“Man, doc, I’m just tired and out of breath doing any little thing the last couple of weeks. Just walking in here I’m winded.” Mr. Saxon, a man in his sixties, had not been in great health, having various issues with high blood pressure, cholesterol, and blood sugar, but this was a definite change for the worse.
As I listened to his heart and lungs, the latter sounded fine but the heart was irregular and racing in the 120’s (with normal being a rate somewhere between 60 and 100). An EKG showed a condition called atrial fibrillation (AF) which accounted for his newfound symptoms.
AF is a condition where the smaller chambers of the heart are quivering rapidly rather than beating rhythmically. The larger pumping chambers, the ventricles, are still beating ok although sometimes too rapidly. Some with AF barely notice it while others experience substantial shortness of breath or worrisome chest pressure and pain, occasionally even triggering a heart attack.
AF is not uncommon, affecting 4% of persons over age 60 and 8% of persons over age 80. Risk factors for it include other types of heart disease, heart failure, valvular abnormalities, diabetes mellitus, and hypertension. As with Mr. Saxon, it sometimes comes to light when a patient develops symptoms of fatigue, shortness of breath, chest pain, palpitations, or feeling faint. Other times we notice it incidentally while carrying out a physical on a patient with no particular symptoms. Still other times someone notices while taking their own pulse or having it recorded by an automatic blood pressure cuff or even a piece of exercise equipment that their heart rate is high and irregular and they come in to find out why.
So what needs to be done once it’s found? There are two main challenges. The first is to decide whether the person just needs their heart rate controlled or whether an attempt should be made to put their heart back into normal sinus rhythm. Often a well-controlled but still irregular AF rhythm is satisfactory as long as the person doesn’t have a lot of symptoms with it. Other times it can be workable and helpful to re-establish a normal rhythm, either by delivering a controlled electrical charge to the heart or with the use of medications.
The second challenge is to prevent a clot from forming in the quivering part of the heart. A clot in the heart runs the risk of going to the brain and causing a stroke. In fact about 15% of strokes are caused by AF, especially if untreated. For this reason, various anticoagulants (blood thinners) are used to prevent this. A simple treatment with aspirin is generally insufficient and more complicated medications are indicated such as warfarin (Coumadin) or some of the newer agents that don’t require frequent blood testing.
The speed with which these challenges have to be solved depends on the severity of the symptoms and the fragileness of the patient. On one end of the spectrum are those with chest pain, shortness of breath and a rapid heart rate who need to be taken directly to the emergency department for swift treatment to prevent a heart attack. On the other end of the spectrum, some have no symptoms at all and a fairly controlled rate and can be readily treated as an outpatient.
Either way, AF needs attention and management. So if your heart is all a flutter, and it’s not because you’re head over heels in love, better get it checked out.