Atrial fibrillation

Definition
Atrial fibrillation is increasingly common with advancing age. During atrial fibrillation, the heart's
two upper chambers (the atria) beat chaotically and irregularly out of coordination with the two
lower chambers (the ventricles) of the heart. The result is an irregular and often rapid heart rate
that causes poor blood flow to the body and symptoms of heart palpitations, shortness of breath
and weakness. Most people with atrial fibrillation have an increased risk of developing blood clots
that may lead to stroke.
Atrial fibrillation is a common heart rhythm problem. More than 2 million Americans have atrial
fibrillation, which can cause palpitations, shortness of breath, fatigue and stroke.
Atrial fibrillation is often caused by changes in your heart that occur as a result of heart disease or
high blood pressure. Episodes of atrial fibrillation can come and go, or you may have chronic
atrial fibrillation.
Although atrial fibrillation usually isn't life-threatening, it can lead to complications. Treatments for
atrial fibrillation may include medications and other interventions to try to alter the heart's
electrical system.

Symptoms
A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump an adequate
amount of blood out to your body with each heartbeat, causing a drop in your blood pressure.
Some people with atrial fibrillation have no symptoms and are unaware of their condition until
their doctor discovers it during a physical examination. Those who do have symptoms may
experience:

Palpitations, which are sensations of a racing, uncomfortable, irregular

heartbeat or a flopping in your chest
Weakness
Lightheadedness
Confusion
Shortness of breath
Chest pain

Atrial fibrillation may be:

Sporadic. In this case it's called paroxysmal (par-ok-SIZ-mul) atrial

fibrillation. You may have symptoms that come and go, lasting for a few
minutes to hours and then stopping on their own.

Chronic. With chronic atrial fibrillation, symptoms may last until they're
treated.

Causes
Normal heartbeat

A normal heartbeat begins when a tiny cluster of cells called the sinus node sends
an electrical signal (1). The signal then travels through the atria and passes
through another group of cells called the atrioventricular node (2). From the
atrioventricular node, the signal travels through the ventricles (3), causing them to
contract and pump out blood. After this, the process starts over (4).

Atrial fibrillation

Electrical signals fire from multiple locations in the atria, causing abnormal
quivering of the atria. (1). The atrioventricular node your heart's natural
pacemaker is unable to prevent all of these chaotic signals from entering the
ventricles (2). Your ventricles respond to these extra, chaotic signals by beating
faster than normal. (3).

To pump blood, your heart muscles must contract and relax in a coordinated rhythm. Contraction
and relaxation are controlled by electrical signals that travel through your heart muscles.
Your heart consists of four chambers two upper chambers (atria) and two lower chambers
(ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called
the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that
starts each heartbeat.
Normally, the impulse travels first through the atria, then through a connecting pathway between
the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal
passes through the atria, they contract, pumping blood from your atria into the ventricles below. A
split second later, as the signal passes through the AV node through the right and left bundle
branches to the ventricles, the ventricles contract, pumping blood out to your body.
In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals.
As a result, they quiver. The AV node the electrical connection between the atria and the
ventricles is overloaded with impulses trying to get through to the ventricles. The ventricles
also beat rapidly, but not as rapidly as the atria. The reason is because the AV node is like a
highway on-ramp only so many cars can get on at one time. The result is an irregular and fast
heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The
normal range for a heart rate is 60 to 100 beats a minute.

Possible causes
Abnormalities or damage to the heart's structure is the most common cause of atrial fibrillation.
Diseases affecting the heart's valves or pumping system are common causes, as is long-term
high blood pressure. However, some people who have atrial fibrillation don't have underlying
structural heart disease, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause
is often unclear. Serious complications are usually rare in lone atrial fibrillation.
Possible causes of atrial fibrillation include:

High blood pressure

Heart attacks
Abnormal heart valves
Congenital heart defects
An overactive thyroid or other metabolic imbalance
Exposure to stimulants, such as medications, caffeine or tobacco, or to
alcohol
Sick sinus syndrome this occurs when the heart's natural pacemaker
stops functioning properly
Emphysema or other lung diseases
Previous heart surgery
Viral infections
Stress due to pneumonia, surgery or other illnesses
Sleep apnea

Risk factors

Age. The older you are, the greater your risk of developing atrial
fibrillation. As you age, the electrical and structural properties of the atria
can change. This may lead to the breakdown of the normal atrial rhythm.

