Atrial Fibrillation

Atrial Fibrillation

What is Atrial Fibrillation and How Might It Affect You?

Have you recently been told you have atrial fibrillation (AF)? Or perhaps your smartwatch flagged an irregular heart rhythm? As a cardiologist specialising in heart rhythm disorders, I see patients every week who are confused and concerned about their AF diagnosis and worry about what this means in terms of heart disease.

What is Atrial fibrillation (AF)

Atrial fibrillation (AF) is the most common heart rhythm disorder, affecting the upper chambers of your heart called the atria. In normal circumstances, your heart beats in a regular, coordinated rhythm controlled by electrical signals. With atrial fibrillation, these electrical signals become chaotic and disorganised, causing the atria to quiver or "fibrillate" rather than contract effectively. This irregular rhythm means your heart cannot pump blood as efficiently as it should, and blood may pool in the atria, potentially forming dangerous clots. While AF itself is rarely immediately life-threatening, it significantly increases your risk of stroke because of a blood clot, and can lead to heart failure if left untreated. The condition affects nearly 1.5 million people in the UK, with numbers expected to double by 2050 as our population ages.

AF can be paroxysmal (coming and going in episodes that typically last less than 7 days and often stop spontaneously) or persistent (continuing for more than 7 days or requiring medical intervention to restore normal rhythm). Paroxysmal atrial fibrillation is particularly common in younger patients and generally responds better to treatment, though both types can significantly impact your quality of life and require specialist care.

While some of my patients experience noticeable symptoms like heart palpitations or shortness of breath, others feel perfectly fine and are surprised when AF is discovered during a routine check-up.

The Unexpected Nature of an AF Diagnosis

One of the most common reactions I see is surprise. Many of my patients are athletic, very fit individuals in their 40s and 50s who never expected to have any heart problems. I remember one particular patient – a super-fit gentleman who regularly did weightlifting and was extremely active. When he developed atrial flutter (a close cousin of AF), he was genuinely shocked that someone so healthy could develop a heart rhythm disorder.

This reaction is completely understandable, but it's important to know that AF doesn't discriminate based on fitness level. Even high-profile individuals like former Prime Minister Tony Blair have undergone treatment for heart rhythm disorders. These aren't "old people's heart problems" – this can affect anyone, regardless of how healthy and active they are.

How People Discover They Have AF

Your journey with AF might have started in several ways, and increasingly, technology is playing a crucial role in early detection.

The Apple Watch Revolution

Many of my patients now discover their condition through their Apple Watch or other wearable devices that monitor heart rhythm. This technology has genuinely revolutionised how we detect AF, often catching it before you might notice any AF symptoms. Before we had wearable technology and smartwatches, patients could spend years seeking a diagnosis – they'd experience palpitations, but by the time they reached A&E or got a heart monitor, the episode had settled.

Now, if your Apple Watch alerts you to an irregular heartbeat rhythm, you can capture that exact moment using the ECG function. Simply open the ECG app on your watch, place your finger on the digital crown for 30 seconds, and you'll have a recording that I can interpret immediately.

Other Common Ways AF is Discovered

For others, AF is found during a pre-operative assessment for an unrelated procedure. Imagine preparing for knee surgery only to discover you have a heart rhythm disorder that needs addressing first. This happens more frequently than you might think, and it can feel like quite an unsettling surprise when you thought you were simply getting your knee fixed.

Some patients visit their GP with vague AF symptoms like feeling unusually tired or experiencing occasional fluttering sensations in their chest. Your GP might have examined you, found an irregular pulse, performed an ECG, and referred you after finding AF.

In more acute cases, you might have ended up in A&E during an episode of AF that caused significant symptoms, leaving you feeling frightened and uncertain about what was happening to your body.

Why You Shouldn't Wait to Treat Your AF

If you've been diagnosed with AF, you might be wondering whether it needs immediate attention or if a "wait and see" approach is acceptable. From my extensive clinical experience and the latest research, I can tell you that addressing AF promptly leads to significantly better outcomes.

The clinical evidence is clear: treating AF earlier rather than later gives you the best chance of returning to normal rhythm long-term, which is hugely important, and in certain groups of patients reduces the chances of developing heart failure. When I perform an AF ablation (the most effective treatment for many patients) within a year or two of diagnosis, your chances of success are dramatically higher than if we wait several years.

Unfortunately, if you're relying on the NHS pathway, you might face significant delays. After seeing your GP, you'll likely be referred to a general cardiologist before finally seeing an electrophysiologist (a heart rhythm specialist like myself). Once you're on the waiting list for an ablation, you could wait another year. By that point, your chances of a successful outcome have already diminished significantly.

How Timing Affects Your Treatment Success

Let me share what I've seen in my practice regarding success rates:

If you're relatively young and healthy with paroxysmal AF (where symptoms come and go), and we treat you promptly, your chance of successful treatment exceeds 80%. However, if your AF has become persistent (continuous), those odds drop to about 60-70%.

The longer you wait, particularly if you follow the typical NHS timeline of 18+ months from diagnosis to treatment, your success rate for persistent AF can fall below 50%.

What Treatment Options Do You Have?

When you come to see me with AF, we'll discuss several treatment approaches based on your specific situation.

For some patients, I recommend a cardioversion as a first step. This procedure temporarily restores normal heart rhythm and helps us determine how much your symptoms improve in normal rhythm. It's also useful if there's a clear trigger for your AF, such as excessive alcohol consumption or thyroid problems, which we can address alongside the cardioversion.

For many patients, an AF ablation offers the most definitive solution. This is particularly true if your AF is paroxysmal, if you're significantly affected by symptoms, or if your AF is beginning to affect your heart's pumping function (which can lead to heart failure if left untreated).

What Happens During an Atrial Fibrillation Ablation?

If we decide an ablation is right for you, here's what you can expect from start to finish:

You'll have a pre-assessment the week before your procedure. On the day, you'll arrive at the hospital a couple of hours before your scheduled time. I'll meet with you and the anaesthetist before you undergo general anaesthesia.

In my private practice, all AF ablations are performed under general anaesthetic, which means you'll be completely asleep throughout the entire procedure. This is one of the significant advantages of private treatment – you won't experience any discomfort or awareness during the ablation.

During the procedure, I'll insert catheters through the vein in your groin to access your heart.

Using either radiofrequency energy, cryoablation (freezing), or in some cases the newest technique, pulsed field ablation (PFA), I'll create precise lesions in your left atrium to stop the irregular electrical signals causing your AF. The technology allows me to target exactly the right areas with remarkable precision.

In my private practice, you'll stay overnight for monitoring, and we'll perform an echocardiogram before discharge to ensure everything looks perfect. You might experience some soreness in your groin where we inserted the catheters, and some chest soreness due to the effects of the ablation itself.

I'll advise you to take things easy for about a week, and you might feel somewhat tired or notice mild chest tightness and shortness of breath for 3-4 weeks after the procedure – this is completely normal and part of the healing process.  You might notice episodes of AF in the first three months after the procedure, which is often related to the healing process AF the ablation.  It is only after the first three months we judge how effective it has been.

It's worth noting that in the NHS, due to anaesthetic availability and resource constraints, many AF ablations are performed under heavy sedation rather than general anaesthetic. The NHS also tends to discharge patients the same day to manage bed availability. With private treatment, AF ablation is normally done under general anaesthetic.

Some AF ablations require two procedures to achieve the best long-term results, though many patients are successfully treated with a single procedure.

What Are the Risks of AF Ablation?

I believe in being completely transparent about risks. For AF ablation, I tell my patients to consider two key numbers: 3% and 1 in 1,000.

The 3% represents the risk of complications that are fixable but might require a longer hospital stay. These include things like vascular injury where we insert the catheters, fluid collecting around the heart (pericardial effusion), or temporary nerve damage that typically heals within six months.

The 1 in 1,000 figure represents the risk of more serious complications such as stroke, need for cardiac surgery, or a rare but serious complication called atrial-esophageal fistula. To put this in perspective, this risk is comparable to the everyday risks you take driving in London.

The Cost of AF Treatment

An AF ablation in my private practice costs approximately £22,000. While this represents a significant investment, it's important to consider this in the context of a lifetime of improved quality of life and the potential prevention of serious complications like stroke or heart failure. The cost reflects the sophisticated technology involved, the general anaesthetic for your comfort, overnight monitoring, and the expertise of the entire team caring for you.

When patients ask me about the investment, I often point out that this is less than many people spend on a new car

What Happens If You Don't Treat Your AF?

If you're wondering whether you can simply live with AF, it's important to understand the potential consequences.

Some people do adapt to being in AF and experience minimal symptoms, particularly older patients. However, between 5-10% of patients with untreated AF will develop heart failure that becomes difficult to manage with medications alone.

Even if you feel fine now, AF typically reduces your exercise capacity and quality of life over time, often in ways you might not immediately notice. Many of my patients are surprised by how much better they feel after successful treatment, even those who didn't think their AF was causing significant symptoms.

Can Lifestyle Changes Help Your AF?

Absolutely. In my practice, I've seen remarkable improvements in some patients who make targeted lifestyle changes:

Weight management is particularly important. If you're carrying extra weight, losing even a moderate amount can significantly improve your chances of success with ablation or even help manage AF without a procedure.

Alcohol reduction makes a substantial difference for many patients. If you drink regularly, cutting back can noticeably reduce the frequency of your AF episodes.

While medications like beta-blockers can help control symptoms and rate in some cases, most patients with AF will need to remain on anticoagulants (blood thinners) to reduce stroke risk, regardless of whether they choose ablation or medication management.

Making the Right Decision for Your Heart

Living with atrial fibrillation doesn't mean you have to accept a reduced quality of life or worry about long-term heart damage. With early intervention and the right specialist care, most of my patients return to normal rhythm and enjoy all their usual activities without limitations.

The key is not waiting until it's too late for optimal treatment. If you've been diagnosed with AF or suspect you might have it, seeking specialist care promptly gives you the best chance for a complete recovery and protects your heart health for years to come.

Remember, this isn't about age or fitness level – AF can affect anyone. But with modern technology for diagnosis, sophisticated treatment options, and the right specialist care, you can expect to return to your full, active life. The surprise of an AF diagnosis doesn't have to define your future – with proper treatment, it can simply be a brief chapter in your ongoing story of good health.

Atrial Fibrillation in the UK: The Numbers

Understanding the scope of atrial fibrillation in the UK helps put your condition into perspective:

Nearly 1.5 million people in the UK are living with atrial fibrillation, making it the most common sustained cardiac arrhythmia. Even more concerning, experts believe there are hundreds of thousands more undiagnosed cases.

The prevalence of AF increases dramatically with age—while it affects less than 1% of people under 60, this rises to over 10% in those aged 80 and above. With our aging population, the number of AF cases is expected to double by 2050.

AF accounts for approximately 20% of all strokes in the UK, and these strokes tend to be more severe than strokes from other causes. Proper anticoagulation can reduce this risk by up to 70%, but many patients remain inadequately treated.

Most troubling is the "treatment gap" we see in the UK. While early intervention provides the best outcomes, the average time from diagnosis to specialist treatment in the NHS exceeds 18 months—far longer than the optimal treatment window.

The cost to the NHS for managing AF and its complications exceeds £2.2 billion annually. Earlier intervention would not only improve patient outcomes but could significantly reduce this financial burden on our healthcare system.

Frequently Asked Questions About Atrial Fibrillation

Atrial fibrillation causes blood clots because the irregular rhythm means the atria don't empty completely with each heartbeat. This stagnant blood, particularly in the left atrial appendage, provides the perfect conditions for clot formation. The blood essentially becomes sluggish and sticky, making clots much more likely to develop.

Atrial fibrillation causes stroke because the irregular heart rhythm prevents the atria from contracting effectively. When blood pools in the left atrial appendage, it can form clots. If these clots break free and travel to the brain's blood vessels, they cause a stroke. This is why anticoagulation is so important for AF patients.

Atrial fibrillation causes shortness of breath because the heart's efficiency is reduced when the atria don't contribute their normal "atrial kick" to filling the ventricles. Additionally, the often rapid and irregular heart rate means the heart doesn't have adequate time to fill properly between beats, reducing the amount of blood pumped to your lungs and body.

Pneumonia causes atrial fibrillation because any severe infection or illness creates stress on the body, including the heart. The inflammation, fever, and increased oxygen demands associated with pneumonia can trigger AF in susceptible individuals. This is why AF sometimes develops during acute illnesses and may resolve once the underlying condition is treated.

Those most at risk for atrial fibrillation include people over 65, individuals with high blood pressure, those with heart disease or heart failure, people with diabetes, those with sleep apnoea, individuals with hyperthyroidism, and people who consume excessive alcohol. However, AF can occur in young, healthy individuals without any of these risk factors.

Anyone can get atrial fibrillation, though it becomes more common with age. While we typically see it in older adults, I regularly treat athletes, professionals in their 40s and 50s, and even younger individuals. AF affects approximately 1.5 million people in the UK, and this number is expected to double by 2050.

Atrial fibrillation occurs when the electrical system of the heart becomes disorganised. Instead of the normal, coordinated electrical impulses, multiple chaotic electrical circuits develop in the atria. This can be triggered by various factors including age-related changes to heart tissue, underlying heart conditions, high blood pressure, or sometimes occurs without any identifiable cause.

Warfarin is prescribed for atrial fibrillation to prevent stroke by reducing the blood's ability to clot. Since AF significantly increases stroke risk due to clot formation in the atria, anticoagulation with warfarin (or more commonly newer alternatives like rivaroxaban or apixaban) reduces this risk by approximately 70%.

Atrial fibrillation causes fatigue because the heart's pumping efficiency is reduced. The irregular rhythm and often rapid heart rate mean your heart works harder but less effectively. Additionally, the loss of coordinated atrial contraction reduces the heart's ability to fill properly, leading to reduced blood flow and oxygen delivery to your muscles and organs.

Atrial fibrillation is dangerous primarily because it significantly increases your risk of stroke – AF accounts for approximately 20% of all strokes in the UK, and these strokes tend to be more severe. Additionally, if left untreated, AF can lead to heart failure and can reduce your overall life expectancy. However, with proper treatment, these risks can be substantially reduced.

We give anticoagulants for atrial fibrillation to prevent stroke, which is the most serious complication of AF. Anticoagulants reduce the blood's tendency to clot, dramatically reducing the risk of clots forming in the atria and subsequently travelling to the brain to cause stroke.

Atrial fibrillation occurs in mitral stenosis because the narrowed mitral valve causes increased pressure and enlargement of the left atrium. This structural change creates the perfect environment for AF to develop, as the enlarged, overstretched atrial tissue is more prone to developing the chaotic electrical circuits that characterise AF.

Left atrial enlargement causes atrial fibrillation because the stretched atrial tissue develops abnormal electrical properties. The enlarged atrium provides more space for multiple electrical circuits to develop, and the stretched heart muscle cells become more irritable and prone to generating the chaotic electrical activity that characterises AF.

Athletes can get atrial fibrillation for several reasons. Intense endurance training can cause structural changes to the heart, including atrial enlargement and changes to the electrical system. Additionally, the increased vagal tone common in athletes can predispose to AF. However, it's important to note that exercise-induced AF is different from AF due to underlying heart disease, and the prognosis is generally excellent with appropriate treatment.

If you undergo a successful ablation, your need for blood thinners depends on several factors. For patients with minimal risk factors for stroke (measured by something called a CHA₂DS₂-VASc score), we often discontinue anticoagulants after a successful ablation and a period of normal rhythm. However, if you have additional stroke risk factors like high blood pressure, diabetes, or previous stroke, you'll likely need to continue anticoagulation even after a successful procedure.

Yes, and I often encourage it with appropriate precautions. Exercise is beneficial for your overall cardiovascular health, but you should work with your specialist to determine the right intensity and type of exercise for your specific situation. Many of my patients successfully return to their previous exercise routines after treatment, including competitive sports and activities like cycling and running.

Paroxysmal AF comes and goes, with episodes typically lasting less than 7 days and often stopping spontaneously. Persistent AF continues without interruption for more than 7 days or requires intervention (like cardioversion) to restore normal rhythm. The distinction is important because paroxysmal AF generally responds better to ablation therapy. Your specialist can determine which type you have based on your ECGs and monitoring results.

There are two main categories of medications for AF: rhythm control (trying to maintain normal sinus rhythm) and rate control (controlling how fast your heart beats while in AF). Common rhythm control medications include flecainide, amiodarone, and sotalol. Rate control medications include beta-blockers (e.g. bisoprolol), calcium channel blockers (e.g. verapamil), and digoxin. Every patient responds differently to these medications, and finding the right one often requires careful monitoring and adjustment.

Untreated or poorly managed AF is associated with increased mortality, primarily due to stroke risk and heart failure development. However, with proper treatment—including appropriate anticoagulation and rhythm or rate control strategies—many patients can expect a normal lifespan. Early intervention with ablation for suitable candidates has been shown to improve long-term outcomes and quality of life.

There is a genetic component to AF, particularly for AF that develops at a younger age. If you have AF, first-degree relatives (parents, siblings, children) have approximately a 40% increased risk of developing AF compared to the general population. However, lifestyle factors like obesity, high blood pressure, and excessive alcohol consumption play a much larger role in most cases. Focus on helping your family maintain a heart-healthy lifestyle rather than worrying about genetic risks.

The Science Behind Early Intervention for AF

The recommendation for early intervention in atrial fibrillation isn't just based on clinical experience—it's supported by robust scientific evidence:

The landmark EAST-AFNET 4 trial, published in the New England Journal of Medicine in 2020, demonstrated that early rhythm control therapy (within 1 year of diagnosis) was associated with a lower risk of adverse cardiovascular outcomes compared to usual care. This large randomized trial involving 2,789 patients showed a significant reduction in the composite outcome of cardiovascular death, stroke, and hospitalization for heart failure or acute coronary syndrome.¹

For ablation specifically, the CABANA trial showed that catheter ablation for atrial fibrillation, compared with medical therapy, led to clinically important and significant improvements in quality of life that were maintained for at least 5 years.²

A 2021 meta-analysis published in the European Heart Journal found that AF ablation was associated with significantly lower all-cause mortality and heart failure hospitalization compared to medical therapy alone, particularly when performed early in the disease course.³

The CASTLE-AF study demonstrated that catheter ablation for atrial fibrillation in patients with heart failure was associated with a significantly lower rate of death and hospitalization for worsening heart failure than medical therapy.⁴

Research published in Heart Rhythm in 2018 showed that delaying ablation by 12 months or more after diagnosis was associated with significantly lower success rates and higher rates of progression to persistent AF, supporting the "AF begets AF" concept where the arrhythmia causes electrical and structural changes that make it harder to treat over time.⁵

In the EARLY-AF trial, patients who had ablation as an initial treatment for AF versus medications were approximately 50% less likely to have AF one year later.6

¹ Kirchhof P, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-1316.

² Mark DB, et al. Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019;321(13):1275-1285.

³ Turagam MK, et al. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2019;8(16):e011662.

⁴ Marrouche NF, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018;378(5):417-427.

⁵ Hussein AA, et al. Natural History and Management of Atrial Fibrillation: From an Arrhythmia to Heart Failure. JACC Clin Electrophysiol. 2018;4(3):411-421.

6Andrade JG et al., Cryoablation or Drug Therapy for Initial Treatment of Atrial FibrillationN Engl J Med 2021;384:305-315