Atrial fibrillation (AF) is an abnormal heart rhythm, and is often irregular and fast.
It is the most common heart rhythm disorder in the UK affecting one per cent of people under 65 years old and ten per cent of people over 75 years.
Patients with AF may have no complaints or symptoms, such as palpitations, shortness of breath, lack of energy, light-headedness and chest discomfort.
Some patients with AF may even develop evidence of heart failure or suffer a stroke.
What is atrial fibrillation?
AF can occur at any age but is most common in people aged over 65 and affects seven to ten per cent of people aged 80 and over.
In AF, the top chambers of the heart (atria) have abnormal, disorganised electrical activity. This overrides the sinus node, causing the atria to beat very fast (more than 300 times a minute). It also beats irregularly (known as fibrillating or fibrillation). At this rate, the atria can not pump blood efficiently.
The AV node has a very important protective mechanism - it helps to stop many of the electrical impulses transmitting from the atria to the ventricles. This prevents the ventricles from beating at the same rate as the atria. The rate of the ventricles in AF depends on the AV node and can range from slow to very fast.
The protective function of the AV node means AF is a non-life threatening arrhythmia. But it can still cause the heart function to become impaired and, regardless of how slow or fast the heart is beating, can increase the risk of stroke.
What are the causes of AF?
The cause of atrial fibrillation is still not fully understood. AF is more likely to occur with older age and there are several conditions that can contribute to AF developing:
- ischaemic heart disease
- mitral valve disease
- heart failure
- sleep apnoea
- congenital heart disease
Other factors include:
- respiratory disease / pneumonia / chest infections
- pulmonary embolism (PE)
- carbon monoxide poisoning
For some people there are no obvious reason for developing AF and this is called 'lone' AF.
What are the symptoms of AF?
Some people might not experience any symptoms associated with their AF; but, if they do, the most common are:
- tiredness / lethargy
- reduced exercise capacity
- chest discomfort
Is there more than one type of AF?
There are three types of AF, based on both frequency and duration of AF episodes:
- Paroxysmal AF – intermittent episodes that return to normal rhythm within seven days.
- Persistent AF – Episodes that persist for more than seven days and may stop with treatment or sometimes on their own. If it continues for more than 12 months, it is known as long-standing persistent AF.
- Permanent AF – AF that does not terminate with treatment or it has been decided that accepting AF is the best option for you.
What is normal (sinus) rhythm?
The heart is divided into four chambers: two at the top, called the atria, and two at the bottom, called the ventricles. A normal heartbeat is very coordinated, where the atria is followed by the ventricles in each heartbeat. The average resting heart rate is usually between 60 and 100 bpm (beats per minute). This is called normal sinus rhythm.
The heartbeat needs an electrical conduction system, rather like electrical wiring. This is made up of cells in the heart that send electrical messages or impulses to the heart muscle. These electrical impulses stimulate the heart to contract.
In a normal heart, the electrical impulse starts from our natural pacemaker, the sinoatrial node (SA node). You can find this at the top of the right atrium. This electrical impulse then spreads very quickly throughout the right and left atria, making them contract.
It then goes through a gateway from the atria to the ventricles called the atrioventricular node (AV node). Once it is past the AV node, the electrical impulse speeds its way into the ventricles making them contract and push the blood out of the heart.
You can find the AV node at the lower right atrium, and it acts as an electrical junction between the atria and ventricles. During normal sinus rhythm, the AV node's main function is to delay how quickly the electrical impulse travels between the atria and the ventricles. This means the heart pumps blood more efficiently.
Stroke risk and anticoagulation
During atrial fibrillation, the risk of stroke increases because the atria does not contract/pump normally. This then slows down the blood flow.
This can cause blood to pool inside the heart, which could cause a thrombus (clot) to form. If the blood clot leaves the heart it can travel to any part of the body, including the brain, resulting in a stroke.
Research has shown that strokes caused by AF are can be worse than non AF-related strokes. So people who suffer from AF have a higher chance of a stroke than someone who does not have AF.
We will assess your risk of stroke by using an international scoring system, called the CHA2DS2VASc score. This looks at other conditions that also increase your risk of stroke, such as diabetes.
|Congestive heart failure||1|
|Stroke or TIA||2|
|Vascular heart disease||1|
|Age (65-74 years)||1|
Each condition is given a score of either 1 or 2.
You will get a score of 0 if you do not have any of the above risk factors. You will be considered low risk (less than 1 per cent risk of stroke per year) and an anticoagulant will not be needed.
A score of 1 is a moderate risk and your doctor may recommend an anticoagulant. Anticoagulants (like warfarin or NOACs) are effective at reducing the risk of thrombus by around 50-60 per cent.
In the past, moderate risk patients took antiplatelet drugs, such as aspirin and clopidogrel. But, recent research has shown that antiplatelets are ineffective in reducing the risk of stroke while increasing the risk of bleeding.
A score of 2 or greater means there is a high risk of having a stroke and an anticoagulant is usually recommended.
The table below shows your stroke risk percentage per year according to your CHADSVASC score. For example, if you have a CHADSVASc score of 2 you have a 2.2 per cent risk each year of having a stroke without anticoagulation. So, two people in every 100 people over a year will have a stroke.
|CHADSVASc score||Annual stroke risk percentage|
Although anticoagulants can reduce the presence of clots and risk of stroke, they can increase the risk of bleeding. So it is important to assess both your stroke and bleeding risks, so your doctor can decide if an anticoagulant's benefits would outwiegh the risks.
To help identify people at a high risk of bleeding, we use another scoring system called HAS-BLED.
|Hypertension (uncontrolled BP, systolic >160 mmhg)||1|
|Abnormal renal or liver function||1 or 2|
|Labile INR (<60 per cent in range)||1|
|Drugs or alcohol||1 or 2|
A score above 3 is considered high risk for bleeding and needs to be carefully monitored. You may still be given an anticoagulant as the risk of having a stroke may be higher than the risk of bleeding.
Your healthcare professional will discuss this with you and also look at other factors, such as controlling blood pressure.
The arrhythmia team includes:
- EP consultants
- clinical nurse specialists
- an arrhythmia pharmacist
- catheter laboratory technicians.
- Dr Jonathan Clague
- Dr Sabine Ernst
- Dr John Foran
- Dr Wajid Hussain
- Dr Julian Jarman
- Dr David Jones
- Dr Vias Markides
- Dr Tushar Salukhe
- Dr Jan Till
- Dr Tom Wong
Clinical nurse specialists
- Natalie Crump
- Sue King
- Sarah Plowright
- Alex Wise
Royal Brompton Hospital
020 7351 8364
If you want to know more about arrhythmia, here are some helpful organisations and websites: