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Living with Atrial Fibrillation

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What is Atrial Fibrillation?[1]

Atrial fibrillation (AF or A-fib) is an abnormal heart rhythm (medically called arrhythmia). It is characterised by rapid and irregular beating of the Atrial chambers of the heart.[2] It often begins as short periods of abnormal beating, which become longer or continuous over time.[3] It may also start as other forms of arrhythmia such as Atrial flutter before transforming into AF[4]. Episodes can be asymptomatic[5]. Symptomatic[6] episodes may involve heart palpitations, fainting, light-headedness, shortness of breath, or chest pain.[7]

Atrial fibrillation is associated with an increased risk of heart failure, dementia, and Stroke[8]. It is a type of supraventricular tachycardia[9].

The NHS says[10] a normal heart rate should be regular and between 60 and 100 beats a minute when resting. You can measure your heart rate by checking the pulse in your wrist or neck.

The first known report of an irregular pulse was by Jean-Baptiste de Sénac in 1749[11]. Thomas Lewis was the first doctor to document this by ECG in 1909[12].

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Picture Credit: Normal rhythm tracing (top) Atrial fibrillation (bottom). Attribution: BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0&gt;, via Wikimedia Commons.
https://upload.wikimedia.org/wikipedia/commons/3/34/Atrial_Fibrillation.png This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

Risk Factors
High blood pressure (hypertension) and valvular heart disease are the most common modifiable risk factors for AF.[13] Other heart-related risk factors include heart failure, coronary artery disease, cardiomyopathy, and congenital heart disease.[14] In low- and middle-income countries, valvular heart disease is often attributable to rheumatic fever.[15] Lung-related risk factors include Chronic Obstructive Pulmonary Disease (COPD), obesity, and sleep apnea. Other risk factors include excess alcohol intake, smoking, diabetes mellitus, and thyrotoxicosis (another term for hyperthyroidism).[16] However, about half of AF cases are not associated with such risks.[17] Medical professionals might suspect AF after feeling the pulse and confirm the diagnosis by interpreting an electrocardiogram (ECG) – a typical ECG in AF shows irregularly spaced QRS complexes without P waves.[18]

Healthy lifestyle changes, such as weight loss in obese people, increased physical activity, and drinking less alcohol, can lower the risk for Atrial fibrillation and reduce its burden if it occurs.[19] AF is often treated with medications to slow the heart rate to a near-normal range (known as rate control) or to convert the rhythm to normal sinus rhythm (known as rhythm control)[20].

An Electrical cardioversion[21] can convert AF to normal heart rhythm and is often necessary for emergency use if the person is unstable[22].

Ablation[23] may prevent recurrence in some people.[24] For those at low risk of Stroke, AF does not necessarily require blood thinners (anticoagulants) though some healthcare providers may prescribe aspirin or an anti-clotting medication.[25] For those at more than low risk, experts generally recommend an anti-clotting medicine. Anti-clotting medications include warfarin and direct oral anticoagulants. Most people with AF are at higher risk of Stroke[26] , and while these medications reduce stroke risk, they increase rates of major bleeding.[27]

Atrial fibrillation is the most common serious abnormal heart rhythm, and as of 2020, it affected more than 33 million people worldwide.[28] It affects up to 800,000 people in the UK[29].


Picture Credit: “File:Diagram of the human heart (cropped).svg” by Wapcaplet is licensed under CC BY-SA 3.0.

As of 2014, AF affected about 2 to 3% of the population of Europe and North America.[30] In the developing world, about 0.6% of males and 0.4% of females are affected.

The percentage of people with AF increases with age: 0.1% under 50 years old, 4% between 60 and 70 years old, and 14% over 80 years old being affected.[31] A-fib and Atrial flutter resulted in 193,300 deaths in 2015, up from 29,000 in 1990.[32]

Cardiac Cycle of the Human Heart[33]
The cardiac cycle is the performance of the human heart from the beginning of one heartbeat to the start of the next. It consists of two periods:

  • one during which the heart muscle relaxes and refills with blood (called diastole), following
  • a period of robust contraction and pumping of blood (called systole).