Heart disease. Anyone with heart disease, including valve problems,

history of heart attack and heart surgery, faces an increased risk of atrial
fibrillation.

Other chronic conditions. People with thyroid problems, high blood

pressure, sleep apnea and other medical problems have an elevated risk
of atrial fibrillation.

Alcohol use. Use of alcohol, especially binge drinking, can trigger an

episode of atrial fibrillation.

Family history. An increased risk of atrial fibrillation runs in some

families. In some of these cases, specific genes have been identified as
the likely cause of atrial fibrillation.

Tests and diagnosis

To make a diagnosis of atrial fibrillation, your doctor may do tests that involve the following:

Electrocardiogram (ECG). Patches with wires (electrodes) are attached

to your skin to measure electrical impulses given off by your heart.
Impulses are recorded as waves displayed on a monitor or printed on
paper.

Holter monitor. This is a portable machine that records all of your

heartbeats. You wear the monitor under your clothing. It records
information about the electrical activity of your heart as you go about your
normal activities for a day or two. You can press a button if you feel
symptoms, and then your doctor can figure out what heart rhythm was
present at that moment.

Event recorder. This device is similar to a Holter monitor except all of

your heartbeats are not recorded. There are two recorder types: One uses
a phone to transmit signals from the recorder while you're experiencing
symptoms. The other type is worn all the time (except while showering) for
as long as a month. Event recorders are especially useful in diagnosing
rhythm disturbances that occur at unpredictable times.

Echocardiogram. In this test, sound waves are used to produce a video

image of your heart. Sound waves are directed at your heart from a wandlike device (transducer) that's held on your chest. The sound waves that
bounce off your heart are reflected back through your chest wall and
processed electronically to provide video images of your heart in motion to
detect underlying structural heart disease.

Blood tests. These help your doctor rule out thyroid problems or blood
chemistry abnormalities that may lead to atrial fibrillation.

Complications
Sometimes, atrial fibrillation can lead to the following complications:

Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to pool in
your atria and form clots. If a blood clot forms, it could dislodge from your
heart and travel to your brain. There it might block arterial blood flow,
causing a stroke. The risk of stroke in atrial fibrillation depends on your
age (you have a higher risk as you age) and on whether you have high
blood pressure or a history of heart failure or previous stroke, and other
factors. Most people with atrial fibrillation have a much greater risk of
stroke than do those who don't have atrial fibrillation. Medications such as
blood thinners can greatly lower your risk of stroke or damage to other
organs caused by blood clots.

Heart failure. Atrial fibrillation alone, especially if not controlled, may

weaken the heart, leading to heart failure a condition in which your
heart can't circulate enough blood to meet your body's needs.

Treatments and drugs

Treatments for atrial fibrillation include medications and procedures that attempt to either reset
the heart rhythm back to normal or control the heart rate so that the heart doesn't beat
dangerously fast, though it may still beat irregularly. Treatments also include blood thinners to
prevent blood clots.
The treatment option best for you will depend on how long you've had atrial fibrillation, how
bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the
goals of treating atrial fibrillation are to:

Reset the rhythm or control the rate

Prevent blood clots

Sometimes atrial fibrillation will correct or "reset" itself. In some people, a specific event or an
underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. If the condition that
triggered your atrial fibrillation can be treated, you might not have any more heart rhythm
problems or at least not for quite some time. If your symptoms are bothersome or if this is your
first episode of atrial fibrillation, your doctor may attempt to reset the rhythm. Or it may be best to
simply take medications to control the heart rate and prevent blood clots.
The best strategy for you depends on many factors, including whether you have other problems
with your heart and how well you tolerate the medications available to treat atrial fibrillation or
control the rate. In some cases, you may need a more invasive treatment, such as catheter or
surgical techniques.
Resetting the rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. This can be
accomplished in some cases, depending on the underlying cause of atrial fibrillation and how long
you've had it. To correct atrial fibrillation, doctors may be able to reset your heart to its regular
rhythm (sinus rhythm) using a procedure called cardioversion. Cardioversion can be done in two
ways:

Cardioversion with drugs. This form of cardioversion uses medications

called anti-arrhythmics to help restore normal sinus rhythm. Depending on
your heart condition, your doctor may recommend trying intravenous or
oral medications to return your heart to normal rhythm. This is often done
in the hospital with continuous monitoring of your heart rate. If your heart
rhythm returns to normal, your doctor often will prescribe the same antiarrhythmic or a similar one long term to try to prevent recurrent spells of
atrial fibrillation.

Electrical cardioversion. In this brief procedure, an electrical shock is

delivered to your heart through paddles or patches placed on your chest.
The shock stops your heart's electrical activity for a split second. When
your heart begins again, the hope is that it resumes its normal rhythm. The
procedure is performed under anesthesia.

Before undergoing cardioversion, you may be given a blood-thinning medication, such as warfarin
(Coumadin), for several weeks to reduce the risk of blood clots and stroke. Alternatively, you may
undergo transesophageal echocardiography a test to exclude the presence of a blood clot

just before cardioversion. In transesophageal echocardiography, a tube is passed down your

esophagus and detailed ultrasound images are made of your heart. Unless the episode of atrial
fibrillation lasted less than 24 hours, you will require warfarin for at least four to six weeks after
cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm.
Maintaining normal rhythm
After electrical cardioversion, anti-arrhythmics often are prescribed to help prevent future
episodes of atrial fibrillation. Commonly used medications include amiodarone (Cordarone,
Pacerone), propafenone (Rythmol), procainamide (Procanbid) and dofetilide (Tikosyn). Although
these drugs can help maintain sinus rhythm in many people, they can cause side effects, such as
nausea, dizziness and fatigue. In rare instances, they may cause ventricular arrhythmias lifethreatening rhythm disturbances originating in the heart's lower chambers. These medications
may be needed indefinitely. Unfortunately, even with medications, the chance of another episode
of atrial fibrillation is high.
Rate control
Sometimes atrial fibrillation can't be converted back to a normal heart rhythm. Then the goal is to
slow the heart rate (rate control). Traditionally, doctors have prescribed the medication digoxin
(Lanoxin). It can control heart rate at rest but not as well during activity. Most people require
additional or alternative medications, such as calcium channel blockers or beta blockers. In
general, your heart rate should be between 60 and 100 beats a minute when you're at rest. Your
doctor can give you guidelines for your maximal heart rate.
Some people may not be able to tolerate medications, or medications don't work to control the
heart rate. In these cases, AV node ablationmay be an option.
AV node ablation involves applying radio frequency energy to your atrioventricular (AV) node
through a long, thin tube (catheter) to destroy this small area of tissue. The procedure prevents
the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though,
and anticoagulant medication is still required. A pacemaker is then implanted to establish a
normal rhythm.After AV node ablation, you'll need to continue to take anticoagulant medications
to reduce the risk of stroke because your heart is still in atrial fibrillation.
Surgical and catheter interventions
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases,
your doctor may recommend a procedure to destroy the area of heart tissue responsible for the
erratic electrical signals and restore your heart to a normal rhythm. These options can include:

