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Encyclopaedia Topic: Atrial fibrillation

Introduction
The heart has two upper chambers and two lower chambers. The upper chambers are called atria and the lower
chambers ventricles. Atrial fibrillation is a condition in which the upper chambers of the heart contract at a very
high rate and in an entirely disorganised manner. Only the strongest impulses are passed down to the main lower
pumping chambers (the ventricles), so the pulse, which is caused by the contraction of the left ventricle, is
extremely irregular and of variable force.

Although established atrial fibrillation may sometimes appear in otherwise seemingly healthy people, research has
shown that people with the condition are significantly more at risk of heart trouble and strokes than others. Fifteen
per cent of all people who have had strokes have atrial fibrillation.

The upper and lower chambers of the heart have walls of almost pure muscle. When we talk of the heart beating,
we are really referring to the sudden tightening of this muscle so that the chambers become smaller and the blood
in them is squeezed out.

The control of the heartbeat starts with a small clump of muscle cells in the upper right chamber, called the
sinoatrial node. This acts as the hearts natural pacemaker by conveying electrical impulses to the atrioventricular
node, which is located in between the upper and lower chambers.

This determines the rate of contraction of the lower chambers (ventricles) and the pulse rate. Atrial fibrillation
occurs when the atrioventricular node receives more impulses than it can conduct and causes irregular squeezing
of the ventricles.
Symptoms
The most obvious symptom of atrial fibrillation is a completely irregular but fast heart-beat rate, usually over 140
beats per minute. In the early stages, affected people have palpitations and are aware of the irregularity of the
hearts action, but with time, if the condition persists, as it commonly does, most of them become accustomed to
the symptom and fail to notice it.

Atrial fibrillation inevitably reduces the efficiency and performance of the heart. Consequences of this may include
inadequate supply of blood to the heart, low blood pressure, disorder of the heart muscle, or even heart failure.
Causes
The condition mostly affects elderly people with high blood pressure, coronary artery disease that has affected the
heart muscle, and heart valve disease, especially abnormal narrowing of the valve between the atrium and the
ventricle on the left side of the heart (mitral stenosis). It may also affect middle-aged people who apparently have
no heart problems.

In people who do not apparently have structural heart disease, atrial fibrillation may be due to overactivity of the
thyroid gland, excessive alcohol intake, inflammation of the bag surrounding the heart (pericarditis) or
inflammation of the heart muscle. There is also a condition called sick sinus syndrome in which there is a
malfunction of the conducting system of the heart at the atrial level. This may feature fibrillation among other
forms of irregularity.

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Diagnosis
Atrial fibrillation can be strongly suspected simply by feeling the pulse, but a complete diagnosis calls for full
medical investigation.

One of the most important tests is the electrocardiograph (ECG). This device draws a tracing on a strip of paper to
give an accurate representation of the changes in electrical activity occurring in the heart, and can also give
evidence of any previous heart disease that may have been the cause of the condition. The irregularity of the
heart action is usually immediately obvious.

Routine blood tests can also be useful in the diagnosis. They may show anaemia, which may be complicating the
situation, impaired kidney function, or thyroid gland overactivity (thyrotoxicosis). A chest X-ray in a young patient
may suggest the presence of heart disease that may have been present from birth. In an older patient it can give
information on the size of the heart and whether heart failure is present.
Treatment
The treatment will vary from case to case and requires expert attention from a heart specialist (cardiologist). The
first step is to be sure whether the cause of the atrial fibrillation is known and can be treated. If so, this may be all
the treatment that is required.

The initial treatment is aimed at reducing the beating rate of the left ventricle to between 60 and 100 beats per
minute, by the use of drugs such as the heart-strengthening digoxin, the beta blockers [CC1] or the
calcium-channel blockers, or a combination of these drugs. Some combinations, however, can produce
dangerous slowing of the heart.

Anticoagulant drugs [CC2] are commonly used to prevent problems such as strokes from blood-clot embolism. In
any case that is diagnosed early, a decision also has to be made about whether to attempt to reverse the
fibrillation with electrical shock (cardioversion). This procedure is most likely to be successful when the atrial
fibrillation has lasted only a short time.

In patients who have had atrial fibrillation for more than two days, cardioversion is associated with an increased
risk of clot formation and embolism. In such cases anticoagulant treatment with warfarin [CC3] (a drug used to
prevent the blood from thickening into clots) is given for three weeks before cardioversion and for at least four
weeks afterwards. Electrical cardioversion has a success rate of more than 90% when given to those patients
who are most likely to benefit from it.