After emptying, the heart immediately relaxes and expands to receive another influx of blood returning from the lungs and other systems of the body before it again contracts to pump blood to the lungs and those systems. A normally performing heart must be fully expanded before it can efficiently pump again.

Assuming a healthy heart and a typical rate of 70 to 75 beats per minute, each cardiac cycle, or heartbeat, takes about 0.8 seconds to complete the cycle[34]. There are two Atrial and two ventricle chambers of the heart; they are paired as the left heart and the right heart—that is, the left atrium with the left ventricle, the right atrium with the right ventricle—and they work together to repeat the cardiac cycle continuously.

Genetics
Inherited Atrial fibrillation is called Familial Atrial Fibrillation. AF has been associated with changes in certain genes in a small number of cases. Although the exact incidence of familial Atrial fibrillation is unknown, recent studies suggest that up to 30% of people with the condition may have a relative with the same problem. Research into the genetic factors associated with Atrial fibrillation continues with the hope that genetic testing might someday be possible. Such testing could help doctors more accurately determine a person’s risk of Atrial fibrillation and develop plans to prevent or manage the condition[35].

Familial Atrial Fibrillation is more common than was previously recognised, highlighting the importance of genetics in disease pathogenesis. In four families with AF, researchers excluded linkage to chromosome 10q22-q24, establishing that at least two disease genes are responsible for this disorder[36]. Furthermore, a study was carried out to examine the heritability of AF in Icelanders, using a nationwide genealogy database and population-based data on AF[37]. The heritability of AF has been elegantly demonstrated in the Icelandic population[38].

Signs and Symptoms
With Atrial fibrillation, the heart rate is irregular and can sometimes be very fast – in some cases, it can be considerably higher than 100 beats a minute[39]:

  • It can cause problems including dizziness, shortness of breath and tiredness.
  • You may be aware of noticeable heart palpitations, where your heart feels like it’s pounding, fluttering or beating irregularly, often for a few seconds or, in some cases, a few minutes.
  • Sometimes Atrial fibrillation does not cause any symptoms, and a person with the condition is completely unaware that their heart rate is irregular[40].

Some people with Atrial fibrillation don’t notice any symptoms[41]. Those who do have Atrial fibrillation symptoms may have signs and symptoms such as:

  • Sensations of a fast, fluttering or pounding heartbeat (palpitations)
  • Chest pain
  • Dizziness
  • Fatigue
  • Lightheadedness
  • Reduced ability to exercise
  • Shortness of breath
  • Weakness

Atrial Flutter[42]
Atrial Flutter is similar to Atrial fibrillation (which causes the heart to beat in irregular patterns). People with atrial flutter have a heart rhythm that’s more organised and less chaotic than Atrial fibrillation. Sometimes a person may have episodes of both atrial flutter and atrial fibrillation. People with Atrial flutter may not have symptoms. However, the disorder can increase the risk of stroke, heart failure and other complications.

There are effective treatments for Atrial flutter, including medication or procedures designed to scar small areas of heart tissue (ablation[43]). Treatment for Atrial flutter is also slightly different. Catheter ablation is considered the best treatment for Atrial flutter, whereas medicine is often the first treatment used for Atrial fibrillation.

Causes[44]
Problems with the heart’s structure are the most common cause of Atrial fibrillation. Possible causes of Atrial fibrillation include:

  • Coronary artery disease
  • Heart attack
  • A heart defect that you’re born with (congenital heart defect)
  • Heart valve problems
  • High blood pressure
  • Lung diseases
  • Physical stress due to surgery, pneumonia or other illnesses
  • Previous heart surgery
  • Problem with the heart’s natural pacemaker (sick sinus syndrome)
  • Sleep apnea
  • Thyroid disease – such as an overactive thyroid (hyperthyroidism) and other metabolic imbalances
  • Use of stimulants, including certain medications, caffeine, tobacco and alcohol
  • Viral infections

When the heart beats normally, its muscular walls tighten and squeeze (contract) to force blood out and around the body. Then the walls relax so the heart can fill with blood again. This process is repeated every time the heart beats. In Atrial fibrillation, the heart’s upper chambers (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions. This reduces the heart’s efficiency and performance. Atrial fibrillation happens when abnormal electrical impulses suddenly start firing in the atria. These impulses override the heart’s natural pacemaker, which can no longer control the heart’s rhythm and causes a highly irregular pulse rate.

