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Atrial Fibrillation (AFib, AF)

Brief Overview: Atrial fibrillation (AFib) is a chronic cardiac arrhythmia characterized by irregular and often rapid atrial activity, resulting in an irregularly irregular ventricular rhythm. This can lead to inefficient cardiac output and a markedly increased risk of stroke and systemic embolism.
AFib may be paroxysmal (intermittent), persistent, long-standing persistent, or permanent. Management focuses on stroke prevention, symptom control (rate or rhythm), and treatment of underlying contributors.

Prevalence: According to Cleveland Clinic, “More than 33 million people age 55+ worldwide have an AFib diagnosis. Estimates predict that 12 million people in the U.S. will have AFib by 2030.”

Etiology: According to UpToDate, “changes in the anatomy and electrophysiology of the atrial myocardium are likely important. Thus, AF is usually associated with some underlying heart disease. Atrial enlargement, an elevation in atrial pressure, or infiltration or inflammation of the atria are often seen. Premature atrial complex (PAC; also referred to a premature atrial beat, premature supraventricular complex, or premature supraventricular beat) appears to be most important as a trigger in patients with paroxysmal AF who have normal or near-normal hearts.”

Risk Factors:

  • Increasing age
  • Excessive alcohol consumption
  • Family history of AFib
  • Genetics
  • Hyperthyroidism
  • HTN
  • CAD
  • Heart failure (HF), cardiomyopathy
  • Valvular heart disease
  • Diabetes
  • Obesity, sedentary lifestyle
  • OSA
  • Endurance athletics

Commonly Associated Conditions:

  • Ischemic stroke or transient ischemic attack (TIA)
  • Heart failure
  • Hypertension
  • Coronary artery disease
  • Valvular heart disease
  • Chronic kidney disease
  • Obstructive sleep apnea
  • Thyroid disease

Common Medications:

  • Anticoagulants – apixaban, dabigatran, edoxaban, rivaroxaban, warfarin
  • Rate control agents – beta blockers, nondihydropyridine calcium channel blockers (diltiazem or verapamil), amiodarone
  • Rhythm control agents – flecainide, propafenone, amiodarone, dronedarone, dofetilide, sotalol

Common Labs, Imaging, and Tests:

  • 12-lead ECG
  • Echocardiogram
  • Stress test
  • Labs: CBC, HgbA1c, CMP, TSH, free T4, troponins (in select patients)
  • Chest X-ray in select patients

Common Symptoms:

  • Can be asymptomatic
  • Palpitations
  • Fatigue, weakness
  • Dizziness, lightheadedness
  • Mildly reduced exercise capacity
  • Increased urination
  • Dyspnea at rest or with minimal exertion
  • Angina
  • Presyncope, syncope

Common Treatments:

  • Rate control strategy (most common)
  • Rhythm control strategy (selected patients: symptomatic, younger, heart failure, or early AFib)
  • Anticoagulation for stroke prevention
  • Electrical cardioversion (acute or elective)
  • Catheter ablation for symptomatic or drug-refractory AFib
  • Risk factor modification: weight loss, BP control, sleep apnea treatment
  • Left atrial appendage occlusion (e.g., Watchman) for patients unable to tolerate anticoagulation

Physical Findings:

  • Irregularly irregular pulse
  • Variable heart rate
  • Possible hypotension if poorly controlled
  • Signs of heart failure (edema, crackles) in advanced cases
  • Often normal exam between episodes in paroxysmal AFib

Potential Complications and Contraindications:

  • Complications:
    • Ischemic stroke or systemic embolism
    • Heart failure exacerbation
    • Tachycardia-induced cardiomyopathy
    • Increased mortality
  • Contraindications / cautions:
    • Bleeding risk with anticoagulation (requires monitoring)
    • Antiarrhythmic drug toxicities (thyroid, lung, liver with amiodarone)
    • Caution with rate-control agents in hypotension or advanced conduction disease
    • Per UpToDate, “certain medication (eg, theophyllineand adenosine) or drug (eg, cocaine or methamphetamine) exposures trigger or increase the risk of AF.”

General Health and Lifestyle Guidance:

  • Stress importance of anticoagulation adherence if prescribed.
  • Encourage blood pressure control and diabetes management.
  • Promote weight loss and regular physical activity, as tolerated and approved by healthcare provider.
  • Limit alcohol and avoid binge drinking. Abstaining from alcohol may be recommended.
  • Healthcare provider should screen for, and treat, sleep apnea. Encourage patient to discuss any sleep related symptoms or concerns with healthcare provider.
  • Encourage smoking cessation.
  • Reinforce follow-up with cardiology and regular monitoring, as directed by patient’s healthcare providers

Suggested Questions to Ask Patients:

  • Do you feel palpitations or notice an irregular heartbeat?
  • How often do you feel short of breath or fatigued?
  • Have you had any recent dizziness, fainting, or chest pain?
  • Are you taking your blood thinner as prescribed? Any bleeding or bruising?
  • Do you monitor your heart rate or blood pressure at home?
  • Have you been told you have sleep apnea or thyroid disease?
  • Any recent hospitalizations or cardioversions?
  • Are symptoms limiting your daily activities?

Suggested Talking Points:

  • AFib is common and treatable, but it increases stroke risk if not managed.
  • Blood thinners greatly reduce stroke risk and are a key part of treatment.
  • Lifestyle changes can help reduce AFib episodes.
  • Report any signs of stroke or unusual bleeding immediately. Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.