What might have caused my atrial fibrillation (AF)?
AF is very common and the number of individuals that are affected is increasing. There is no question that there is a clear age-related incidence of AF. This would therefore imply that there is a powerful element of ‘wear and tear’ involved in the development of this heart rhythm abnormality, increased by factors such as smoking, obesity and drinking alcohol.
Undoubtedly there are other influences such as high blood pressure and if a close family member has had AF then the likelihood of other individual members having the condition is increased. Also, some people may have an underlying problem with the thyroid gland which may cause AF or an underlying problem with the structure of their heart.
Why do I have AF? I am quite fit and healthy.
You can develop AF if you are fit and healthy. If you have AF and are fit and healthy two factors may be at play. One is the influence of genetics and the other the influence of exercise. It’s increasingly apparent, particularly in young individuals, that a family history can be a common feature. It’s also become apparent that people who exercise on a very regular basis, and participate in exercise to a very high level, might enhance their AF risk.
What symptoms do you normally get during an episode of AF?
Some patients have very rapid AF and get very few symptoms; others have infrequent short bursts of paroxysmal AF and get quite debilitating symptoms. The sorts of symptoms individuals experience include an awareness of the heartbeat, a general feeling that things just aren’t right in the chest. The rare individual might suffer some chest discomfort and some get dizziness and more rarely a feeling that they might faint.
If AF is more persistent then a general exhaustion and debilitation might well be present. Some people with paroxysmal AF are aware of the heart beat being irregular with a general non-specific awareness that things are just not quite right during an attack and then there is substantial debilitation for a prolonged period afterwards which may extend well into the next day.
My AF seems worse at night. Is this normal?
An episode of AF starting at night is not uncommon. If your AF occurs at night, one of the useful investigations may be an ambulatory ECG monitor (24 hour tape). Some patients are seen to have slow heart rates at night which may predispose to the onset of AF and under these conditions the implantation of a pacemaker may allow one to control the symptom very efficiently without much drug therapy or without an AF ablation, although these should also be considered, possibly as therapies in conjunction with a pacemaker.
I have been diagnosed with AF. Is it likely that my children will also develop AF?
AF is an age-related condition and the very fact of ageing itself may be the determinant of AF in a particular individual simply combined with other factors that may have developed during their lifetime, such as the appearance of blood pressure or obesity. Accordingly, the impact of AF in an individual, and the likelihood of this appearing in their children, will be determined by things like the age of appearance in the parent and other co-factors such as other environmental influences. For example, the amount of alcohol consumed or participating in an extreme amount of exertion. Because of these multiple influences you should not be concerned about the risk for family members.
Why does my AF come and go when others have it persistently?
The pattern of the AF and the way it affects individuals differs. In some people the attacks go on for short periods of time then spontaneously revert to a normal rhythm. This is usually called paroxysmal AF. The reason that the attacks terminate spontaneously as they do is often unclear. In some people they will be found to be in AF which is there all the time. This is generally referred to as persistent AF. This might have started in some patients as paroxysmal AF that has now become persistent. In some patients an attack will just start and never cease and that again is referred to as being persistent. Research is going on at the moment to try and work out why it is that paroxysmal becomes persistent in some individuals and not in others.
I have been diagnosed with AF. What investigations would the doctor generally conduct on my first visit?
If you have AF, a doctor will first take your medical history and then perform a medical examination, paying particular attention to your blood pressure to see if there is any evidence of fluid overload caused by heart failure. They would listen to the heart to see if they can hear any murmurs that might indicate that there are problems with the heart valves and obtain an ECG which will provide the diagnosis. AF cannot be diagnosed without conducting an electrical ECG recording. Once an ECG recording has been obtained and the history considered, then in most individuals appropriate treatment can be decided upon.
What are the main objectives that the doctor should discuss with me with regard to the management of my AF?
There are three main issues that the doctor should consider. The most important thing is the risk of stroke. Stroke arises in patients with AF usually as a result of what is called thromboembolism. What happens under these circumstances is that a clot is formed in the heart. This arises because the atrial chambers are not properly expelling blood. For reasons that we do not fully understand, the clot can occasionally break free and in the occasional unfortunate individual, this can result in a stroke.
The second consideration is symptom control. The main issue with AF in terms of its day-to-day impact is on quality of life, and this can vary quite substantially in individual patients. For some this has little impact upon their quality of life and in others the impact can be devastating.
The final issue is the potential impact the AF is having upon heart function in general. It might be that AF has emerged with relatively few symptoms, but has over a period of time lead to damage to the main pumping chambers of the heart, the ventricles.
How often should my healthcare professional review the treatments that I am taking?
In the initial phase your healthcare professional should give a description of your AF and outline the treatment plan.
The second phase would be the initiation and assessment of treatment and the third phase would follow entry into a period of stability. It is likely at this point quality of life will have been improved and AF might have been completely suppressed.
In the first and second phases, relatively regular reviews are normally. Once the main treatments have been adopted, then a follow up at six or 12 months is usual.
What are the differences between the anticoagulants available?
Warfarin has been used for many years and is effective when used correctly. Its downside is that it can be hard to get the dose right for some patients as warfarin’s action varies between individuals, and it can interact with certain foods and other medications. For this reason, you may need to go for regular blood tests at a clinic. There are three alternative anticoagulants to warfarin, called apixaban, dabigatran and rivaroxaban. These novel oral anticoagulants or NOACs are not affected by food or other drugs, so you do not need monitoring by regular blood tests. In terms of their ability to reduce your stroke risk, they are at least as good as warfarin, but some of the NOACs work differently to others. Your doctor will discuss these options with you and agree your personalised treatment plan.
Do the more recently introduced anticoagulants have an antidote like warfarin? If I start bleeding, can it be stopped?
There are clear guidelines and measures that can be undertaken to manage bleeding when it does occur, whatever anticoagulation treatment you may be taking. The action of warfarin lasts for several days and an injection of vitamin K can reverse its effects, but this takes eight to twelve hours and is therefore not a true antidote (which reverses the effects immediately). Compared with warfarin, the blood thinning effect of NOACs wears off much faster. It is reassuring that in all the studies with the more recently introduced oral anticoagulants, they had at least a comparable safety profile to warfarin in terms of overall bleeding rates.
My GP has prescribed me aspirin – is this right?
Older NICE guidelines (from 2006) suggested that aspirin could be used in patients at low or medium risk of stroke. However, more recent evidence and international guidelines recognise that aspirin is much less effective in preventing stroke in AF, and is no safer than an anticoagulant in terms of bleeding risk. Recently published updated NICE guidance (June 2014) recommend anticoagulation for all patients who are thought to be at risk of stroke from AF, but no longer recommend aspirin as a treatment option.
Does age affect how I should be treated for my AF?
As you get older, both your chance of having AF and your chance of having a stroke increase significantly. Older patients also have a somewhat higher bleeding risk with anticoagulation. However, overall, older patients are more likely to benefit from receiving anticoagulation when compared to younger patients. The risks and benefits of treatment should be considered for every individual to ensure the anticoagulation they receive is appropriate for them. Your own doctor, with knowledge of your medical history, is in the best position to advise you of the most appropriate treatment.