Atrial fibrillation can also be associated with other health conditions[45] such as:

  • asthma
  • lung cancer
  • pulmonary embolism.

The cause of AF is not fully understood, but it tends to affect certain groups of people, such as older people and people living with long-term (chronic) conditions such as heart disease, high blood pressure or obesity. It may be triggered by certain situations, such as drinking too much alcohol or smoking. At least one thing is certain: more men than women have Atrial fibrillation.

Management of Atrial Fibrillation
Atrial fibrillation complications can be life-threatening and can cause severe impairments. It’s important to manage Afib to reduce your risk of complications.

Your health care provider might recommend certain strategies to prevent complications. Your treatment plan might include lifestyle modifications, medications and or surgery.

To reduce the chance of potential complications of Afib, it is recommended to take the following steps to ensure your heart is as healthy as possible[46]:

  • Monitor and control your blood pressure. People with hypertension (high blood pressure) are more likely to develop Afib. And Afib and high blood pressure are both leading causes of stroke.
  • Eat a heart-healthy diet.
  • Exercise regularly.
  • Follow your health care provider’s instructions carefully. For example, take all medications as prescribed and attend all your medical appointments.
  • Limit alcohol and caffeine.
  • Maintain a healthy weight.
  • Manage stress.
  • Stop smoking.

g963_1117_atrial_fibrillation_web-qg_1217

The British Heart Foundation[47] adds:

  • Cut down on alcohol: try halving your units or mixing fruit juice with sparkling water as an alternative.
  • Control high blood pressure: by cutting down on salt and managing stress.
  • Work on your cholesterol levels: by eating more fibre and swapping saturated fats (butter, takeaway meals) for unsaturated fats (olive oil, oily fish).
  • Be mindful of your blood sugar levels (especially if you have diabetes). Swap sugary snacks for fruits and choose sugar-free drinks.

“Atrial fibrillation – your quick guide” is a short, illustrated leaflet that explains what it is, what the symptoms are and how you can treat it. It’s useful for you if you’ve been diagnosed with AF or if you think you might have symptoms of it, go to The British Heart Foundation website to download your free copy: https://www.bhf.org.uk/informationsupport/publications/heart-conditions/Atrial-fibrillation—your-quick-guide

Medications[48]
There are several prescription medications available to help manage Atrial Fibrillation. Each medicine may have different effects, including controlling the heart rate, preventing blood clots, and normalising the rhythm of the heartbeat.

Due to the irregular heartbeat of AF, blood can pool in the heart and increase the risk of blood clots. If these blood clots enter the bloodstream, they can lead to a Stroke. Drugs known as blood thinners are available by prescription to prevent blood clot formation or to treat an existing blood clot. Examples of drugs that help prevent blood clots include[49]:

  • Anticoagulants: a group of medications that reduce the body’s ability to form blood clots by interrupting the blood clotting process. The formation of a blood clot relies on substances called clotting factors undergoing a coagulation cascade. Anticoagulants help to combat this process. Examples of anticoagulants include warfarin, dabigatran etexilate, rivaroxaban, edoxaban tosylate and apixaban.
  • Antiplatelets: Antiplatelet drugs are medications that prevent platelets, also known as thrombocytes, from sticking together. Platelets are small fragments of cells, and their main function is to stick to the lining of blood vessels and form a blood clot to help stop or prevent bleeding. However, a high number of platelets can result in unnecessary clotting, thereby increasing the risk of a stroke. A doctor may only recommend antiplatelets for individuals with a high risk of AF or other cardiovascular events. A person should not start or stop aspirin without first consulting a doctor. Examples of antiplatelets include clopidogrel bisulfate and aspirin.
  • Heart rate control: these medications, known as anti-arrhythmic drugs, help control heart rate. Typically, they slow the heart rate by blocking irregular electrical signals in the atria, which prevents their transmission to the ventricles. Examples of heart rate-controlling medications include: Examples of beta-blockers include: atenolol, bisoprolol, carvedilol phosphate, metoprolol succinate, nadolol, and propranolol hydrochloride.
  • Beta-blockers: Beta-blockers are also known as beta-adrenergic blocking agents. They are a group of drugs that block the action of certain hormones that can affect the heart rate. They can block the release of epinephrine and norepinephrine, which would otherwise cause a rapid heartbeat and heart palpitations. Beta-blockers can also reduce the production of angiotensin II. In doing so, they help blood vessels relax, easing the passage of blood.
  • Calcium channel blockers: Calcium channel blockers (CCBs) can increase blood flow and oxygen to the heart. Calcium plays a vital role in muscle contraction and allowing the heart to pump blood around the body. CCBs reduce the amount of calcium that can enter cardiac muscle cells and blood vessel walls, which helps lower blood pressure and slow a person’s heart rate. Examples of calcium channel blockers include diltiazem hydrochloride and verapamil hydrochloride.
  • Digoxin: Digoxin is a drug that can help manage heart rate. It influences the electrical activity in the heart, increasing the force of contraction while slowing conduction to decrease heart rate. A doctor may prescribe digoxin if beta-blockers or CCBs cannot be tolerated. Alternatively, they may suggest using digoxin in addition to these drugs if a person requires a further reduction in their heart rate.
  • Heart rhythm control: The drugs to achieve heart rhythm control attempt to restore the heart rhythm to normal. Experts may also refer to this as pharmacological or chemical cardioversion. Electrical signals help the heart contract in a coordinated way. A-fib disrupts this signalling pathway, leading to an abnormal heart rhythm. These drugs allow the heart to reset into a normal rhythm. Examples of heart rhythm controlling medications include: Sodium channel blockers and Potassium channel blockers. Examples of sodium channel blockers include flecainide acetate, propafenone hydrochloride, quinidine, gluconate. Examples of potassium channel blockers include: amiodarone hydrochloride, sotalol hydrochloride and dofetilide.

Which drugs are best for which people?
Doctors look at various factors before developing a treatment plan. These include:

  • the person’s age
  • the severity of their symptoms
  • the frequency of symptoms
  • the heart rate
  • the risk of stroke
  • any underlying heart disease or other health conditions

word-image-3930-5
How a stroke can occur during atrial fibrillation
Attribution: National Heart Lung and Blood Institute (NIH), Public Domain via Wikimedia Commons.File URL: https://upload.wikimedia.org/wikipedia/commons/3/34/Atrial_fib_stroke.jpg

Many doctors use the CHA₂DS₂-VASc score to assess a person’s stroke risk and determine which AF medications would best meet their needs. As the threshold of stroke risk for initiating oral anticoagulants is lowered after the introduction of the nonvitamin K antagonist oral anticoagulants, the focus of stroke prevention in patients with nonvalvular Atrial fibrillation has shifted away from predicting high-risk patients toward initially identifying patients with a truly low risk of ischemic stroke, who do not need antithrombotic therapy[50].

This scoring approach calculates a patient’s risk of stroke by awarding points based on whether he/she:

  • has congestive heart failure
  • has high blood pressure
  • is aged 65–74 years or older
  • has diabetes
  • has previously had a stroke or blood clot
  • has an underlying vascular disease, such as having had a heart attack in the past
  • was assigned female at birth

When to use AF medications
There are three basic types of Atrial fibrillation[51]:

  • Paroxysmal: This is more common in the early stages of the condition, wherein episodes occur intermittently but not frequently.
  • Persistent: This develops when an irregular heartbeat lasts more than seven days.
  • Long-standing persistent (formerly known as permanent): A doctor will describe AF as long-standing persistent when it is not possible to bring the heart back to a regular rhythm.

