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Atrial Fibrillation

What is atrial fibrillation?

Atrial fibrillation, or AFib, is a kind of abnormal heart rhythm (arrhythmia). Normally, a specific group of cells begins the signal to start your heartbeat. These cells are in the sinoatrial (SA) node. This node is in the right atrium, the upper right chamber of the heart. The signal quickly travels down the heart’s conducting system. It travels to the upper-left filling chamber of the heart (left atrium) and to the left and right ventricle, the 2 lower pumping chambers of the heart. As it travels, the signal triggers the chambers of the heart to contract. The atria contract with each heartbeat to move blood into the ventricles.

During AFib, the signal to start the heartbeat is disorganized. This causes the atria to quiver (fibrillate). The disorganized signals are then transmitted to the ventricles. It causes them to contract irregularly and sometimes quickly. The contraction of the atria and the ventricles is no longer coordinated. The amount of blood pumped out to the body will vary with each heartbeat. The ventricles may not be able to pump blood efficiently to the body.

The quivering atria can lead to blood pooling. This increases the risk of forming blood clots. These clots can then travel to the brain, causing a stroke. This is why AFib greatly increases the risk for stroke.

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Sometimes AFib occurs briefly and then goes away. This is called paroxysmal atrial fibrillation. AFib that lasts for 7 days or longer is called persistent atrial fibrillation. AFib that lasts longer than a year is called long-standing persistent atrial fibrillation. Persistent AFib may be called permanent atrial fibrillation when a decision is made to no longer control the heart’s rhythm or despite best efforts, normal rhythm can't be restored.

AFib is common in adults. The risk increases with age. It is more common in men than women.

What causes atrial fibrillation?

AFib can happen from any type of problem that changes the way the heart handles electricity. Sometimes the cause is unknown. There is a range of things that can increase this risk. Some of the risks include:

  • Older age
  • High blood pressure
  • Coronary artery disease
  • Heart failure
  • Rheumatic heart disease from a past Streptococcus infection
  • Heart valve defects such as mitral valve prolapse with regurgitation
  • Pericarditis
  • Congenital heart defects
  • Sick sinus syndrome
  • Hyperthyroidism
  • Obesity
  • Diabetes
  • Lung disease
  • Obstructive sleep apnea
  • Metabolic syndrome
  • High-dose steroid therapy

AFib is also more likely to happen during an infection or right after surgery. Stress, caffeine, and alcohol may also set off attacks. People who do a lot of repeated vigorous endurance exercises, such as running marathons, can develop atrial fibrillation.

Certain people may be at greater risk of developing AFib. This is because of differences in genes they inherited from their parents. This is not yet fully understood.

Who is at risk for atrial fibrillation?

AF is more common in people who are over 65. It’s also more common in men than women. Underlying heart disease, high blood pressure, thyroid problems, too much alcohol use, sleep apnea, and certain lung disease put people at risk for atrial fibrillation.

What are the symptoms of atrial fibrillation?

AFib can cause different symptoms. This is especially true when it is not treated. These can include:

  • The feeling that your heart is skipping beats or beating too hard (heart palpitations)
  • Shortness of breath
  • Chest pain
  • Dizziness or fainting
  • Weakness and tiredness (fatigue)
  • Confusion
  • Swelling in the feet, ankles, and legs

Sometimes AFib has no symptoms. The first symptom of atrial fibrillation may be symptoms of a stroke.

How is atrial fibrillation diagnosed?

Diagnosis starts with a health history and physical exam. An internist or primary care healthcare provider will often makes the diagnosis. You may be sent to a cardiologist for more assessment and treatment.

An electrocardiogram (ECG) is very important for a diagnosis. Healthcare providers use this test to study the heart signal and rhythm. In some cases, the diagnosis can be made based on this test alone. If the AFib comes and goes, you might need an electrocardiogram over a longer period with a Holter monitor or an event recorder to pick up the rhythm. Sometimes you may have a small implanted heart recording device called implantable loop recorders put under the skin over the heart. This can monitor for AFib over several years.

Other tests might be used to help plan treatment. These might include:

  • Echocardiogram, to check the hearts structure and function
  • Cardiac stress testing, to check the blood flow in the heart
  • Blood work, to check for thyroid levels, diabetes, and possible health conditions
  • Sleep study, when obstructive sleep apnea is suspected

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How is atrial fibrillation treated?

Your healthcare providers will work with you to create a specific treatment plan. Treatment options vary according to your health history, your symptoms, and your preferences. Some people who don’t have any symptoms may not need a large amount of treatment. Some general categories of treatment include:

  • Blood-thinning (anticoagulant) medicines or aspirin, to help prevent stroke
  • Medicines to slow the heartbeat, such as beta-blockers, digoxin, and calcium channel blockers
  • Medicines to help prevent AFib (antiarrhythmics)
  • Treatment for the main cause of AFib, if known
  • Medicines to treat heart failure if present, such as ACE inhibitors

Before other treatment is started, you may first need a procedure called an electrical cardioversion. This can help get the heart back into a normal rhythm. It involves delivering a shock to the heart to stop the signal that is making the atria quiver. You may need a special echocardiogram called a trans-esophageal echocardiogram. This is to make sure you don't have a clot in your heart that could cause a stroke once if the cardioversion is successful.