Radiofrequency catheter ablation. In many people who have atrial

fibrillation and an otherwise normal heart, atrial fibrillation is caused by
rapidly discharging triggers, or "hot spots." These hot spots are like
abnormal pacemaker cells that fire so rapidly that the atria fibrillate. When
present, these triggers are most commonly found in the pulmonary veins,
the veins that return blood from the lungs to the heart. Radio frequency
energy directed to these hot spots through a catheter (called
radiofrequency ablation, pulmonary vein ablation or pulmonary vein
isolation) may be used to destroy these hot spots, scarring the tissue and
thereby disrupting the erratic electrical signals. This eliminates the
arrhythmia without the need for medications or implantable devices. In
some cases, additional spots are treated in your heart depending on
the electrical circuits found and sometimes other types of catheters that
can freeze the heart tissue (cryotherapy) are used.
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Surgical maze procedure. The maze procedure is often done during an open-heart
surgery. Using a scalpel, doctors create several precise incisions in the atria to create a
pattern or maze of scar tissue. Because scar tissue doesn't carry electricity, it interferes
with stray electrical impulses that cause atrial fibrillation. Radio frequency or cryotherapy
can also be used, and there are several variations of the surgical maze technique. The
procedure has a high success rate, but because it usually requires open-heart surgery,
it's generally reserved for people who don't respond to other treatments or when it can be
done during other necessary heart surgery, such as coronary artery bypass surgery or
heart valve repair. Some people require a pacemaker after the procedure.
Newer and less invasive techniques are being developed to create the atrial scar tissue.
Doctors at some centers use radio frequency or cryotherapy applied to the outside
surface of the heart through a small chest incision or through a scope placed into the
chest cavity (thorascopic approach). Microwave, laser and ultrasound energy are also
being studied as options to perform the maze procedure.

Preventing blood clots

Most people who have atrial fibrillation or who are undergoing certain treatment for atrial
fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher
if other heart disease is present along with atrial fibrillation. Your doctor may prescribe bloodthinning medications (anticoagulants), such as warfarin (Coumadin) or aspirin, in addition to
medications designed to treat your irregular heartbeat. Many people have spells of atrial
fibrillation and don't even know it so you may need lifelong anticoagulants even after your
rhythm has been restored to normal.
Atrial flutter
Atrial flutter is similar to atrial fibrillation, but slower. If you have atrial flutter, the abnormal heart
rhythm in your atria is more organized and less chaotic than in the abnormal patterns common
with atrial fibrillation. Sometimes you may have atrial flutter that develops into atrial fibrillation and
vice versa. The symptoms, causes and risk factors of atrial flutter are similar to atrial fibrillation.
For example, strokes are a common concern in someone with atrial flutter.
One difference between atrial flutter and atrial fibrillation is that many people with atrial flutter
respond better to treatment such as catheter ablation. As with atrial fibrillation, atrial flutter is
usually not life-threatening when it's properly treated.

Lifestyle and home remedies

There are some things you can do to try and prevent recurrent spells of atrial fibrillation. You may
need to reduce or eliminate your intake of caffeine and alcohol, which can overstimulate the heart
and trigger an episode of atrial fibrillation. It's also important to be careful when taking over-thecounter (OTC) medications. Some, such as cold medicines containing pseudoephedrine, contain
stimulants that can trigger atrial fibrillation. Also, some OTC medications adversely interact with
anti-arrhythmic medications.

You may need to make lifestyle changes that improve the overall health of your heart, especially
to prevent or treat conditions such as high blood pressure. Your doctor may advise that you:

Eat heart-healthy foods

Reduce your salt intake, which can help lower blood pressure
Increase your physical activity
Quit smoking
Avoid alcohol

Atrial Fibrillation
Atrial Fibrillation Overview
Atrial fibrillation describes an irregular and often rapid heart rhythm. The irregular rhythm, or
arrhythmia, results from abnormal electrical impulses in the heart. The irregularity can be
continuous, or it can come and go.
Normal heart contractions begin as an electrical impulse in the right atrium. This impulse comes
from an area of the atrium called the sinoatrial (SA) or sinus node, the "natural pacemaker."

As the impulse travels through the atrium, it produces a wave of muscle

contractions. This causes the atria to contract.

The impulse reaches the atrioventricular (AV) node in the muscle wall between
the 2 ventricles. There, it pauses, giving blood from the atria time to enter the
ventricles.

The impulse then continues into the ventricles, causing ventricular contraction
that pushes the blood out of the heart, completing a single heartbeat.

In a person with a normal heart rate and rhythm the heart beats 50-100 times per minute.

If the heart beats more than 100 times per minute, the heart rate is considered fast
(tachycardia).

If the heart beats less than 50 times per minute, the heart rate is considered slow
(bradycardia).

In atrial fibrillation, multiple impulses travel through the atria at the same time.