AF used to be classified as either chronic or acute, but in 2014, new guidelines from the American College of Cardiology and American Heart Association changed the classification of Atrial fibrillation from two types to four by adding permanent AF.[52]

You can start with one type of AF that eventually becomes another type as the condition progresses. Most people with AF will need to take medication to manage their symptoms and reduce their risk of stroke. For some people, medication alone is not enough to control A-fib. In these cases, a doctor may recommend more intensive treatment options, such as catheter ablation, surgical maze procedures, or electrical stimulation.

Atrial fibrillation is not usually life-threatening, but it can be uncomfortable and often requires treatment. The treatment may involve[53]:

  • medicines to prevent a stroke (people with Atrial fibrillation are more at risk of having a stroke)
  • medicines to control the heart rate or rhythm
  • cardioversion – where the heart is given a controlled electric shock to restore normal rhythm
  • catheter ablation – where the area inside the heart that’s causing the abnormal heart rhythm is destroyed using radiofrequency energy, after which you may then need to have a pacemaker fitted to help your heart beat regularly

Side Effects[54]
Anticoagulants

Possible side effects of anticoagulants include:

  • excessive bleeding
  • dizziness
  • headaches
  • changes in bowel movements

Antiplatelets

Possible side effects of antiplatelets include:

  • bleeding more easily
  • stomach pain
  • diarrhoea
  • indigestion or heartburn

As with any drug, some people may experience side effects when taking AF medications. These may include a risk of excessive bleeding, hypotension, and a slow heart rate. If medications do not resolve the irregular heart rhythms, a doctor may suggest surgical options to help treat the condition.

Beta Blockers

Generally, people can tolerate beta-blockers well. However, some individuals may still experience side effects, such as:

Side effects from CCBs are rare, but they can include:

  • constipation
  • slow heart rate
  • low blood pressure
  • dizziness

Digoxin

Potential side effects of digoxin include:

  • confusion
  • dizziness
  • nausea
  • diarrhoea
  • blurry vision
  • skin rashes

Sodium channel blockers

Potential side effects of sodium channel blockers include:

  • vision problems
  • dizziness
  • headaches
  • changes in bowel movements

Potassium channel blockers

Possible side effects of potassium channel blockers include:

  • headaches
  • dizziness
  • abdominal pain
  • insomnia

Prognosis[55]
People with Atrial fibrillation have a significantly higher risk of stroke than the average population. They also tend to have more severe strokes with more serious complications and a higher chance of death from stroke.

That said, Atrial fibrillation is generally not life-threatening, and many people live normal healthy lives with the condition, but it can be uncomfortable and often needs treatment.

AF increases the risk by about four to five times of having a transient ischaemic attack (TIA) or Stroke because when the atria in the heart do not contract properly, there is a risk of blood clot formation. Clots from the atria may break off and go to other parts of the body. A blood clot passing up to the arteries supplying the brain may cause a Stroke.

For this reason, treatment may involve medication to control the heart rate or rhythm, and medication to prevent clots from forming in the blood.

Stroke
Clots in the general circulation of blood can block arteries in the brain, causing a Stroke. The risk of a Stroke in people with Atrial fibrillation (AF) is four to five times greater than in the general population. However, the risk depends on several factors, including age, whether you have high blood pressure, heart failure, diabetes and a previous history of blood clots.

Heart failure
If your Atrial fibrillation is persistent, it may start to weaken your heart muscle. In extreme cases, it can lead to heart failure, where your heart cannot pump blood around your body as efficiently as before.


Picture Credit: “File:RiskFactors.jpg” by YaizaRodriguezGarcia is licensed under CC BY-SA 4.0

Sources and Further Reading

Please email me at mpollins@onesmartplace.com if you would like a copy of my papers on similar matters:

  • Cardioversions – what they are and how they work
  • Information about Heart Attacks, Cardiac Arrests & Strokes

CAUTION: This paper is not medical advice. No advice is implied or given in articles published by us but is only for general information. You should always seek the advice of your GP or other qualified health provider with any questions you may have regarding a medical condition. This paper is compiled from the sources stated but has not been medically reviewed. It should never be used as a substitute for obtaining advice from a consultant Cardiothoracic Surgeon (or Cardiologist) or other qualified clinician/medical practitioner. If you have already been given dietary advice, you should not make changes without first talking to your GP, consultant or dietitian. Any medications mentioned may include names for US drugs which may have a different name to those available in the UK. The facts are believed to be correct as at the date of publication, but there may be certain errors and omissions for which we cannot be responsible. There is no implied endorsement or promotion of any organisation by the writer. The hyperlinks were valid at the date of publication.

