Atrial Fibrillation: Understanding its Symptoms and Warning Signs

September is National Atrial Fibrillation Awareness Month.

I saw a commercial the other day which caught my attention. It was either real people or actors saying they had experienced certain symptoms and, since “they didn’t wait” to tell their healthcare provider, their atrial fibrillation (Afib) had been promptly diagnosed and appropriately treated. I don’t recall if it was selling a medication or if it was a public service announcement, but if their goal was to make me aware of Afib, it would likely work (if I didn’t have such a strong family history, since I was a doctor, and already was keenly aware of it before).

Atrial fibrillation is a disordered electrical disturbance where the atria, the small compartments of the heart, stop beating in synchrony. It is described as the heart looking like a bag of worms. The erratic impulses cross over to the ventricles and are irregularly propagated causing irregular myocardial contractions. Unmedicated Afib is usually rapid and irregularly irregular (that is, without a discernible pattern).

Afib is the most common cardiac dysrhythmia, and by 2030, it is predicted there will be more than 12 million Americans living with it. Afib contributes to approximately 158,000 deaths yearly and that has been rising over the past few decades because life expectancy has been creeping up (until the last few years, of course, when COVID-19 has reversed that trend). The prevalence and incidence of Afib increase sharply after 65 years of age, and more than 10 percent of patients 85 years old or older have Afib.

Risk factors for Afib include advancing age, family history, obesity, smoking, alcohol use disorder, stress, and certain medical conditions like hypertension, diabetes, hyperthyroidism, heart disease including valvular disease and heart failure, and chronic kidney disease. The dysrhythmia can lead to blood clots in the heart, heart failure, other complications caused by decreased cardiac output, and the dreaded stroke.

Afib causes approximately 20 percent of strokes, although in patients over 80 years old, it is more like 1 in four strokes. It probably is associated with an even higher number because Afib itself increases the risk of ischemic embolic cerebrovascular accidents, but anticoagulation for Afib also results in hemorrhagic strokes, too.

There are typical signs and symptoms which are associated with Afib including heart palpitations, irregular heartbeat, fatigue, chest pain, shortness of breath, dizziness or lightheadedness, syncope, and hypotension. Patients may be asymptomatic and unaware that they are in Afib. Making the public aware of potential presentations of Afib is the goal of that commercial I mentioned at the beginning of this piece. If you, or someone you know, experiences any of these signs or symptoms, you should seek medical attention immediately, not pull an “I’ll tell my doctor about it when I see her next.”

In the emergency department, they would do an electrocardiogram to look at the heart rhythm, draw blood work to see if the patient had a heart attack, get a chest X-ray, and possibly have the patient undergo an echocardiogram. Treatment would be supportive initially to manage the heart rate, prevent complications, and possibly try to convert the patient into a normal cardiac rhythm.

New-onset Afib is what it sounds like. It is the first presentation of Afib, what type it will ultimately be is as yet undetermined. Paroxysmal Afib consists of usually short-lived, self-terminating episodes which recur sporadically.

Persistent Afib lasts longer than a week and requires intervention to cease. Management can consist of rate control, usually with beta blockers or calcium channel blockers; attempts to put the patient back into sinus rhythm, which can be done by electrical cardioversion, chemically with antiarrhythmics, or by surgical ablation; and anticoagulation to minimize the risk of stroke from intra-atrial clot.

If Afib continues for more than a year, it is deemed long-standing persistent. When a physician and patient decide cardioversion is no longer going to be an option, Afib is deemed permanent. The expression, chronic Afib includes both persistent and permanent Afib. Chronic, persistent, and permanent Afib are all comorbid conditions/complications (CCs). Paroxysmal and unspecified Afib are not.

Older, sicker hearts can develop slow heart rhythms and require pacemakers. If the underlying rhythm is slow atrial fibrillation, it would continue to be codable. These patients are often maintained on anticoagulation, too, so they would get a long-term anticoagulation use code as well.

I’m not sure it is appropriate to say, “Happy National Atrial Fibrillation Awareness Month,” but I will say it anyway. Be aware of Afib and do what you can to decrease your risk.

Modify your lifestyle to decrease your risk.

Quit smoking, control your weight, exercise, get enough sleep, limit your stress, and refrain from excessive alcohol and caffeine. Take your blood pressure, diabetes, and cholesterol-reducing medications as prescribed.

Happy National Atrial Fibrillation Awareness Month!

Programing note: Listen to Dr. Erica Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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