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Atrial fibrillation

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Artial fibrillation is a common type of arrhythmia where the electrical impulses become uncoordinated, making your heart beat as fast as 300 times per minute. Atrial fibrillation can also be dangerous as the blood pools in the atrium because it doesn’t pump all the blood into the ventricle. This causes a blood clot (thrombus) to form. The clot can break off and travel to another part of the body leading to severe complications like a stroke.

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What Is Atrial Fibrillation?

Atrial fibrillation (AF) is a common type of arrhythmia in which the electrical impulses become uncoordinated, thus making your heart beat as fast as 300 times per minute. Atrial fibrillation can be dangerous as the blood pools in the atrium because it does not pump all the blood in the ventricle. This causes a blood clot (thrombus) to form. The clot can break off and travel to another part of the body, leading to severe complications such as a stroke.

Types

There are four types of atrial fibrillation depending on the frequency with which it occurs and its response to treatment.


  • Paroxysmal or intermittent — Paroxysms or brief events of atrial fibrillation may occur off and on but may not last for more than seven days. 

  • Persistent — This type of atrial fibrillation is continuous and persists for more than seven days. 

  • Longstanding persistent — This type of atrial fibrillation continues for more than a year. 

  • Permanent — This type of atrial fibrillation does not respond to any treatment.

Symptoms

Atrial fibrillation (AF) is a condition characterized by irregular heart beat and rapid heart rate. In this condition, the two atria of the heart beat irregularly and hence lose coordination with the ventricles.


Arrhythmia is fairly subjective and so are the symptoms. That being said, the common symptoms of arrhythmia are -




  • Bradycardia (slow heartbeat)

  • Tachycardia (fast heartbeat) or fluttering

  • Shortness of breath

  • Chest pain

  • Lightheadedness or dizziness

  • Fainting or feeling faint


One might feel these symptoms intermittently and it might not mean that something is gravely wrong, but if these symptoms occur suddenly and frequently, you should see a doctor immediately. (Read: Expert tips to prevent heart disease)

Read more about causes, symptoms, diagnosis and treatment of heart disease.

Causes And Risk Factors

Causes

Variations with the tissue of the heart or to the electrical conduction system of the heart can be causative factors towards AF. Impairment to either of these can cause the heart to pump with more speed and irregularity, leading to AF.  

The causes of atrial fibrillation are listed below:


  • Electrolyte disturbances

  • Hypoxia

  • Thyroid disorders

  • Structural heart and valvular diseases

  • Ischemic heart disease

  • Metabolic disturbances

  • Sometimes, it can be without any underlying etiology (called as Lone AFL)


AF can occur for a few hours in a day or may even occur for a whole day. In case it continues for a long duration, one should always seek medical treatment.

Risk Factors

Certain cardiovascular disorders such as coronary artery disease (CAD), cardiomyopathy, high blood pressure, a previous heart attack, and a recent heart attack can lead to arrhythmia.

Moreover, arrhythmia can be caused by

  • Diabetes

  • Hyperthyroidism

  • Stress

  • Alcohol and drug abuse  

  • Smoking

  • Certain medicines, dietary supplements and herbal treatment

  • Air pollution

  • Electric shock

  • Age - AF increases with age, particularly after the age of 65 years. 

  • Family history, genetics - AF runs in the family. If someone in the family has it, there are more chances that you may get it too. Genetics may play a role in AF, and the risk increases when combined with aspects such as weight, age, or sex.

  • Lifestyle habits - Certain lifestyle behaviours such as alcohol, drug use, smoking, excessive activity, seen in competitive athletes, and leading a stressful life can predispose one to AF.

  • Surgery - Post oesophagus, lungs or heart surgery can predispose an individual to AF.

Prevention

Certain causative factors of AF may not be able to be prevented. However, after a healthy lifestyle such as eating healthy, avoiding unhealthy foods high in refined carbohydrates, saturated or trans-fat, controlling cholesterol, maintaining optimum blood pressure, limiting alcohol to two drinks per day, quitting smoking, and exercising to maintain a healthy weight can help prevent most types of AF.

Diagnosis

To diagnose AF, first a history and physical examination will be performed. Before treating your arrhythmia, the doctor will first ask about any triggers you might have, such as heart disease or thyroid problem. Then, he/she will try to identify where the arrhythmia starts in the heart and whether it is abnormal through certain diagnostic tests such as


  • ECG (electrocardiogram): It measures the electrical activity of the heart. In this test, electrodes are attached to the patient’s chest, legs and arms. It is a simple and cheap test that can be performed in any clinic and even on an outpatient basis. It can help in diagnosing AF.

  • Holter monitor: The test is usually used to diagnose bradycardia (slow heart rate), AF, palpitations and arrhythmia. Moreover, it is used for patients who have suffered a recent heart attack.