  1. Mostly excerpted from: https://en.wikipedia.org/wiki/Atrial_fibrillation ↑
  2. See: Heart Disease Other Related Conditions”. cdc.gov. 3rd September 2014. Source: https://www.cdc.gov/heartdisease/other_conditions.htm ↑
  3. Source: Zoni-Berisso, M; Lercari, et al (2014). “Epidemiology of atrial fibrillation: European perspective”. Clinical Epidemiology. 6: 213–20. ↑
  4. Source: Bun, Sok-Sithikun; Latcu, Decebal Gabriel; Marchlinski, Francis; Saoudi, Nadir (2 April 2015). “Atrial flutter: more than just one of a kind”. European Heart Journal. Oxford University Press (OUP). 36 (35): 2356–2363. ↑
  5. Explanation: In medicine, any disease is classified asymptomatic if a patient tests as carrier for a disease or infection but experiences no symptoms. Whenever a medical condition fails to show noticeable symptoms after a diagnosis it might be considered asymptomatic. ↑
  6. Explanation: When someone has the common symptoms associated with a disease or condition, they are considered symptomatic. ↑
  7. Source: Gray, David (2010). Chamberlain’s Symptoms and Signs in Clinical Medicine: An Introduction to Medical Diagnosis (13th ed.). London: Hodder Arnold. pp. 70–71. ISBN 9780340974254. ↑
  8. Source: Munger, TM; Wu, LQ; Shen, WK (January 2014). “Atrial fibrillation”. Journal of Biomedical Research. 28 (1): 1–17. ↑
  9. Explanation: Supraventricular tachycardia (SVT) is a condition where your heart suddenly beats much faster than normal. It’s not usually serious, but some people may need treatment. See: https://www.nhs.uk/conditions/supraventricular-tachycardia-svt/ ↑
  10. At: https://www.nhs.uk/conditions/atrial-fibrillation/ © Crown copyright is acknowledged. ↑
  11. Source: Munger, TM; Wu, LQ; Shen, WK (January 2014). “Atrial fibrillation”. Journal of Biomedical Research. 28 (1): 1–17. ↑
  12. Ibid ↑
  13. Sources: (1) Anumonwo, JM; Kalifa, J (November 2014). “Risk Factors and Genetics of Atrial Fibrillation”. Cardiology Clinics. 32 (4): 485–94, and (2) Nguyen, TN; Hilmer, SN; Cumming, RG (10 September 2013). “Review of epidemiology and management of atrial fibrillation in developing countries”. International Journal of Cardiology. 167 (6): 2412–20. ↑
  14. See: Anumonwo, JM; Kalifa, J (November 2014). “Risk Factors and Genetics of Atrial Fibrillation”. Cardiology Clinics. 32 (4): 485–94. ↑
  15. Source: Mischke, K; Knackstedt, C; Marx, N; Vollmann, D (April 2013). “Insights into atrial fibrillation”. Minerva Medica. 104 (2): 119–30. ↑
  16. Sources: (1) Munger, TM; Wu, LQ; Shen, WK (January 2014). “Atrial fibrillation”. Journal of Biomedical Research. 28 (1): 1–17.. (2) Staerk, L; Sherer, JA; Ko, D; Benjamin, EJ; Helm, RH (April 2017). “Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes”. Circulation Research (Review). 120 (9): 1501–17., and (3) Mischke, K; Knackstedt, C; Marx, N; Vollmann, D (April 2013). “Insights into atrial fibrillation”. Minerva Medica. 104 (2): 119–30. ↑
  17. Source: Munger, TM; Wu, LQ; Shen, WK (January 2014). “Atrial fibrillation”. Journal of Biomedical Research. 28 (1): 1–17. ↑
  18. Source: Ferguson C, Inglis SC, Newton PJ, Middleton S, Macdonald PS, Davidson PM (2013). “Atrial fibrillation: stroke prevention in focus”. Australian Critical Care. 27 (2): 92–98. ↑
  19. Source: Chung, MK; Eckhardt, LL; Chen, LY; Ahmed, HM; Gopinathannair, R; Joglar, JA; Noseworthy, et al., American Heart Association Electrocardiography and Arrhythmias Committee and Exercise Cardiac Rehabilitation, and Secondary Prevention; Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health (March 2020). “Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association”.. ↑
  20. Source: Anumonwo, JM; Kalifa, J (November 2014). “Risk Factors and Genetics of Atrial Fibrillation”. Cardiology Clinics. 32 (4): 485–94. ↑
