Atrial Fibrillation
Atrial fibrillation is the most common cardiac arrhythmia — causing an irregular heartbeat that significantly increases stroke risk. Expert assessment, anticoagulation, and rhythm management are key to long-term protection.
Heart palpitations can feel like fluttering, pounding, or skipped beats
Atrial fibrillation is the most common sustained cardiac arrhythmia, characterised by disorganised electrical activity in the atria causing an irregular and often rapid heart rate. Beyond symptoms, AFib carries a fivefold increased risk of ischaemic stroke and is a significant contributor to heart failure and cognitive decline. Early diagnosis and a structured management strategy are essential to reduce these risks.
Types of AFib
- Paroxysmal AFib terminates spontaneously within seven days, often within 48 hours. Episodes may be infrequent and brief, making ambulatory monitoring essential for diagnosis.
- Persistent AFib lasts longer than seven days and requires medical or electrical intervention to restore sinus rhythm.
- Long-standing Persistent AFib has been continuous for more than 12 months. Rhythm control remains possible but requires more aggressive strategies.
- Permanent AFib is a joint decision between patient and clinician to no longer pursue rhythm restoration, focusing instead on rate control and stroke prevention.
Symptoms
AFib commonly presents with palpitations — described as a fluttering, racing, or irregular heartbeat — alongside breathlessness, fatigue, reduced exercise tolerance, dizziness, and chest discomfort. A significant proportion of patients are entirely asymptomatic, with AFib detected incidentally on ECG or during investigation for stroke. Asymptomatic AFib carries the same stroke risk as symptomatic disease and requires equivalent treatment.
Causes & Risk Factors
AFib is strongly associated with hypertension, coronary artery disease, valvular heart disease, heart failure, and obstructive sleep apnoea. Hyperthyroidism, chronic kidney disease, and excessive alcohol consumption are important reversible causes. Risk increases significantly with age, and a family history of AFib confers independent genetic susceptibility.
Diagnosis
A standard 12-lead ECG confirms AFib when present at the time of recording. For paroxysmal AFib with intermittent symptoms, prolonged ambulatory monitoring via Holter monitor, event recorder, or implantable loop recorder is required to capture episodes. Echocardiography assesses for structural heart disease, left atrial enlargement, and left ventricular function — all of which influence treatment decisions. Thyroid function and electrolyte testing are performed to identify reversible precipitants.
Stroke Risk Assessment & Anticoagulation
Stroke prevention is the single most important therapeutic priority in AFib management. Risk is stratified using the CHA₂DS₂-VASc score — a validated tool assigning points for age, hypertension, diabetes, prior stroke, heart failure, vascular disease, and sex. Patients with a score of two or more (men) or three or more (women) are recommended long-term anticoagulation. Direct oral anticoagulants (DOACs) — apixaban, rivaroxaban, edoxaban, or dabigatran — are preferred over warfarin for most patients due to superior efficacy and safety profiles. For patients who cannot tolerate anticoagulation, left atrial appendage closure (LAAC) — a catheter-based procedure that seals the primary site of clot formation in the heart — offers an alternative stroke prevention strategy.
Rate & Rhythm Control
Rate control — slowing the ventricular response with beta-blockers, calcium channel blockers, or digoxin — is appropriate for patients with minimal symptoms or those where rhythm restoration is not feasible. Rhythm control aims to restore and maintain sinus rhythm through antiarrhythmic medications (flecainide, amiodarone, sotalol) or catheter ablation. Pulmonary vein isolation (PVI) via radiofrequency or cryoablation is the most effective rhythm control strategy for paroxysmal and early persistent AFib, with superior long-term outcomes compared to antiarrhythmic drugs alone. Electrical cardioversion restores sinus rhythm rapidly and is used both acutely and as part of planned rhythm management.
When to Seek Specialist Review
Seek cardiology assessment for new or recurrent palpitations, unexplained breathlessness or fatigue, or incidentally detected irregular pulse. Urgent evaluation is required if AFib is accompanied by haemodynamic compromise, pre-syncope, or suspected stroke symptoms — call 995 immediately in the latter case.
Experiencing palpitations, an irregular heartbeat, or recently diagnosed with AFib? Dr. Peter Chang consults at Paragon Medical Centre, Orchard Road. Book a specialist assessment today.