  • Echocardiogram: Echocardiography is basically real-time imaging of the heart (similar to sonography). It is especially helpful in the diagnosis of valvular heart disease, which remains silent for several years.

  • Transesophageal echocardiography (TEE) - This test uses sound waves that take images of one’s heart via the oesophagus. It identifies whether AF is causing blood clots to form in the upper chambers of the heart.  

  • Sleep study- To identify if sleep apnea is the cause of AF.

  • Tilt table test: For this test, you are asked to lie flat on a table and the table is then tilted as if you were standing up. Your doctor will observe how your heart responds to the change in angle.

  • Electrophysiological testing and mapping: Your doctor will insert catheters in various parts of your body. At the tip of these catheters are electrodes that will collect information about your heart’s electrical impulses.

  • Blood tests- To assess the levels of thyroid hormone and potassium and to identify the cause of AF. It will assess how well one’s kidneys and livers are functioning to assess the mode of treatment. 

  • Chest X-ray- This will identify complications of AF such as large fluid collections in hearts or lungs.

Treatment

The treatment method will depend on your age; if you have any pre-existing conditions, your family history, medications you might be taking, as well as the severity and symptoms of your arrhythmia.

There are a number of treatment options:

Lifestyle changes: Your doctor will ask you to make lifestyle changes that will keep your heart healthy. You may be advised to eat heart-healthy foods, exercise regularly, increase physical activity and cut down on stress, alcohol and caffeine.

Medications: You may be advised to have certain medication, which when taken exactly as per prescription can help prevent heart attack, stroke, and prevent the progression of coronary artery disease. 

There are four types of medicines to treat arrhythmia, namely,


  • Anti-arrhythmic drugs such as lidocaine and propranolol.

  • Ca channel blockers such as diltiazem

  • Beta-blockers such as metoprolol to decrease heart rate

  • Anticoagulants or blood thinners (in addition to other medicines) such as aspirin and warfarin to make it harder for the blood to clot and to prevent stroke.


Procedures - Certain procedures may be performed when medications fail to act.

Cardiac ablation: In addition to the medication, there are minimally invasive methods such as cardiac ablation, which can treat many types of arrhythmias. The procedure destroys or ablates specific cells in your heart that cause your arrhythmia.

Electrical Cardioversion - This procedure electrically resets the heart. This may be used in combination with medications to maintain the normal rhythm of the heart. The shock delivered by the cardioversion procedure will attempt to synchronize the heartbeat and re-establish a normal rhythm.

Left atrial appendage (LAA) closure- The LAA is a small sac in the top left chamber of the heart (atrium). For AF, there is a high risk of clot formation, which may accumulate in the LAA. Closure of this can help prevent these clots from circulating throughout your body and causing complications such as stroke.

Surgery

There are surgeries to help ease your troubles, namely, the maze procedure (here a number of incisions are made on the walls of the left and right atrium. These incisions form scar tissues that disrupt the uneven electrical impulses) and coronary bypass surgery.

Excision or exclusion of the left atrial appendage: Here, the LAA is removed, and the remaining tissue is closed with a stapler-like device or excluded with a device called the AtriClip. The AtriClip is externally implanted from the heart and prevents the flow of blood between the left atrium and the LAA. During surgical procedures to treat atrial fibrillation, the left atrial appendage is removed, and the tissue is closed with a special stapling device or it can be excluded with a device called the AtriClip. The AtriClip is implanted from outside the heart and stops the blood flow between the LAA and left atrium.

Certain arrhythmias may be life-threatening if not treated right away, so do not ignore your symptoms even if they seem harmless. Let your doctor be the judge of it.

Lifestyle/management

In addition to medications, certain lifestyle changes can improve the health of your heart. 


  • Be attentive to which activities cause AF and try to avoid those activities. 

  • Moderate or limit alcohol consumption.

  • Quit smoking.

  • Reduce caffeine use or consumption of caffeinated products such as coffee, tea, colas, energy drinks and certain OTC medications. 

  • Avoid self-medication, particularly when you have a cough or cold, as certain medications contain ingredients that may predispose an individual to AF. 

  • Check blood pressure and control it if it is on the higher side.

  • Be active and maintain a healthy body weight.

  • Bring blood sugar levels under control.

  • If an individual is suffering from sleep apnoea, treat it to reduce AF symptoms.

Do’s And Don’ts

DO’s


  • Do control and monitor the amount of caffeine you take. 

  • Do remain active and stay healthy.

  • Do maintain a healthy body weight.


DON’TS

  • Don’t consume too much of alcohol.

  • Don’t compromise on sleep. Get a good rest of ~7–9 h at night. 

