Surviving Disease – Atrial Fibrillation

Atrial Fibrillation.

Many people have heard about Atrial Fibrillation. Even so, I hope you continue to read about this relatively common heart disease, which can be unpleasant. Moreover, if not treated, it can be life-threatening in some circumstances. 

Causes are too many to mention (a thousand), but the big ones are:

• High blood pressure, mostly from obesity and advanced age. 
• Atherosclerosis (vascular disease)
• Heart valve disease which leads to less efficiency of the heart as a pump
• Cardiomyopathy (enlarged heart muscle as seen in CHF and other disorders)
• Pericarditis (inflammation of the lining around the heart muscle)
• COPD (chronic obstructive pulmonary disease – commonly seen in smokers)
• Diabetes type 2 (can happen with type 1 but is more common in type 2)
• Pulmonary embolism (a blood clot that has traveled to the lungs) 

Congenital heart diseases and athletes with predisposition to heart disease. Wow, Athletes! I had a patient in his 20s who had something called Wolff Parkinson White syndrome which is a serious congenital defect with atrial fibrillation. I was glad he told his doctor how he was feeling and we did identify an abnormality on his ECG for something referred to as a delta wave. Something subtle that can be easily missed.

If you remember, my father had heart disease, most likely due to smoking and being overweight. He had a heart attack, mitral valve disease, and congestive heart failure – all risk factors. What I did not mention is that he also had developed  AFib (atrial fibrillation) sometime after his heart attack.

I am writing this not so much for my father’s story but for my mother.

One evening my sister called me and reported “Mom says she can’t breathe, I am taking her to the hospital”. I suggested calling 911 but they were already on their way and nearly at the ER. On arrival at the ER, her heart rate was noted to be 182 bpm; they believed she was in AFib. 

A year earlier, she was not feeling well. I checked her pulse and it was irregular (which can indicate atrial fibrillation). I told her she needed to go to the hospital, however, she wanted to wait and see if she felt better just resting for a while. I was nervous about waiting and encouraged her to go. Despite my concern, she continued to refuse to go to the hospital so I rechecked her pulse after she told me she was feeling better. It felt regular. I explained that this type of issue requires more than just feeling her pulse and I told her to make an appointment with her primary care doctor to evaluate her heart rhythm. Several things could be responsible for her irregular pulse but without the proper diagnostic tools (such as an electrocardiogram) we could not be certain and even then she could need additional testing.

She went to the doctor and reported to the medical assistant what had happened. The MA told her that her pulse was regular so she never reported it to her doctor or the Nurse Practitioner. It is critical that people always report symptoms and issues to their providers and not dismiss them. Getting older sometimes makes it hard to face a potential problem. It is more convenient to dismiss it or to persuade yourself that your doctor is too busy and you don’t want to “bother them”. Especially when symptoms come and go; you don’t want anyone to think you are a hypochondriac when they can’t see your symptoms for themselves.

Atrial fibrillation is simply an abnormal heart rhythm; it can have a very rapid rate and the beats are irregular. The rapid rate can cause problems such as shortness of breath, dizziness and be difficult to feel if it is irregular or count how fast the rate is. Some people complain of a feeling of pounding heartbeats (palpitations).  

Here are some of the symptoms people may complain of with atrial fibrillation:

• Irregular heartbeat.
• Heart palpitations (rapid, fluttering, or pounding)
• Lightheadedness.
• Extreme fatigue.
• Shortness of breath.
• Chest pain.

The heart has things called pacemakers; specific cells that tell the heart when to contract. Like a car that sets the pace for all the other cars before a race. Sometimes something goes wrong and these pacemaker cells do not function properly. I will go into it more at a later time; however, for right now I am trying to keep things as simple as possible.

The heart has 4 chambers;  2 upper chambers (atrium) and 2 lower chambers (ventricles). They contract at specific intervals so as to empty the upper chamber into the lower chamber. First the right side of the heart and then the left side. This process is what gives us our blood pressure. 

Just before the valve closes between the upper and lower chamber, the upper chamber gives one last hard squeeze which fills the lower chamber completely; also called “atrial kick” which can affect your blood pressure. This cycle is repeated on each side of our heart. It is also the classic reason we hear the “Lub Dub” sound doctors are listening for when they use their stethoscope on your chest. It is the rhythmic closing of the heart valves as blood is pumped in and out of the chambers.

If the upper chamber is not contracting normally as seen in AFib; that chamber does not really squeeze normally but is more like a quiver (random contractions). If the heart rate is too fast then the atrial muscle does not have time to relax between contractions. When this happens it reduces the heart’s efficiency and therefore its performance, often resulting in lower blood pressure and other symptoms.

It is my understanding that there can be hundreds of causes for AFib, including the usual culprits; heart disease, smoking, heavy alcohol consumption, obesity, high blood pressure, heart valve problems, legal (caffeine) and illegal (you know what those are) drugs and last but not least, the one everyone will go through – aging. 