  21. Explanation: Electric cardioversion uses a machine and sensors (electrodes) to deliver quick, low-energy shocks to the chest. Electric cardioversion allows a health care provider to instantly see if the procedure has restored a typical heartbeat. Note: a Chemical (pharmacological) cardioversion uses medicine to restore the heart’s rhythm. It takes longer to work than electric cardioversion. Source: Mayo Clinic at: https://www.mayoclinic.org/tests-procedures/cardioversion/about/pac-20385123 ↑
  22. Source: Oishi, ML; Xing, S (February 2013). “Atrial fibrillation: management strategies in the emergency department”. Emergency Medicine Practice. 15 (2): 1–26, quiz 27. PMID 23369365 ↑
  23. Explanation: Ablation, a procedure to treat atrial fibrillation, uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats. This can help the heart maintain a normal heart rhythm. There are some risks associated with the procedure, however. Although rare, there is the risk of death. Source: Hopkins Medicine at: www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation ↑
  24. Source: Amerena, JV; Walters, TE; Mirzaee, S; Kalman, JM (4th November 2013). “Update on the management of atrial fibrillation”. The Medical Journal of Australia. 199 (9): 592–97. ↑
  25. Source: Freedman, B; Potpara, TS; Lip, GY (20th August 2016). “Stroke prevention in atrial fibrillation”. Lancet. 388 (10046): 806–17. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31257-0/fulltext ↑
  26. Source: Hindricks, Gerhard; Potpara, Tatjana; Dagres, Nikolaos; Arbelo, Elena; Bax, Jeroen J.; Blomström-Lundqvist, Carina; Boriani, Giuseppe; Castella, Manuel; Dan, Gheorghe-Andrei; Dilaveris, Polychronis E.; Fauchier, Laurent (29 August 2020). “2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)”. European Heart Journal. 42 (5): 373–498. doi:10.1093/eurheartj/ehaa612. ISSN 1522-9645. PMID 32860505. ↑
  27. Source: Steinberg, BA; Piccini, JP (14 April 2014). “Anticoagulation in atrial fibrillation”. BMJ (Clinical Research Ed.). 348: g2116. ↑
  28. Sources: (1) Munger, TM; Wu, LQ; Shen, WK (January 2014). “Atrial fibrillation”. Journal of Biomedical Research. 28 (1): 1–17, and (2) Chung, MK; Eckhardt, LL; Chen, LY; Ahmed, HM; Gopinathannair, R; Joglar, JA; Noseworthy, PA; Pack, QR; Sanders, P; Trulock, KM; American Heart Association Electrocardiography and Arrhythmias Committee and Exercise Cardiac Rehabilitation, and Secondary Prevention; Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health (March 2020). “Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association”. Circulation. 141 (16): e1-23. ↑
  29. Source: https://www.nhsinform.scot/illnesses-and-conditions/heart-and-blood-vessels/conditions/atrial-fibrillation © Crown copyright aclnowledged ↑
  30. Source: Zoni-Berisso, M; Lercari, F; Carazza, T; Domenicucci, S (2014). “Epidemiology of atrial fibrillation: European perspective”. Clinical Epidemiology. 6: 213–20. ↑
  31. Ibid ↑
  32. Sources: (1) GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). “Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015”. Lancet. 388 (10053): 1459–544, and (2) GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). “Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013”. Lancet. 385 (9963): 117–71. ↑
  33. See https://en.wikipedia.org/wiki/Cardiac_cycle for further explanation. ↑
  34. Source: Gersh, Bernard J (2000). Mayo Clinic Heart Book. New York: William Morrow. pp. 6–8. ISBN 0-688-17642-9. ↑
  35. Source: https://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/expert-answers/atrial-fibrillation-genetics/faq-20111614. See also, https://www.frontiersin.org/articles/10.3389/fcvm.2020.00014/full ↑