Instead of a coordinated contraction, the atrial contractions are irregular,

disorganized, chaotic, and very rapid. The atria may contract at a rate of 400-600
per minute.

These irregular impulses reach the AV node in rapid succession, but not all of
them make it past the AV node. Therefore, the ventricles beat slower, often at
rates of 110-180 beats per minute in an irregular rhythm.

The resulting rapid, irregular heartbeat causes an irregular pulse and sometimes a
sensation of fluttering in the chest.

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Atrial fibrillation can occur in several different patterns.

Intermittent (paroxysmal): The heart develops atrial fibrillation and typically

converts back again spontaneously to normal (sinus) rhythm. The episodes may
last anywhere from seconds to days.

Persistent: Atrial fibrillation occurs in episodes, but the arrhythmia does not
convert back to sinus rhythm spontaneously. Medical treatment is required to end
the episode.

Permanent: The heart is always in atrial fibrillation. Conversion back to sinus

rhythm either is not possible or is deemed not appropriate for medical reasons.

Atrial fibrillation, often called A Fib, is a very common heart rhythm disorder.

It affects about 1% of the population, mostly people older than 50 years. This
amounts to more than 2 million people.

The risk of developing atrial fibrillation increases as we get older. About 5% of

people older than 80 years have atrial fibrillation.

For many people, atrial fibrillation may cause symptoms but does no harm.

Complications can arise, but appropriate treatment reduces these risks.

If treated properly, atrial fibrillation rarely causes serious or life-threatening

problems.

Atrial Fibrillation Causes

Atrial fibrillation may occur without evidence of underlying heart disease. This is more common in
younger people, about half of whom have no other heart problems. This is often called lone atrial
fibrillation. Some of the causes not involving the heart include the following:

Hyperthyroidism (overactive thyroid)

Alcohol use (holiday heart)

Pulmonary embolism (a blood clot in the lungs)

Pneumonia

Most commonly, atrial fibrillation occurs as a result of some other cardiac condition
(secondary atrial fibrillation).
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Heart valve disease: This can be something you are born with or be caused by
infection or degeneration/calcification of valves with age.

Enlargement of the left ventricle walls (left ventricular hypertrophy)

Coronary heart disease (or coronary artery disease): This results from
atherosclerosis, deposits of fatty material inside the arteries that cause blockage or
narrowing of the arteries.

High blood pressure (hypertension)

Cardiomyopathy (disease of the heart muscle) leading to congestive heart failure

Sick sinus syndrome (improper production of electrical impulses because of

malfunction of the SA node)

Pericarditis (inflammation of the sac surrounding the heart)

Atrial fibrillation frequently occurs after cardiothoracic (open heart) surgery, but often resolves in a
few days.
For many people with infrequent and brief episodes of atrial fibrillation, the episodes are brought
on by a number of triggers. Because some of these involve excessive alcohol intake, this is
sometimes called holiday heart. Some of these people are able to avoid episodes or have fewer
episodes by avoiding their trigger. Common triggers include alcohol and caffeine in susceptible
individuals.

Atrial Fibrillation Symptoms

Symptoms of atrial fibrillation vary from person to person.

A number of people have no symptoms.

The most common symptom in people with intermittent atrial fibrillation is

palpitations, a sensation of rapid or irregular heartbeat. This may make some
people very anxious. Many people also describe an irregular fluttering sensation
in their chests.

Some become light-headed or faint.

Other symptoms include weakness, lack of energy or shortness of breath with

effort, and chest pain.

When to Seek Medical Care

Call for treatment within 24 hours if you have atrial fibrillation that comes and goes, have
previously been evaluated and treated, and are not experiencing chest pain, shortness of breath,
weakness, or fainting.

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Call if you have persistent atrial fibrillation while you are on medical therapy for the condition or
you note worsening of your symptoms, or new symptoms such as fatigue or mild shortness of
breath.
Call if you have questions about medications and dosages.
Call 911 for emergency medical services when atrial fibrillation occurs with any of the following:

Severe shortness of breath

Chest pain

Fainting or light headedness

Weakness

Very rapid heartbeat or palpitations

Not all heart palpitations are atrial fibrillation, but a continuing feeling of your heart fluttering in
your chest together with a fast or slow pulse should be evaluated by your doctor or at a hospital
emergency department.

