Heart
Atrial Fibrillation
An irregular, often rapid heart rate that causes poor blood flow and significantly increases the risk of stroke.
Atrial fibrillation (AFib) is the most common sustained cardiac arrhythmia, characterised by disorganised electrical activity in the atria causing an irregular and often rapid heart rate. The condition significantly elevates stroke risk and contributes to heart failure and cognitive decline.
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Atrial fibrillation disrupts the heart's normal electrical rhythm, leading to poor circulation and a dramatically increased risk of stroke.
What Atrial Fibrillation Is
In a normal heartbeat, the two upper chambers (the atria) give a coordinated squeeze that tops up the pumping chambers below. In atrial fibrillation (AF), the atria stop squeezing and quiver instead, firing chaotic electrical signals. The result is an irregular pulse, often fast, and atria that are no longer emptying properly.
It is the commonest sustained rhythm disturbance we see, affecting roughly one in twenty-five people over 60 and more with each decade. AF is rarely life-threatening in the moment, but it carries two real consequences: a markedly higher risk of stroke, because still blood in the atria can form a clot, and, over years, a heart that tires. Both are largely preventable once AF is known about.
It is the commonest sustained rhythm disturbance we see, affecting roughly one in twenty-five people over 60 and more with each decade. AF is rarely life-threatening in the moment, but it carries two real consequences: a markedly higher risk of stroke, because still blood in the atria can form a clot, and, over years, a heart that tires. Both are largely preventable once AF is known about.
Paroxysmal, Persistent, Permanent
AF is described by how long episodes last, and the pattern tends to drift towards longer episodes over time.
- Paroxysmal — episodes start and stop on their own, usually within a day or two and always within a week
- Persistent — an episode lasts more than a week, or needs a medication or a shock to restore normal rhythm
- Long-standing persistent — continuous AF for more than a year where rhythm control is still being attempted
- Permanent — a shared decision that normal rhythm will not be chased, and effort goes into rate control and stroke prevention instead
How It Feels, or Doesn't
Many people feel an irregular thudding or racing in the chest, a fluttering in the throat, breathlessness, unusual tiredness, or that they simply run out of steam faster than usual. Some feel light-headed.
But roughly a third of people with AF feel nothing at all, and it is picked up on a routine ECG, a pre-operative check, or — least welcome — only after a stroke. This is why we take an irregular pulse seriously even in someone who feels well, and why a smartwatch flagging an irregular rhythm is worth bringing to a doctor rather than ignoring.
But roughly a third of people with AF feel nothing at all, and it is picked up on a routine ECG, a pre-operative check, or — least welcome — only after a stroke. This is why we take an irregular pulse seriously even in someone who feels well, and why a smartwatch flagging an irregular rhythm is worth bringing to a doctor rather than ignoring.
The Stroke Question: CHA₂DS₂-VASc and Blood Thinners
The single most important decision in AF is whether you need a blood thinner. When the atria fibrillate, blood stagnates in a small pouch called the left atrial appendage, a clot can form, and if it travels to the brain it causes a stroke — and AF-related strokes tend to be large ones.
We estimate your risk with the CHA₂DS₂-VASc score, which adds points for age, high blood pressure, diabetes, heart failure, vascular disease, prior stroke and being female. Above a low threshold, a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, dabigatran or edoxaban is recommended — these have largely replaced warfarin and need no routine blood monitoring. Aspirin does not protect against AF stroke. For people who genuinely cannot take anticoagulation, a left atrial appendage closure device is an alternative.
We estimate your risk with the CHA₂DS₂-VASc score, which adds points for age, high blood pressure, diabetes, heart failure, vascular disease, prior stroke and being female. Above a low threshold, a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, dabigatran or edoxaban is recommended — these have largely replaced warfarin and need no routine blood monitoring. Aspirin does not protect against AF stroke. For people who genuinely cannot take anticoagulation, a left atrial appendage closure device is an alternative.
Rate or Rhythm: Two Ways to Treat the Beat
Separate from stroke prevention, we decide how to handle the rhythm itself. Neither approach is ‘better’ in the abstract; it depends on your symptoms, age and how long AF has been present.
- Rate control — a beta-blocker or a calcium channel blocker to keep the resting heart rate comfortably below about 110, accepting the irregular rhythm
- Rhythm control with medication — an antiarrhythmic drug, sometimes with a planned electrical cardioversion to reset the rhythm
- Catheter ablation (pulmonary vein isolation) — a keyhole procedure that electrically isolates the triggers around the pulmonary veins. It is the most effective option for paroxysmal AF, and doing it earlier rather than after years of AF gives better results
Finding and Fixing the Triggers
AF is often the surface sign of something treatable underneath, and modern care puts as much weight on the drivers as on the rhythm.
- Blood pressure — the commonest driver; getting it to target reduces AF episodes
- Obstructive sleep apnoea — very common in AF and easily missed; treating it markedly cuts recurrence, so we screen for it
- Alcohol — dose-related, and even moderate drinking provokes AF in susceptible people; cutting back helps
- Weight — losing 10% of body weight measurably lowers AF burden
- Thyroid overactivity and very heavy endurance exercise are other correctable contributors
Living With AF in Singapore
Most people with well-managed AF live completely normal lives — working, travelling and exercising. To catch episodes we use a 24-hour to 14-day Holter or patch monitor (about SGD 300 to SGD 600), an implantable loop recorder for elusive symptoms, or a single-lead smartwatch ECG.
Go to an emergency department if a fast irregular heartbeat comes with chest pain, fainting, or severe breathlessness. Otherwise, AF is managed in the clinic: we review it, the anticoagulant and the triggers from Paragon Medical Centre on Orchard Road, and refer for ablation (roughly SGD 20,000 to SGD 40,000 privately, with Medisave and insurance often applicable) when rhythm control is the right path.
Go to an emergency department if a fast irregular heartbeat comes with chest pain, fainting, or severe breathlessness. Otherwise, AF is managed in the clinic: we review it, the anticoagulant and the triggers from Paragon Medical Centre on Orchard Road, and refer for ablation (roughly SGD 20,000 to SGD 40,000 privately, with Medisave and insurance often applicable) when rhythm control is the right path.
Atrial Fibrillation: Common Questions
Concerned About Atrial Fibrillation?
Dr. Peter Chang offers specialist assessment and personalised management at Paragon Medical Centre, Singapore.