Atrial Fibrillation

“Atrial fibrillation (A-Fib) is the world’s most common cardiac

arrhythmia, affecting more than 2.2 million Americans and millions of
people worldwide”1(Fuster and Ryden et al, 2001).

Each year, approximately 160,000 people in the US are diagnosed with A-Fib.
Although A-Fib itself is not life-threatening, it is considered a medical
emergency and can lead to complications such as stroke and heart
failure. It is important to understand what A-fib is, how it is diagnosed
and how it can be treated in order to prevent progression of this very
serious cardiac disease.

What is A-Fib?

Atrial fibrillation is type of abnormal heart rhythm and involves the two
upper chambers (atria) of the heart. Its name comes from the fibrillating
(i.e.,quivering) of the heart muscles of the atria, instead of a coordinated
contraction. In A-Fib, the normal electrical impulses that are generated
by the sinoatrial node are overwhelmed by disorganized electrical
impulses that originate in the atria, (the atrial rate may be as hight as 300
to 600 times each minute),and only a limited number of impulses
successfully reach the ventricles. The result is an irregular heartbeat,
which may occur in episodes, or it can occur all the time for years.
American College of Cardiology (ACC), American Heart Association
(AHA) and European Society of Cardiology (ESC) recommend in their
guidelines the following classification system base on simplicity and
clinical relevance.2

First detected AF – only one diagnosed episode.

Paroxysmal AF – recurrent episodes that self terminate in less the 7 days.

Persistent AF – recurrent episodes that last more than 7 days.

Permanent – an ongoing long-term episode

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Most common causes of AF are hypertension, coronary artery disease, diseased
heart valves, post-heart surgery, chronic lung disease, heart failure,
congenital heart disease. Less frequent causes are hyperthyroidism,
pericarditis, and viral infection.

What are the symptoms and the risk of AF?

Some people with AF have no symptoms. Others will experience

palpitations, fatigue, lightheadedness or dizziness, uncomfortable feeling
in the chest, shortness of breath (even at rest).

Rapid heart rate may result in the heart being unable to provide adequate blood
flow and oxygen delivery to the rest of the body. Therefore, common
symptoms may include shortness of breath which often worsens with
exertion (dyspnea on exertion), shortness of breath even when lying flat.
Due to inadequate blood flow, patients may also complain of light-
headedness, may feel like they are about to faint (presyncope), or may
actually lose consciousness (syncope)3

People with AF usually have a significantly increased risk of stroke (up to 7

times that of the general population) because blood may pool and form
clots in the poorly contracting atria.

Atrial fibrillation also reduces the ability of the heart to pump effectively by
about 20 – 25 %. When the heart is unable to pump enough blood, the
body begins to compesate by retaining fluid. Fluid accumulates in the
lower legs (edema) and the lungs (pulmonary edema). Pulmonary edema
makes breathing more difficult a reduces the ability of the lungs to add
oxygen to and remove carbon dioxide from the blood. This life-
treatening complication is called heart failure.

Reduced quality of life associated with a lack of energy, and other symptoms.
With untreated A-Fib, it is often difficult to be active.

Dx and tx

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 A number of test are available to diagnose Atrial Fibrilation. An ECG
can be performed to diagnose atrial fibrillation. Characteristic findings
are the absence of P waves, with unorganized electrical activity in their
place, and irregular R-R intervals due to irregular conduction of
impulses to the ventricles. If paroxysmal A-Fib is suspected but an ECG
during an office visit only shows a regular rhythm, A-Fib episodes may
be detected and documented with the use of ambulatory Holter
monitoring (24 hrs ECG). If the episodes are too infrequent to be
detected by Holter monitoring, then patient can be monitored for longer
periods ((a month) with an ambulatory event monitor. Ultrasound-based
scan Echocardiogram of the heart may help indentify left and right atrial
size, valvular heart disease, left ventricular size and function, pulmonary
hypertension, presence of thrombus and pericardial disease. Significant
enlargement of both the left and right atria is associated with long-
standing atrial fibrillation

The main goals of treatment are to return the heart to a normal sinus rhythm if
possible. Besides the use of blood thinners, there are 2 types of
medications that are used to treat atrial fibrillation. Medications that
control heart rhythm and may restore the normal heart rate beat if taken
during an episode of atrial fibrillation (Rythmol, Flecainide, amiodarone)
and medication that control heart rate (Digoxin, beta-blockers, atenolol,
metoprolol and calcium channel blockers). Prevention of rapid heart
beat during atrial fibrillation often makes the symptoms less severe.
Another effective and useful way to restore a normal heart rhythm is
electrical cardioversion, but only if the atrial fibrillation has not been
present for a long time. If the atrial fibrillation has been present for more
than a few months, there is a high probability that it will return shortly
after cardioversion. In some patients with atrial fibrillations, medications
or cardioversion are not effective in preventing episodes or in controlling
heart rate. Catheter ablation is a catheter technique intended to cure atrial
fibrillation without major surgery. Specially designed catheter is used to
cauterize the “short circuits” that are generating the atrial fibrillation.
AV node ablation is another procedure to eliminate the rapid and
irrgegular heart beat. This procedure is performed only in patients who
do not respond to medications or cannot take them because of side
effects. Radiofrequency catheter destroys the AV node. The patient
requires a permanent pacemaker and anticoagulant medication. Because
this is not the most desired treatment option, it is not used to treat A-Fib
often. Pacemakers are devices that monitor and regulate the rhythm of
the heart. Implanted beneath the skin, they transmit electrical impulses to
stimulate the heart if it beats too slowly.

Although Atrial Fibrilation is not directly life threatening if left

untreated it may