Exams and Tests

The evaluation may include the following tests:
Electrocardiogram(ECG): This is the primary test to determine when an arrhythmia is atrial
fibrillation. The test can also sometimes reveal damage to the heart, if there is any.
Lab tests: There is no lab test that can confirm that you have atrial fibrillation. Tests are done to
check for certain underlying causes of atrial fibrillation and to rule out heart damage, as from a
heart attack. If you are already taking medication for atrial fibrillation, a drug level may be
checked to make sure there is enough of the drug in your system to work.

Complete blood cell count

Markers for heart injury (enzymes such as troponins and creatine kinase [CK])

Digoxin drug level (in patients taking this medication)

Prothrombin time (PT) and international normalized ratio (INR): If you are taking
warfarin (Coumadin) to prevent blood clotting, these tests show how well the
drug is working to lower your risk of a blood clot.

Serum electrolytes to evaluate sodium and potassium levels

Thyroid function tests for hyperthyroidism

Chest x-ray: This imagery is used to evaluate for complications such as fluid in the lungs or to
estimate heart size

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Echocardiogram or transesophageal echocardiogram: This is an ultrasound test that uses sound

waves to make a picture of the inside of the heart while it is beating.

This test is done to identify problems in heart valves or ventricular function or to

look for blood clots in the atria.

This very safe test uses the same technique used to check a fetus in pregnancy.

Ambulatory electrocardiogram (ECG): This test involves wearing a monitor for a period of time
(usually 24-48 hours) to try to document the arrhythmia while you go about your everyday
activities.

The device you wear for 24 to 48 hours is called a Holter monitor.

An Event monitor is a device that can be worn for 1-2 weeks and records the heart
rhythm when it is activated by the patient.

These tests may be used if your symptoms come and go and your ECGs do not
reveal the arrhythmia.

Atrial Fibrillation Treatment

In making the diagnosis, your health care provider will consider the severity of symptoms and
whether they are new or have been going on for some time. You may be referred to a specialist in
heart disorders (cardiologist) during this evaluation. Choice of treatment for atrial fibrillation
depends on the type you have, the severity of your symptoms, the underlying cause, and your
overall health.

Self-Care at Home
There is no effective home treatment for atrial fibrillation. If your doctor recommends
lifestyle changes or prescribes medicine, follow his or her recommendations exactly. This
is the only way to see whether the treatment works.
Medical Treatment
Treatment for atrial fibrillation traditionally seeks three goals: to slow down the heart rate, to
restore and maintain normal heart rhythm, and to prevent stroke.

Control rate: The first treatment goal is to slow down the ventricular rate, if it is
fast.

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If you experience serious clinical symptoms, such as chest pain or

shortness of breath related to the ventricular rate, the health care provider
in the emergency department will decrease your heart rate rapidly with IV
medications.

If you have no serious symptoms, you may be given medications by

mouth.

Sometimes you may require a combination of oral medications to control

your heart rate.

Restore and maintain normal rhythm: About half the people with newly diagnosed
atrial fibrillation will convert to normal rhythm spontaneously in 24-48 hours.
However, atrial fibrillation typically returns.

As already mentioned, not everyone with atrial fibrillation needs to take

medication to maintain normal rhythm.

The frequency with which your arrhythmia returns and the symptoms it
causes partly determine whether you receive rhythm-controlling
medication, which is usually called anti-arrhythmia medication.

Medical professionals tailor each person's anti-arrhythmia medication(s)

carefully to produce the desired effect without making the dose too high.

Most of these medications cause unwanted side effects, which limit their
use. These medications should be discussed with a doctor.

Prevent stroke: Stroke is a devastating complication of atrial fibrillation. It occurs

when a piece of a blood clot formed in the heart breaks off and travels to the
brain, where it blocks blood flow.

Coexisting medical conditions, such as hypertension, congestive heart

failure, heart valve abnormalities, or coronary heart disease, significantly
increase the risk of stroke. Age older than 65 years also increases the risk
of stroke.

