Atrial Fibrillation

The clinical manifestations of atrial fibrillation vary greatly from person to person.
Some patients may be completely asymptomatic (silent AF), while others experience disabling symptoms:

• Palpitations: sensation of rapid, irregular, or “chaotic” heartbeats, sometimes described as “the heart trying to jump out of the chest”;
• Shortness of breath (dyspnea): during exertion or even at rest;
• Unusual fatigue;
• Reduced exercise capacity;
• Feeling unwell, lightheadedness, dizziness;
• Chest pain or discomfort;
• Anxiety, often linked to the awareness of palpitations;
• Increased urination (polyuria) during episodes.

The severity of symptoms is not necessarily correlated with the seriousness of the AF or the risk of complications. Some highly symptomatic patients may have a low risk of complications, while others who are completely asymptomatic may have a high risk.

It is important to note that approximately 30% of patients with atrial fibrillation experience no symptoms. The diagnosis is then made incidentally during a routine medical examination or after the occurrence of a complication.

It is recommended to consult a doctor in the following situations:

• If you experience persistent or recurrent palpitations;
• In case of unusual shortness of breath, especially if it worsens over time;
• If you feel unexplained fatigue or a decrease in physical abilities;
• In case of faintness, dizziness, or loss of consciousness;
• If you have chest pain, particularly if it is accompanied by other symptoms;
• If you have a family history of atrial fibrillation or sudden cardiac death, even in the absence of symptoms.

A consultation with a cardiologist or an electrophysiologist will allow the necessary tests to be performed for diagnosis:

• Electrocardiogram (ECG): a basic examination that can confirm AF if present at the time of the test;
• Holter ECG: continuous recording of heart activity for 24 to 48 hours, particularly useful for paroxysmal AF;
• Event monitor or implantable recorder: for infrequent arrhythmias;
• Echocardiogram: to assess the structure and function of the heart;
• Blood tests: to look for secondary causes (thyroid disorders, electrolyte imbalances).

These diagnostic tests can be performed at the various Rythmopole Paris centers, particularly at Cardiopôle Yvart (15th district of Paris) and Centre Damrémont (18th district of Paris).

Atrial fibrillation can occur in individuals with or without underlying heart disease. Several risk factors and triggers have been identified:

• Non-modifiable risk factors
  Age: The risk of AF increases significantly with age. Its prevalence is around 0.5% before the age of 50 but exceeds 10% after the age of 80;
• Genetic predisposition: Certain forms of AF, particularly those occurring at a young age, may have a genetic component;
• Sex: Men are more frequently affected than women, although this gap narrows with age.
• Modifiable cardiovascular risk factors
  High blood pressure: A major risk factor for AF, present in about 70% of patients;
• Obesity: Each increase in body mass index (BMI) raises the risk of AF by approximately 4–5%;
• Diabetes;
• Metabolic syndrome;
• Sleep apnea: Present in 40 to 50% of AF patients;
• Physical inactivity;
• Smoking;
• Excessive alcohol or stimulant consumption (caffeine, drugs).

Associated heart conditions

• Ischemic heart disease (heart attack, coronary artery disease);
• Heart failure;
• Valvular diseases, especially mitral valve disorders;
• Cardiomyopathies (hypertrophic, dilated, restrictive);
• Congenital heart disease;
• Pericarditis, myocarditis;
• History of heart surgery.

Other causes

• Hyperthyroidism;
• Infections, particularly lung infections;
• Electrolyte imbalances;
• Chronic lung disease;
• Pulmonary embolism;
• Intense physical or emotional stress.

In some cases, no specific cause is identified, in which case it is referred to as “isolated” or “idiopathic” atrial fibrillation. However, with the improvement of diagnostic techniques, this category tends to decrease.

Atrial fibrillation can lead to several serious complications, some of which may be life-threatening or impact functional prognosis:

Stroke (Cerebrovascular Accident)
This is the most feared complication of atrial fibrillation:

• In the absence of effective atrial contraction, blood can stagnate and form clots, particularly in the left atrial appendage.
• These clots may detach and travel through the circulation, especially to the brain, causing an ischemic stroke.
• AF increases the risk of stroke fivefold; approximately 20–30% of all ischemic strokes are attributable to this arrhythmia.
• The stroke risk is not the same for all AF patients; it depends on additional risk factors assessed by clinical scores (mainly the CHA₂DS₂-VASc score), which take into account age, sex, history of stroke, hypertension, diabetes, heart failure, and vascular disease.
• Strokes related to AF tend to be more severe, with higher mortality and greater residual disability compared to strokes of other origins.

Heart failure
Atrial fibrillation and heart failure have a complex, bidirectional relationship:

• AF can cause or worsen heart failure through several mechanisms: loss of atrial contribution to ventricular filling, rapid and irregular ventricular rate, and decreased cardiac output.
• Conversely, heart failure promotes AF by causing atrial dilation and electrical remodeling.
• More than 30% of patients with AF will develop heart failure, and about 40% of patients with heart failure will experience AF.
• The coexistence of both conditions significantly worsens prognosis.