  • Don’t ignore arrhythmias, even if they are not causing one any harm.[4]


What to eat and what to avoid: When an individual has AF, it is important to identify one’s triggers for the same. Identifying your threshold can help control symptoms of AF. Consuming a Mediterranean diet can help in the control of AF symptoms. A Mediterranean diet emphasizes foods that are plant-based and rich in vegetables, fruits, fish, legumes, nuts and olive oil. Foods that should be included are fish that are rich in omega-3, such as tuna, mackerel, sardines, and salmon. Fresh fruits such as strawberries, cranberries and others can be included. Including whole grains such as barley, oats, quinoa and brown rice can be beneficial. Including extra virgin olive oil and nuts such as walnuts, almonds and hazelnuts are beneficial and cardio-protective. Foods that should be avoided are red meats (beef, pork, and mutton), processed foods (chips, fast food) and bakery items (biscuits, cakes), sugary items and fruit juices, which contain excess sugar. 

Prognosis And Complications

Prognosis

The prognosis of AF depends on identifying the cause. Once the cause for AF is identified, the treatment can cure the arrhythmias. However, in individuals who have chronic heart diseases, the prognosis may be poor. In such cases, precautions and lifestyle changes should be instituted to prevent stroke and other complications should be taken.

Complications

More serious forms of this condition are listed below:

Brain stroke: AF leads to clot formation in the heart that can cause embolism in the brain and lead to brain stroke. It can lead to cardiac symptoms such as breathlessness, angina and heart failure because of the loss of effective contraction of the upper chamber of the heart and decreased cardiac output.

Sudden cardiac arrest - In cases of other cardiac related comorbidities, there is an increased risk of the heart to suddenly stop beating, leading to a cardiac arrest. 

Ventricular fibrillation: One of the deadliest types of arrhythmia is ventricular fibrillation. Here, the ventricles begin to quiver rather than pump blood. Because there is no effective heartbeat, blood pressure drops drastically cutting off blood supply to the organs, leading to collapse and cardiac arrest. Death ensues if the person does not immediately get medical attention.

Cognitive impairment and dementia- Because of decreased blood supply to the brain, owing to the abnormal rhythm of the heart, cognitive impairment, dementia or Alzheimer’s disease may occur. 

Heart failure: Another complication of AF is heart failure. It occurs when the heart cannot pump enough blood to meet the body’s requirements. Fatigue, shortness of breath, and fluid retention are common symptoms of this condition.

Alternative Treatments

A number of alternative treatments are available to treat AF. 

Yoga- which comprises pranayama (breathing exercises), asanas (body postures), and dhyana (meditation), decreases symptoms of AF and improves the quality of life. 

Acupuncture- This process comprises the insertion of fine needles at specific points on the skin, which are considered to be energy lines (meridians). This has been reported to be helpful in treating the symptoms of AF and prevents its recurrences.

Biofeedback- This involves a behavioural approach such as self-hypnosis, muscle relaxation and other methods of meditation to help individuals control the heart rate in AF.

Vitamins and antioxidants- Vitamins C and E help in reducing the occurrence of AF post-cardiac surgery, and antioxidants have been seen to reduce the occurrence of AF.

References


  1. Atrial Fibrillation. NIH. Available at: https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation#:~:text=Atrial%20fibrillation%20is%20a%20type,persistent%2C%20and%20permanent%20atrial%20fibrillation. Accessed on: March 30, 2021. (https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation#:~:text=Atrial%20fibrillation%20is%20a%20type,persistent%2C%20and%20permanent%20atrial%20fibrillation)

  2. Atrial fibrillation. Harvard Health Publishing. Available at: https://www.health.harvard.edu/a_to_z/atrial-fibrillation-a-to-z. Accessed on: March 30, 2021. (https://www.health.harvard.edu/a_to_z/atrial-fibrillation-a-to-z)

  3. Atrial Fibrillation. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/16765-atrial-fibrillation-afib. Accessed on: March 30, 2021. (https://my.clevelandclinic.org/health/diseases/16765-atrial-fibrillation-afib)

  4. Six Do’s and Don'ts When You Have a Heart Rhythm Problem. Penn Medicine. Available at: https://www.pennmedicine.org/updates/blogs/heart-and-vascular-blog/2016/august/6-dos-and-donts-when-you-have-a-heart-rhythm-problem. Accessed on: March 30, 2021. (https://www.pennmedicine.org/updates/blogs/heart-and-vascular-blog/2016/august/6-dos-and-donts-when-you-have-a-heart-rhythm-problem)

  5. Managing your atrial fibrillation: What to eat (and avoid). Cleveland Clinic. Available at: https://health.clevelandclinic.org/managing-your-atrial-fibrillation-what-to-eat-and-avoid/. Accessed on: March 30, 2021. (https://health.clevelandclinic.org/managing-your-atrial-fibrillation-what-to-eat-and-avoid/)

  6. Kanmanthareddy A, et al. J Thorac Dis. 2015;7(2):185–192.

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