Most people with atrial fibrillation take a blood-thinning drug called

warfarin (Coumadin) to lower this risk. Warfarin blocks certain factors in
the blood that promote clotting. Acutely, the initial blood thinner is IV or
subcutaneous heparin to thin your blood rapidly, then a decision is made
whether you need oral warfarin.

People at lower risk of stroke and those who cannot take warfarin may use
aspirin. Aspirin is not without its own side effects, including bleeding
problems and stomach ulcers.

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Defibrillation (cardioversion): This technique uses electrical current to "shock" the heart back to
normal sinus rhythm. This is sometimes called DC cardioversion.

This is done by connecting a device called an external defibrillator to the chest

with patches or paddles.

When this is performed in a hospital, an anesthetic is given first so the patient is

fully sedated and asleep during the procedure because the electrical discharge is
painful.

Defibrillation works very well; more than 90% of people convert to sinus rhythm.
It is most successful if your atrial fibrillation is new (that is, hours, days, or a few
weeks). For many, however, this is not a permanent solution because the
arrhythmia often comes back.

Defibrillation increases the risk of stroke and thus requires pretreatment with an
anticoagulant medication.

Catheter ablation (radiofrequency [RF] ablation). This technique electrically burns/destroys some
of the abnormal conduction pathways in the atria.

The catheter delivers radiofrequency energy, which interrupts (ablates) a portion

of the abnormal electrical conduction pathway. This inactivates the abnormal
pathway to provide more consistent flow of electrical impulses.

In atrial fibrillation, RF ablation is a relatively new procedure and is currently best

reserved for patients who have tried antiarrhythmic medications without success
or who cannot take these medications. Current success rates are in the 60-70%
range. However, serious complications associated with the procedure can occur,
and these need to be discussed carefully with the doctor before undergoing this
procedure.

Pacemaker: A pacemaker is an electronic device that prevents slow heartbeats, and may reduce
the likelihood of atrial fibrillation in a small number of patients. The artificial pacemaker takes the
place of the "natural pacemaker," the SA node, supplying electrical impulses to keep the heart
beating in a normal rhythm when the SA node no longer can.

The pacemaker is usually implanted in both the right atrium and right ventricle.
The goal is to override your own atrial fibrillation with a new atrial electrical
pacemaker, and turn off your own, native arrhythmic focus. A minority of patients
are offered this technique currently. This is a more complex technique and device,
and no long-term data regarding success is available yet.

A pacemaker is occasionally used in conjunction with radiofrequency ablation of

the AV node, which disconnects the atria from the ventricle, so rapid heart rates
cannot be conducted to the ventricles. This creates complete heart block, and now
the ventricles are totally dependent on the artificial, electrical pacemaker in the
right ventricle.

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Some machines and devices in your surroundings can interfere with the
production of electrical impulses by your pacemaker. For example, airport
security devices can deactivate pacemakers. Be sure you are familiar with which
types of devices may have this effect, and avoid those devices.

Carry an identification card that shows that you have a pacemaker. You will need
to present this identification when going through airport security and ask to be
hand searched as some security machines may inactivate pacemakers. Always tell
any medical or dental personnel that you have a pacemaker.

Medications
The choice of medication depends on the type of atrial fibrillation you have, the underlying cause,
your other medical conditions and overall health, and the other medications you take. Ironically,
many anti-arrhythmia medications may induce abnormal heart rhythms.
Anti-arrhythmia medications

Miscellaneous anti-arrhythmia medications: These drugs control the heart rhythm

rather than rate. They reduce the frequency and duration of atrial fibrillation
episodes. They are often given to prevent return of atrial fibrillation after
cardioversion. The most commonly used drugs are amiodarone (Cordarone,
Pacerone), sotalol (Betapace), propafenone (Rythmol), and flecainide
(Tambocor). Overall, these drugs are 50-70% effective.

Beta-blockers: These drugs slow the heart rate by decreasing the rate of the SA
node and by slowing conduction through the AV node. Therefore, the heart's
demand for oxygen is decreased, and the blood pressure is stabilized. Examples
include propranolol (Inderal) or metoprolol (Lopressor Toprol XL).

