Atrial fibrillation in older adults: symptoms, stroke prevention and treatment

The BHF explains that in AF the electrical signals in the top chambers (atria) of the heart are not sent out properly. Instead of being steady and regular they quiver or twitch, so the heart beats randomly and does not pump blood as well as it should. The NHS says the cause is a problem with the electrical system that makes the heart beat.

The BHF describes four patterns: paroxysmal (episodes within 7 days that usually stop without treatment), persistent (episodes lasting more than 7 days, usually needing treatment), long-standing (continuous for 1 year or more) and permanent (living with AF long term, even after treatment). Atrial flutter is a related rhythm where the heart beats much faster than normal but regularly, and some people alternate between flutter and AF.

The NHS lists an irregular pulse, sudden pounding, racing, fluttering or skipping heartbeat, a rate over 100 beats per minute, tiredness, finding it harder to exercise, chest pain or tightness, and feeling short of breath, lightheaded, dizzy or faint. Because dizziness, tiredness and faintness are also common in older people for many other reasons, and because some people have no symptoms, AF may be picked up when a nurse or doctor checks the pulse.

The BHF notes you can feel your pulse at the wrist: a normal resting rate is steady and usually between 60 and 100 beats a minute, whereas in AF the pulse has no set pattern and beats vary in strength. Smart watches and similar devices can help notice a possible problem, but the BHF says only a healthcare professional can diagnose AF.

The NHS says to see a GP if you think you have AF, if palpitations keep happening or get worse, or if treatment is not helping. It says to call 999 if you currently have a fast or irregular heartbeat and also have chest pain, shortness of breath, sweating, feeling or being sick, fainting, dizziness or falling over, 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. Several of these are stroke signs. The NHS says not to drive yourself to A&E. The BHF also says you can call 111 for an assessment of AF symptoms.

Anyone can get AF. The NHS lists age 55 or older, being male, overweight or obesity, smoking, certain medicines (levothyroxine, lithium and some asthma medicines such as salbutamol) and endurance sports. Conditions it names include high blood pressure, heart failure, mitral valve problems, a previous heart attack, chronic kidney disease, an overactive thyroid, diabetes and sleep apnoea. The BHF adds heart valve disease, cardiomyopathy, coronary heart disease, pericarditis, lung conditions, pulmonary embolism and sick sinus syndrome, and triggers such as alcohol, caffeine, smoking, recreational drugs, emotional stress and spicy food.

The NHS says that sometimes AF is caused by another condition or medicine, and that treating the condition or stopping the medicine can improve symptoms. In older people taking several medicines, this is a reason for a medication review.

If a GP thinks AF is possible, the NHS says they refer you to a cardiologist, who asks about symptoms, checks heart rate and arranges tests to check heart rhythm and look for other causes. These may include an electrocardiogram (ECG), an echocardiogram, a chest X-ray and blood tests.

The NHS says treatment may include medicine to control heart rate and rhythm, such as beta blockers, and to lower the risk of blood clots and stroke (anticoagulants). Other options are ablation (destroying a small area of heart tissue by burning, freezing or high-energy electrical pulses), electrical cardioversion to reset the rhythm, and a pacemaker or implantable cardioverter defibrillator. Regular check-ups should confirm symptoms are controlled.

The BHF says anticoagulants and DOACs are the most effective treatments to reduce stroke risk. Whether to start one, and which, is a decision made with the clinician, who weighs stroke risk against bleeding risk and other medicines taken; do not stop an anticoagulant without advice, and report any significant bleeding or a fall with head injury straight away.

The NHS suggests avoiding triggers such as caffeine, spicy food, stress, dehydration and lack of sleep, keeping to a healthy weight, eating a balanced diet and aiming for at least 150 minutes of moderate exercise a week, while avoiding intense exercise and exercise during symptoms. It advises not smoking and not drinking too much alcohol. You may need to tell the DVLA, and think about travel with medicines and insurance. The BHF says AF will affect your life but is manageable, and notes emotional support hubs and a Heart Helpline staffed by cardiac nurses.