  36. See: https://www.sciencedirect.com/science/article/pii/S0735109703004650 ↑
  37. See: Article on European Heart Journal, at: https://academic.oup.com/eurheartj/article/27/6/708/2887151 ↑
  38. Source: Arnar DO, Thorvaldsson S, Manolio TA, Thorgeirsson G, Kristjansson K, Hakonarson H, Stefansson K. Familial aggregation of atrial fibrillation in Iceland. Eur Heart J. 2006; 27:708–712. See: https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.120.316575 ↑
  39. Source: https://www.nhs.uk/conditions/atrial-fibrillation/ © Crown copyright acknowledged. ↑
  40. Some people with Diabetes are never aware they have AF as Diabetes is known to mask heart flutters. ↑
  41. Source: https://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/symptoms-causes/syc-20350624 ↑
  42. Sources: https://www.mayoclinic.org/diseases-conditions/atrial-flutter/symptoms-causes/syc-20352586 and https://www.nhs.uk/conditions/atrial-fibrillation/ © Crown copyright aclnowledged. ↑
  43. Explanation: Ablation is a procedure to treat Atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats. This can help the heart maintain a normal heart rhythm. Source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation ↑
  44. Based mainly on: https://www.nhs.uk/conditions/atrial-fibrillation/ © Crown copyright aclnowledged ↑
  45. Source: https://www.bhf.org.uk/informationsupport/conditions/atrial-fibrillation ↑
  46. Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/atrial-fibrillation/afib-complications ↑
  47. See: https://www.bhf.org.uk/informationsupport/conditions/atrial-fibrillation ↑
  48. Source: mainly from: https://www.medicalnewstoday.com/articles/237191.php ↑
  49. See https://www.heart.org/en/health-topics/atrial-fibrillation/treatment-and-prevention-of-atrial-fibrillation/atrial-fibrillation-medications ↑
  50. See: https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.018551 ↑
  51. Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/atrial-fibrillation ↑
  52. Source: https://www.healthline.com/health/atrial-fibrillation/types-of-atrial-fibrillation ↑
  53. Source: https://www.nhs.uk/conditions/atrial-fibrillation/ © Crown copyright aclnowledged ↑
  54. Source: NHS. © Crown copyright acknowledged. ↑
  55. Source: https://www.nhsinform.scot/illnesses-and-conditions/heart-and-blood-vessels/conditions/atrial-fibrillation © Crown copyright aclnowledged ↑

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Martin Pollins

Martin Pollins is a Chartered Accountant and MBA with wide experience in corporate finance and business management. He has served on the boards of several companies, including those listed on the London Stock Exchange, AIM and OFEX. He is the Chairman and Founder of OneSmartPlace and was a Council member of the Institute of Chartered Accountants in England and Wales from 1988 to 1996. He was managing partner of PRB Martin Pollins, based in Sussex, the first Accountancy firm to advertise on British television. He went on to create and launch the CharterGroup Partnership (the UK’s first Accountancy network) and then LawGroup UK (at the time, one of the largest networks of lawyers in the UK). In recent years, he helped to raise several £millions to fund British films such as The Da Vinci Code, Bridge of San Luis Rey, Head in the Clouds and Merchant of Venice with actors such as Charlize Theron, Robert De Niro, Al Pacino, F. Murray Abraham. Kathy Bates, Gabriel Byrne, Geraldine Chaplin, Tom Hanks, Ian McKellen, Audrey Tautou, Penélope Cruz, Steven Berkoff, Lynn Collins, Jeremy Irons, Joseph Fiennes and many more. He has written several business publications (see https://onesmartplace.com/resources/)

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