When anticoagulation treatment is required but there are medical reasons for not using warfarin or the patient
does not wish to take it, a good effect can be achieved from taking a quarter of a standard aspirin tablet (75 mg)
each day. Research suggests that in low-risk patients with atrial fibrillation, aspirin is as effective as warfarin in
preventing stroke.

There have been recent concerns about the effects of cranberry juice on the effectiveness of warfarin. The
Committee on Safety of Medicines is is currently reviewing reports, which suggest that cranberry juice acts to
increase the potency of warfarin and may therefore increase the risk of haemorrhage. Present advice is to avoid
or limit drinking cranberry juice if you are taking warfarin, until the situation has been investigated further.

Another possibility is to implant an artificial pacemaker to replace the job of the atrioventricular node. This
treatment may be considered in patients in whom medication is ineffective or unsuitable.
Complications
Because the blood in the upper chambers of the heart is not being carried through in a regular manner, there is a
tendency for blood clots to form in these chambers. These clots may then be swept into the ventricles and
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pumped into the lungs from the right side of the heart and into the general circulation from the left ventricle. Clots
(emboli) moving in the body will always block arteries, and this can be a serious matter.

The risk of stroke in patients with atrial fibrillation is about double that in the general population. The overall
incidence of stroke in these people is 5 per cent per year. This risk is increased with age, high blood pressure,
heart failure, diabetes and a history of embolism.
Prevention
Healthy life style, regular checks on blood pressure and treatment for raised blood pressure can reduce the
chances of developing the heart problems that cause atrial fibrillation.
References
Implantable cardioverter defibrillators: arrhythmias. A rapid and systematic review. Parkes J, Bryant J, Milne R.
Health Technology Assessment 2000, volume 4, number 26. http://www.ncchta.org/fullmono/mon426.pdf

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of
stroke or transient ischemic attacks (Cochrane Review). Benavente O et al. The Cochrane Library, Issue 1, 2002. http://www.upd

Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of
stroke or transient ischemic attacks (Cochrane Review). Benavente O et al. The Cochrane Library, Issue 1, 2002. http://www.upd

Anticoagulants versus antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and
a history of stroke or transient ischemic attacks (Cochrane Review). Koudstaal PJ. The Cochrane Library, Issue 1,
2002. http://www.update-software.com/abstracts/ab000187.htm

Antiplatelet therapy for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or
transient ischemic attacks (Cochrane Review). Koudstaal PJ. The Cochrane Library, Issue 1, 2002. http://www.update-software.c

Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or
transient ischemic attacks (Cochrane Review). Koudstaal PJ. The Cochrane Library, Issue 1, 2002. http://www.update-software.c

Electrical cardioversion for atrial fibrillation and flutter (Cochrane Review). Mead GE et al. The Cochrane Library,
Issue 1, 2002. http://www.update-software.com/abstracts/ab002903.htm

Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter (Cochrane Review). Segal JB
et al. The Cochrane Library, Issue 1, 2002. http://www.update-software.com/abstracts/ab001938.htm

Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in
chronic atrial fibrillation. The Copenhagen AFASAK study. The Lancet 1989, volume 1, pages 175-179.

Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five
randomized controlled trials on behalf of the Atrial Fibrillation Investigators (AFI). Archives of Internal Medicine
1994, volume 154, pages 1449-1457.

The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. The Boston
Area Anticoagulation Trial for Atrial Fibrillation (BAATAF). New England Journal of Medicine 1990, volume 323,
pages 1505-1511.

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Atrial fibrillation in general practice: how useful is echocardiography in selection of suitable patients for
anticoagulation? Cantley P et al. British Journal of General Practice 2000, volume 49, pages 219-220.

Primary prevention of arterial thromboembolism in non-rheumatic atrial fibrillation in primary care: randomised
controlled trial comparing two intensities of coumarin with aspirin. Hellemons BSP et al. British Medical Journal
1999, volume 319, pages 958-964.

Determinants of successful direct current cardioversion for atrial fibrillation and flutter: the importance of rapid
referral. Houghton AR. British Journal of General Practice 2000, volume 50, pages 710-711.

ABC of Atrial Fibrillation: Differential Diagnosis of Atrial Fibrillation. Lip GY, Watson RDS. British Medical Journal
1995, volume 311, pages 1495-1498. http://bmj.com/cgi/content/full/311/7018/1495

The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based
decision analysis. Protheroe J et al. British Medical Journal 2000, volume 320, pages 1380-1384. http://bmj.com/cgi/content/full/3

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