Persistent atrial fibrillation: symptoms, diagnosis and treatment in the UK

Atrial fibrillation (AF) is a heart rhythm problem in which the heartbeat is not steady. The British Heart Foundation explains that the electrical signals in the top chambers of the heart, the atria, do not get sent out properly, so they quiver rather than contracting steadily. This makes the heartbeat irregular and means the heart does not pump blood as well as it should.

AF is grouped by how long episodes last. The British Heart Foundation describes paroxysmal AF as episodes that start and stop within 7 days and usually stop on their own, and persistent AF as one or more episodes lasting more than 7 days that you will usually need treatment for. It also lists long-standing AF, which is continuous for a year or more, and permanent AF, where you live with AF long term even after treatment. The NHS notes that symptoms may stop after treatment in persistent AF and that, over time, some people may always have symptoms.

The categories describe where someone is at a moment in time. A person can move from one to another, and the label guides which treatments are likely to be discussed.

The NHS lists an irregular pulse, a pounding, racing, fluttering or skipping heartbeat, a heartbeat faster than 100 beats per minute, feeling very tired, finding it harder to exercise, chest pain or tightness, and feeling short of breath, lightheaded or dizzy. It also says sometimes there are no symptoms, and AF is found at a routine check-up or when you are having tests for something else.

The NHS advises seeing a GP if you think you may have symptoms, if palpitations keep happening or are getting worse, or if you have been diagnosed and treatment is not helping your symptoms. It says to call 999 if you currently have a fast or irregular heartbeat together with chest pain, shortness of breath, sweating, feeling or being sick, fainting, dizziness or falling, a severe headache, weakness or numbness on one side of the face or body, blurred vision or loss of sight, or confusion or difficulty speaking. The NHS adds that you should not drive yourself to A&E.

The NHS says AF is caused by a problem with the electrical system that makes the heart beat. Anyone can get it, but you are more likely to if you are aged 55 or older, are a man, are living with obesity or overweight, smoke, take certain medicines such as levothyroxine, lithium or some asthma medicines like salbutamol, or do endurance sports. Other conditions can also cause it, including high blood pressure, heart failure, mitral valve problems, a heart attack, chronic kidney disease, an overactive thyroid, diabetes and sleep apnoea.

The British Heart Foundation says that damage to the heart is the most common cause, and that triggers can include alcohol, caffeine, smoking, recreational drugs, emotional stress and spicy food. It also notes that many people have no other conditions or risk factors but still get AF, and that the risk increases with age. The NHS adds that when AF is caused by another condition or a medicine, treating the condition or stopping the medicine can improve symptoms.

The British Heart Foundation says AF is usually noticed when a healthcare professional checks your pulse during an examination or health check, and that an irregular pulse leads to further tests. An ECG records the rhythm, rate and electrical activity of the heart and is the key test for confirming the pattern. NICE guidance on AF recommends manual pulse palpation when AF is suspected, for example in people with breathlessness, palpitations, fainting or dizziness, chest discomfort, or a stroke or transient ischaemic attack, followed by a 12-lead ECG if an irregular pulse is found.

The NHS says that if a GP thinks you could have AF you will be referred to a cardiologist, who will ask about your symptoms, check your heart rate and arrange tests to look for other causes. These tests may include an ECG, an echocardiogram, a chest X-ray and blood tests. The British Heart Foundation notes that smart watches can sometimes help flag a rhythm problem, but that only a healthcare professional can diagnose AF.

AF can lead to blood clots forming in the heart, which is why stroke prevention is a core part of care. The NHS lists anticoagulants, which lower the risk of blood clots and stroke, among the main medicines for AF, and the British Heart Foundation says anticoagulants and DOACs are the most effective treatments to reduce stroke risk in AF.

NICE guidance recommends using the CHA2DS2-VASc score to assess stroke risk, offering a direct-acting oral anticoagulant to people with a score of 2 or above after taking bleeding risk into account, and using the ORBIT score to assess bleeding risk. It also says not to offer aspirin on its own solely for stroke prevention in AF. Your clinician will weigh your own risks, so do not stop or change anticoagulants without advice.

NICE guidance offers rate control as the first-line strategy for most people, except in some situations, for example where there is a reversible cause, heart failure thought to be primarily caused by AF, new-onset AF, atrial flutter, or where an ablation strategy to restore normal rhythm is considered suitable. Rhythm control, with medicines or electrical cardioversion, can be considered for people whose symptoms continue after the heart rate has been controlled or for whom rate control has not worked.

NICE also says that when AF has lasted longer than 48 hours or its duration is uncertain and long-term rhythm control is being considered, cardioversion should be delayed until the person has been on therapeutic anticoagulation for a minimum of 3 weeks. If drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic persistent AF, NICE says to consider left atrial ablation, using radiofrequency or cryoballoon techniques, after discussing the risks and benefits. The NHS describes ablation as using burning, freezing or high-energy electrical pulses to destroy a section of the heart, and cardioversion as using electricity to reset the rhythm.

The NHS says there is currently no cure for AF, but treatment should help manage symptoms and lower the risk of complications such as blood clots, stroke and heart failure. It says you should be able to carry on doing most things as usual, including exercise, though intense exercise should be avoided and you should not exercise when you have symptoms. If you drive, you may need to tell the DVLA, and your doctor can tell you if this applies. There may also be practical things to think about such as travelling with medicine and insurance.

Helpful steps listed by the NHS include avoiding triggers such as caffeine, spicy food, stress, dehydration and lack of sleep, keeping to a healthy weight, eating a balanced diet, aiming for at least 150 minutes of moderate exercise a week, not smoking and not drinking too much alcohol. The British Heart Foundation adds controlling blood pressure and cholesterol and managing conditions such as diabetes. The British Heart Foundation and MyHeart are named by the NHS as sources of support.

On the NHS the route usually runs from the GP to a cardiologist, with tests and a treatment plan agreed with you, and regular check-ups afterwards. Some people choose to see a private cardiologist or electrophysiologist for speed or a second opinion, particularly when ablation is being considered. Whichever route is used, ask who will manage your anticoagulation and monitoring over the long term.