Other complications

• Systemic embolism: clots formed in the atria may travel elsewhere in the body (kidneys, lower limbs, intestines).
• Cognitive decline and dementia: AF is associated with an increased risk of cognitive impairment, even in the absence of clinically apparent stroke, possibly due to silent cerebral micro-emboli.
• Tachycardiomyopathy: prolonged rapid ventricular rates can lead to ventricular dilation and dysfunction, generally reversible after restoring rate or rhythm control.
• Reduced quality of life: even without severe complications, AF can significantly impact quality of life due to symptoms and treatment constraints.
• Recurrent hospitalizations and high healthcare costs.
• Increased mortality: AF is associated with a twofold increase in all-cause mortality, even after adjusting for associated comorbidities.

These complications highlight the importance of appropriate AF management, which includes not only controlling the arrhythmia itself but also preventing thromboembolic complications and addressing associated risk factors.

The management of atrial fibrillation is based on a comprehensive approach with four main objectives. At the Rythmopôle Center, our specialists develop a personalized treatment plan for each patient.

Prevention of thromboembolic complications
Stroke prevention is a top priority:

• Risk assessment: mainly using the CHA₂DS₂-VASc score
• Oral anticoagulation for most at-risk patients:
  • Direct oral anticoagulants (apixaban, rivaroxaban, etc.)
  • Vitamin K antagonists (warfarin, fluindione)
• Left atrial appendage closure: an alternative for patients who cannot take anticoagulants

Heart rate control
The goal is to maintain a reasonable ventricular rate:

• Beta-blockers: first-line treatment
• Calcium channel blockers (diltiazem, verapamil)
• Digoxin: generally used in combination
• Amiodarone: for difficult cases

Heart rhythm control
The goal is to restore and maintain a normal sinus rhythm:

• Cardioversion: restoration of sinus rhythm by electrical shock or medications
• Antiarrhythmic drugs: to maintain sinus rhythm
• Catheter ablation: interventional treatment aimed at isolating the pulmonary veins
  • Atrial fibrillation ablation is performed at the Institut Mutualiste Montsouris by the Rythmopôle Paris electrophysiologists.

Management of risk factors
Addressing contributing factors is essential:

• Control of high blood pressure
• Management of overweight and obesity
• Treatment of sleep apnea
• Reduction of alcohol consumption
• Regular, appropriate physical activity

The choice among therapeutic options depends on many factors, including the patient’s age, type of atrial fibrillation, severity of symptoms, and associated comorbidities. A personalized approach, discussed between the patient and their electrophysiologist, is essential to optimize outcomes.

The prevention of atrial fibrillation is primarily based on controlling modifiable risk factors:

Lifestyle

• Healthy diet: favor a Mediterranean-style diet, rich in fruits, vegetables, fish, olive oil, and low in saturated fats.
• Regular physical activity: moderate exercise (such as brisk walking) for at least 150 minutes per week is recommended. However, very intense and prolonged endurance exercise may paradoxically increase the risk of AF in some individuals.
• Weight management: maintain a healthy weight or lose weight in cases of overweight or obesity. Significant weight loss in obese patients with AF can reduce arrhythmic burden and improve treatment outcomes.
• Limiting alcohol: even moderate alcohol consumption can increase the risk of AF. Abstinence or very limited consumption is recommended.
• Smoking cessation: smoking is an independent risk factor for AF.
• Stress management: relaxation techniques, meditation, or yoga can help reduce stress, a potential trigger for AF.

Control of medical risk factors

• Monitoring and treating high blood pressure: keep blood pressure well controlled (generally < 130/80 mmHg).
• Good diabetes management.
• Screening and treatment of sleep apnea.
• Regular thyroid function monitoring, especially in at-risk individuals.

Medication precautions

• Use caution with medications that may promote AF, such as certain decongestants, stimulants, or bronchodilators.
• Avoid self-medication without medical advice.

These preventive measures are particularly important for individuals with a family history of AF or other non-modifiable risk factors.

Rythmopôle Paris offers comprehensive expertise in the management of atrial fibrillation:

• A team of electrophysiologists specialized in the diagnosis and treatment of heart rhythm disorders, including all forms of atrial fibrillation.
• Advanced technical facilities enabling all necessary tests for accurate diagnosis and risk assessment.
• Expertise in atrial fibrillation ablation procedures, performed at the Institut Mutualiste Montsouris.
• A personalized approach, taking into account the specific characteristics of each patient (age, type of AF, comorbidities, preferences).
• Comprehensive care that integrates stroke prevention, arrhythmia control, and treatment of risk factors.
• Tailored follow-up provided across multiple centers in the Île-de-France region, ensuring easy access to care.
• Coordination with other specialists (cardiologists, neurologists, endocrinologists) for a multidisciplinary approach.