery narrowing.   In general, because atrial fibrillation and flutter are both associated and indeed can be caused by alcohol, you intake should not exceed national guidelines (men > 20 units, women > 14 units per week) it is therefore recommended that patient with AF are careful about how much alcohol is consumed. 

Do all cases of atrial fibrillation and flutter need to be referred to a Cardiologist?

Many Cardiologists would advocate that every case is seen by a specialist however the prevalence of the condition in the UK means that there are insufficient Cardiologists to assess every case.  A more pragmatic view is therfore that all cases should be assessed by a suitably trained Physician (GP or in Hospital) who should draw from national or local guidelines to provide best care.  An experienced GP with access to local guidelines, an ECG, Echocardiogram, Chest Xray and blood testing will thus usually offer a similar approach to the hospital based Cardiologist. 

If there are minimal symptoms from the condition and a proper risk assessment of stroke made with an appropriate decision about need for anticoagulants, little more would be done in a specialist clinic.

What tests may be needed?

Every case will be different but the following tests can be useful:

  • a 12 lead Electrocardiogram (ECG
  • Blood tests for BNP, Kidney Function, Full Blood Count and Thyroid function if not tested in last year.
  • A Chest X Ray if Echo is not available
  • An Echocardiogram 
  • Exercise ECG testing and ambulatory ECG monitoring are sometimes also indicated. 

How urgently should the problem be addressed?

The clinical urgency depends on the underlying diagnosis and level of symptoms. A small percentage of patients presenting with atrial fibrillation or flutter have serious underlying heart disease that requires urgent attention. It is hard to generalise but if the atrial fibrillation is well tolerated causing no or little symptoms of breathlessness/fatigue it is unlikely that there is an urgent underlying condition.

In contrast patients who have major limitation of any physical activity such as walking, especially with high BNP (blood test) or if cannot lie flat are more likely to have a serious cause and require urgent attention- either via outpatients within a week or via the local medical assessment unit.

Are there any tests that the GP can run that will help while waiting for expert option and tests?

Yes, as well as an ECG, the GP may be able to arrange a simple blood test called ‘BNP’ which is a very useful marker of how bad the problem may be- the higher the BNP, the worse the prognosis.    As a rule of thumb if there are any symptoms such as breathlessness or fatigue and the BNP is grossly elevated (above 95 centile) an ultrasound of the heart (Echocardiogram) and or Cardiologist review should be available within 6 weeks.

Other useful GP tests are Chest X Ray - a normal Chest Xray points to a good prognosis and some of the blood mentioned above.

An Echocardiogram can sometimes be arranged by the GP without specialist opinion - if it is normal this would be very reassuring since it suggests ‘lone atrial fibrillation’ .

What treatment options are there?

Your treatment plan will depend on whether there are underlying medical conditions that may be causing or are associated with the atrial fibrillation/ flutter. For example if the rhythm disturbance is caused by an over active thyroid this would usually be treated first. If there is angina (chest pains on effort) then investigations and treatment of underlying heart disease would be arranged before restoring the heart to normal rhythm. Once these have been addressed there are then TWO main options: 

1/ ‘Rate control’ where the atrial rhythm is accepted as being permanent - but the pulse rate is controlled with drugs if needed. For most people over 70 years of age without symptoms from their Atrial fibrillation this would be the commonest used option. Occasionally where medication is poorly tolerated or ineffective an ablation and pacemaker are recommended.

2/ ‘Cardioversion - Only down in hospital so requires a specialist referral. Cardioversion involves delivery of an electric shock to the heart under heavy sedation or general anaesthetic.  This option is most often offered to most younger patients - with or without symptoms from the fibrillation or flutter. Proper anticoagulation is mandatory for at least three weeks before and three weeks after the Cardioversion.  

Providing it is conducted by properly trained staff in a high volume unit and there has been attention to detail over the anticoagulation, cardioversion is a very safe procedure. 

3/ Ablation  - where a metal tipped catheter is passed up to the heart from the vein at the top of the leg and the circuit responsible for the arrhythmia is destroyed using radio frequency ablation or intense cold (Cryotherapy). It is an invasive procedure sometimes appropriate as the preferred treatment option.  Success rates cary between 98% for common aerial flutter and below 50% for permanent atrial fibrillation. 

This article is an extract taken from the Authors Book "The Naked Heart" by kind permission of Green Pages Publication.

Related stories
Living with AF
Aspirin prevents heart attacks not Stroke
Why 'thin your Blood'
NOAC PRN
How Atrial Fibrillation causes a stroke
See HASTE Patient LIBRARY for more Information on AF 


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Edward Leatham is a Consultant Cardiologist in Surrey and a Trustee of Haste and Haste Academy.

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