Calcium channel blockers: These drugs also slow heart rate by similar
mechanisms as beta-blockers. Verapamil (Calan, Isoptin) and diltiazem
(Cardizem) are examples of calcium channel blockers.

Digoxin (Lanoxin): This drug decreases the conductivity of electrical impulses

through the AV node, but onset of action is slower than beta-blockers and
calcium-blockers. Digoxin is currently used primarily in patients with associated
heart disease, such as a poorly functioning left ventricle.

Dofetilide (Tikosyn): This is an oral anti-arrhythmic drug that must be initiated in

the hospital over a three-day period. Hospitalization is needed to closely monitor
the heart rhythm during the initial dosing period. If the atrial fibrillation responds
favorably during the initial dosing, a maintenance dose is established to be
continued at home.

Other drugs

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Warfarin (Coumadin): This drug is an anticoagulant (blood thinner). It reduces the

ability of the blood to clot. It lowers the risk of an unwanted blood clot forming in
the heart or in a blood vessel. Atrial fibrillation increases the risk of forming such
blood clots. There are other anticoagulant drugs, but warfarin is the only one
taken in pill form and is usually given for daily use. It is extremely important to
follow the exact dosing prescribed and to have regular blood tests (INR) when
recommended by your doctor.

Surgery
Before the development of catheter ablation, open heart surgery was done to interrupt conducting
pathways in both atria. This is called the surgical maze procedure. Maze surgery is usually
considered in patients who need some other type of heart surgery, such as valve repair or
coronary artery bypass surgery.

Follow-up
If you have no heart disease and medications succeed in controlling your heart rate, you can be
sent home from the emergency room. You should follow-up with your health care provider within
48 hours.
If your rhythm does not convert to normal by itself, you may need electrical cardioversion, or
defibrillation.

If you have been in atrial fibrillation longer than 48 hours, you will need three
weeks of treatment with an anticoagulant medication, such as warfarin, before
electric shock and for four weeks after.

Anyone with underlying heart disease or those that do not respond to rate
controlling treatment may require hospital care.

Prevention
If you do not have atrial fibrillation, you can lower your chance of getting this arrhythmia by
reducing your risk factors. This includes risk factors for coronary heart disease and high blood
pressure.

Do not smoke.

Maintain a healthy weight.

Make nutritious, low-fat foods the basis of what you eat.

Take part in moderately strenuous physical activity for at least 30 minutes every
day.

Control high blood pressure and high cholesterol.

Use alcohol in moderation, if at all.

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Use caffeine in moderation, if at all. Avoid other stimulants.

If you have atrial fibrillation, your health care provider may prescribe treatments for the underlying
cause and to prevent future episodes of atrial fibrillation. These treatments might include any of
the following (see Medical treatment for more information).

Medications

Cardio version

Pacemaker

Radiofrequency ablation

Maze surgery

Outlook
The most dangerous complication of atrial fibrillation is stroke.

Someone with atrial fibrillation is about 3-5 times more likely to have a stroke
than someone who does not have atrial fibrillation.

The risk of stroke from atrial fibrillation for people aged 50-59 years is about
1.5%. For those aged 80-89 years, the risk is about 30%.

Warfarin (Coumadin), when taken in appropriate doses, and monitored carefully,

reduces this risk of stroke by over two thirds.

It is important to know that clinical trial data has shown that you can live just as
long with atrial fibrillation with a controlled heart rate, for example, with
medications, plus Coumadin as in normal sinus rhythm (AFFIRM trial).

Another complication of atrial fibrillation is heart failure.

In heart failure, the heart no longer contracts and pumps as strongly as it should.

The very rapid contraction of the ventricles in atrial fibrillation can gradually
weaken the muscle walls of the ventricles.

This is uncommon, however, because most people seek treatment for atrial
fibrillation before the heart begins to fail.

For most people with atrial fibrillation, relatively simple treatment dramatically lowers the risk of
serious outcome. People with infrequent and brief episodes of atrial fibrillation may need no
further treatment than learning to avoid the triggers of their episodes, such as caffeine, alcohol, or
overeating.

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