Atrial fibrillation
Atrial fibrillation (AF) is the most common cardiac arrhythmia – in Estonia it has been diagnosed in approximately 26,000 people. AF is generally not a life-threatening arrhythmia, but one of its complications – stroke – can be life-threatening. However, in AF the risk of stroke can be reduced with medications that prevent blood clot formation.
Nature of atrial fibrillation
The heart consists of four chambers: two atria and two ventricles. In normal heart function, the sinus node that controls the heart rhythm sends out regular electrical impulses, known as sinus rhythm, causing the atria to contract first, followed by the ventricles. This allows the heart to pump blood throughout the body.
In AF, the sinus node no longer coordinates the heart rhythm. Electrical impulses move irregularly within the atria, causing them to quiver or fibrillate. The movement of blood from the atria to the ventricles is disrupted and the pulse becomes irregular. An irregular pulse is one of the main features of AF.
AF may present as short episodes (paroxysms), during which the heart rhythm returns to normal between episodes, or as a persistent arrhythmia, where the heart is continuously out of rhythm. AF is usually a chronic condition, and over time episodes tend to become more frequent and more persistent.
Risk factors
The main risk factor for AF is age – it occurs more frequently at older ages. However, lifestyle also plays an important role in whether AF develops. Smoking, excessive alcohol consumption, overweight, low physical activity, unbalanced diet, and excessive stress all promote the development and persistence of AF.
Several chronic diseases also increase the risk of AF, such as hypertension, coronary artery disease, heart failure, diabetes, sleep apnea, and thyroid disorders.
Symptoms
The most common symptoms are palpitations, fluttering or discomfort in the chest, or simply a feeling that the heart is out of rhythm. Shortness of breath, fatigue, reduced exercise tolerance, dizziness or lightheadedness, near-fainting, anxiety or fear, and changes in usual heart rate may also occur. Sometimes there may be no symptoms or noticeable changes in well-being – however, this does not exclude the presence of arrhythmia or the development of complications.
Possible complications
It is possible to live a good quality life with AF for decades, but it is important to be aware of possible complications, the most significant of which are stroke and heart failure. The risk of stroke in people diagnosed with AF is approximately five times higher than in those without this arrhythmia. When the atria do not contract regularly, blood flow in the heart slows and blood clots may form. These clots can travel through blood vessels to different organs; if they reach the arteries of the brain, a stroke occurs.
It is important to know that in AF, the risk of stroke can be effectively reduced with medications that prevent clot formation.
Symptoms of stroke include sudden weakness on one side of the body, speech disturbance, balance problems, facial asymmetry, and severe headache. If these symptoms occur, emergency medical help must be called.
Heart failure, unlike stroke, develops gradually. In heart failure, the heart’s ability to pump enough blood to the organs is reduced. The condition may present with weakness, shortness of breath, and swelling of the legs.
Treatment
The goals of AF treatment are to reduce symptoms, decrease the risk of stroke, and reduce the need for hospitalization. A healthy lifestyle is the cornerstone of achieving these goals, but it is also essential to follow the treatment plan recommended by your doctor – even if you feel well.
Healthy lifestyle
Take a small step toward a healthier lifestyle every day and do not give up if setbacks occur. It is never too late to (re)start. Components of a healthy lifestyle include a varied and healthy diet, appropriate physical activity, quitting smoking, limiting alcohol consumption, good sleep, and keeping chronic conditions under control according to your doctor’s recommendations.
Prevention of blood clots
The majority of patients with AF require long-term oral anticoagulant therapy to effectively reduce the risk of stroke. Common anticoagulants include apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin. Aspirin is not suitable for stroke prevention in patients with AF.
Anticoagulants increase the risk of bleeding, but the doctor takes this into account when prescribing medication and will advise you on how to reduce your bleeding risk.
Some over-the-counter medications or dietary supplements may interact with anticoagulants, and certain painkillers (such as ibuprofen) further increase the risk of bleeding; therefore, it is essential to consult a doctor or pharmacist before using them.
Heart rate control and restoration of sinus rhythm
Palpitations, which are the main complaint in AF, can be alleviated with heart rate-slowing medications such as metoprolol, verapamil, and digoxin, which are taken regularly and long term. In most cases, slowing the heart rate is sufficient to restore good well-being. Restoring sinus rhythm is not necessarily a prerequisite for feeling well.
If symptoms persist despite heart rate-slowing medication, the doctor may recommend restoration of sinus rhythm, known as cardioversion. For this, the patient is usually admitted to hospital for a short period.
Sinus rhythm can be restored either with medications administered into a vein (pharmacological cardioversion) or by a procedure performed under light anesthesia, during which an electrical impulse is delivered through the chest and heart muscle (electrical cardioversion). If the arrhythmia has lasted for more than 48 hours, it may sometimes be necessary to confirm before cardioversion that there is no blood clot in the heart chambers. This can be done using transesophageal echocardiography, during which a probe with an ultrasound transducer at its tip is inserted through the mouth into the esophagus. The examination is similar to gastroscopy.
After cardioversion, the doctor may prescribe long-term medications to help maintain normal heart rhythm and delay further arrhythmia episodes (e.g. metoprolol, propafenone, amiodarone).
If episodes of atrial fibrillation are frequent and significantly affect quality of life, the doctor may recommend catheter ablation. This is a procedure in which the abnormal electrical pathways causing the arrhythmia in the left atrium are eliminated using a probe (catheter) inserted into the heart via the femoral vein. The patient is admitted to hospital for a short period for the procedure. Catheter ablation is a complex procedure, but it generally prevents arrhythmia episodes more effectively than medication.
If a decision is made not to restore sinus rhythm, atrial fibrillation with no symptoms or only mild symptoms does not reduce life expectancy or quality of life.
How can you help yourself?
- Check your pulse from time to time. You can feel your pulse on the palm side of the wrist near the thumb, or on the neck a few centimeters to the right or left of the midline. At rest, the heart should beat regularly, 60–100 times per minute.
- If you feel that your heart has gone out of rhythm, meaning a possible arrhythmia episode has occurred, try to stay calm. In most cases this is not a life-threatening situation, although it may feel uncomfortable. Most episodes resolve on their own within a few days. If your doctor has prescribed medication for atrial fibrillation episodes, use it as instructed. If the episode lasts longer than usual or does not resolve with medication, your condition worsens, or severe chest pain, shortness of breath, or symptoms of stroke occur, seek medical attention.
- Consult your doctor or pharmacist before using any over-the-counter medication or dietary supplement. Some of these may have undesirable interactions with your atrial fibrillation medications. Also avoid substances that can promote arrhythmias, such as caffeine, alcohol, nicotine, and illicit drugs.
Compiled by: Kristin Ly Järving, Tuuli Teeäär, Märt Elmet, Eve Laane, Urmet Arus
2026