Procedures such as catheter ablation or maze surgery may be used to restore normal rhythm if medicines and electrical cardioversion have not worked. Or they may be done if your doctor doesn't want you to take medicines long term. Catheter ablation uses either radiofrequency energy sent through a wire or a freezing balloon to destroy the small patch of heart tissue that causes AFib. Maze surgery uses cuts, ablations in the atria, or both to prevent AFib.

In some cases, the conduction node between the atria and the ventricles (AV node) will be destroyed using catheter ablation. This prevents the problem signals from passing to the ventricles. A pacemaker is then put in to control the heart rate and rhythm in the ventricles.

In the long term, treatment focuses on either controlling the heart rate or preventing the abnormal rhythm.

You may need to take a blood thinner.. What you are prescribed will depend on your risk for stroke. If you are at low risk, you may take daily aspirin or sometimes nothing at all. If you are at high risk, you will need a stronger blood thinner.

You will need regular follow-up for your AFib. Certain blood thinners need more frequent blood tests. You will need tests such as a prothrombin time (PT) if you take warfarin. This test measures the time it takes for your blood to clot. It records your reading as an international normalized ratio (INR). Your healthcare provider can change your medicine dose if needed. Newer blood thinners may call for periodic monitoring of your kidney function. A medical device called a left atrial appendage closure device may be considered to prevent stroke if you can't take blood thinners. It is designed to close off an area in the atrium where most blood clots form that cause stroke.

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What are the possible complications of atrial fibrillation?

Stroke and heart failure are the major complications of AFib. Blood can pool in the atria during AFib. This can cause a clot. This clot can travel to the brain and block a vessel there, causing a stroke. Blood-thinning medicines help reduce this risk.

AFib also sometimes causes heart failure. Because the ventricles are beating so irregularly, they can’t fill normally. The atria also can’t squeeze in the correct way. This also reduces filling in the ventricles. In some cases, this means the heart can’t pump enough blood to the body, causing heart failure. A rapid heart rate in AFib that's not treated will increase the risk for heart failure. Heart failure is treated with lifestyle changes, medicine, procedures, or surgery. Medicines that lower the heart rate will also help prevent heart failure.

AFib is also linked to an increased risk for dementia and a shorter lifespan.

Can atrial fibrillation be prevented?

Controlling risk factors for atrial fibrillation may prevent AFib from developing. This includes managing underlying heart disease, high blood pressure, thyroid problems, sleep apnea, and lung diseases. Risk factor control also means making healthy lifestyle choices. These choices include eating a healthy diet, exercising regularly, maintaining a healthy weight, and not smoking. Drink alcohol only in moderation, if at all. If you have an alcohol abuse problem, consider getting help.

How can I manage atrial fibrillation?

There are steps you can take to help you manage your AFib and maintain a healthy lifestyle. 

  • Eat about the same amount of certain foods such as green leafy vegetables if you are taking warfarin.
  • Eat a heart-healthy diet.
  • Don't smoke.
  • Be physically active and maintain a healthy weight.
  • Keep your cholesterol at healthy levels with lifestyle and medicine.
  • Don't use alcohol or caffeine. They can trigger heart rhythm problems.
  • Don't use certain over-the-counter medicines. They can trigger heart rhythm problems.
  • Make sure all your healthcare providers, dentists, and pharmacists know if you are taking a medicine to prevent blood clots.
  • If you miss a dose of a blood-thinning medicine, don't double up your dose. Ask your healthcare provider what you should do.

When should I call my healthcare provider?

Get emergency medical care if you have severe symptoms such as chest pain or sudden shortness of breath. Also get help if you have signs of severe bleeding.

See your healthcare provider soon if your symptoms are gradually getting worse, or if you have any new mild symptoms or side effects.

Key points about atrial fibrillation

  • AFib is the most common abnormal heart rhythm. The atria quiver instead of contracting the way they should. The heart rate usually increases. It is a serious condition, but most people with AFib can lead normal, active lives. You will need to be checked regularly.
  • Follow all of your healthcare provider’s instructions about medicines, lifestyle, and monitoring.
  • You may be treated with medicine to control your heart rate or rhythm.
  • You may need blood-thinning medicine to help prevent a stroke.
  • If you take certain blood thinners, you will need frequent blood tests and monitoring.
  • Go to all your healthcare provider appointments.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.
Online Medical Reviewer: Lu Cunningham
Online Medical Reviewer: Mandy Snyder APRN
Online Medical Reviewer: Steven Kang MD
Date Last Reviewed: 8/1/2018
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