I am sure most reading this are thinking, “Great, just another thing to worry about!”. But if you look at the list of common causes, these are all within our ability to change – except, of course, aging. Ugh!  

Here are the types of AFib that people need to know:

• Paroxysmal atrial fibrillation – where it comes and goes, like in my mother’s case. 
• Persistent atrial fibrillation; each episode lasts longer than a week usually.
• Permanent and long-standing atrial fibrillation; it is there all the time,  like in my father’s case.

This is the thing: When the upper chamber (atrium) does not empty properly, there is an area where blood can swirl. This swirling can lead to the formation of blood clots which can, if the chamber suddenly contracts normally, send these blood clots out into the body. The right side of the heart feeds the lungs, and the left side of your heart feeds your brain. 

I worked with a doctor who told me that his father had atrial fibrillation.  He went out to golf one day, had a massive stroke and died. No one ever knew he had it and most likely he did not know it either. This is another reason why regular “routine” healthcare is important.  

None of the forms of atrial fibrillation are a good scenario. This is why treatment is needed when it is detected.

There is yet one more thing to worry about. It is called Atrial Flutter. Again the chambers are not contracting in coordination with the ventricle, but this rhythm feels a little more regular and there is usually a pattern. In AFib we say ”irregular irregular” (all over the place – either no pattern or too fast to tell) but with Atrial Flutter we say irregular regular meaning there is more of a pattern unless the rate is fast and then it will be too difficult to tell. With very rapid rates you can hear it called “SupraVentricular Contractions” (SVT) – or fast rate above the ventricles. There are maneuvers doctors can perform or medications to slow the heart rate down just long enough to hopefully see the underlying issue.

Can someone have AFib and AFlutter?  The answer is yes, although AFlutter is reported to be less common.

Regardless, there are several treatment options (medications and procedures) that are best discussed with your cardiologist. You want the best option for you and your specific disease profile–not because your neighbor is taking a particular med or had a particular treatment.  Everyone is unique in their particular healthcare.  Everyone. 

My father, given his heart disease, started on coumadin (anticoagulant) – which some people know is a“rat poison”. When he had his open heart surgery for his bad heart valve, they tried to do an “ablation” (basically burn the tracks the impulses travel on) however it was not successful.  He needed a pacemaker installed and had to stay on an anticoagulation treatment.  

All in all, not the end of the world as he got his new valve and we had him around us for another 10 years!

I learned in the ICU that atrial fibrillation often will come back after a cardioversion (electric shock to the heart) but the atrial flutter does better with that treatment as well as the catheter ablation treatment. 

I had a patient who had severe heart disease with atrial fibrillation, was diabetic, had kidney disease and was not tolerating her anticoagulants. Her cardiologist recommended the insertion of the “Watchman”. This is done in the cardiac cath lab either through the groin or wrist. It is a treatment that should eliminate the risk of blood clots from the left atrial appendage (the area where blood can swirl and form clots) from entering the bloodstream and causing a stroke. 

There are several medications to control heart rate – those that usually end in “olol”, also called beta blockers because of their effect on those cells that control heart rate. There are others, my mother was on a calcium channel blocker which also slows heart rate. Every medication has side effects and should be discussed with your primary care physician to make an informed decision that is the right choice for you.  

In my mother’s case, given her advanced age, leukemia, and mild kidney disease, her cardiologist recommended medication to reduce heart rate and anticoagulation to control the clot issue. She did fine on these.

What is most important are the warning signs. Do not do what my mother did, get stubborn and insist she can “rest” instead of getting medical attention.

If you have:

Heart palpitations  – check your pulse (neck or wrist) – is it fast, irregular, strong or weak, just feels weird, is your pulse slow (less than 60 beats in a minute or fast – greater than 100 beats at rest)?

Are you short of breath?

Lightheaded or dizzy?

Chest pain, even if it comes and goes (it can feel heavy or tight), are you sweaty, feeling or being nauseated? The heart’s blood supply occurs when it is at rest, between contractions, with rapid rates the heart gets a very poor blood supply which can lead to a heart attack.

Do you have jaw, shoulder blade, arm pain, numbness or tingling, or have a history of heart disease? Heart attack is often not like in the movies, symptoms often are referred to as discomfort, not pain. The presentation can vary from person to person. Time is your enemy. In 3 short hours, damage can become irreversible. 

Do you feel like something is wrong and you just aren’t quite sure what is happening?

Call the Emergency response providers and let them figure out what is happening. 

The last thing I would like to leave you with. We control our bodies and wellness. Start healthy practices early on. If you are older and already have multiple risk factors there is much you can do to change your course and extend your life expectancy. There is going to be a lot more to come on that topic and my new favorite 4 letter word. Can anyone guess what it is?

I apologize for not continuing my sister’s story this week but promise it is coming soon. I am working on it, however, it is very technical information and I want it to be approachable information that is easy to understand to anyone who reads it. This blog is, after all, about you and your health education!

Hope you enjoyed the information I have provided to you. Please comment and let me know what your thoughts are and if there is some topic you would like to hear more about. I want this to be as interactive as possible!