Afib shortness of breath

Why Does AFib Make You Feel Short of Breath?

Shortness of breath is a very common symptom that people describe when they’re having episodes of atrial fibrillation, and it’s very common that people who are in AFib all the time feel short of breath.

How Does Atrial Fibrillation Affect Breathing?

1. The Rapid Heart Rate of Atrial Fibrillation Causes Shortness of Breath

The first reason for shortness of breath is the heart rate by itself. You can imagine people who have atrial fibrillation who are not well controlled, will likely have elevated heart rates. The heart rate may be controlled when they’re just sitting down, but with just a little bit of activity the heart rate may become very fast, such as, 120, 140 bpm, several times even faster than that. There are patients who are, even when they’re just sitting and resting, their heart rate is going 100, 110 bpm. You can imagine that if your heart rate’s going very fast consistently, it’s like as if you’re running or exercising all the time. You can imagine when you’re exercising, your heart rate gets up, and you can feel short of breath, and for patients with atrial fibrillation, they may feel this way all the time. So sometimes just the heart rate by itself can make a person feel short of breath.

2. The Loss of Normal Atrial Contraction During Atrial Fibrillation Can Cause Shortness of Breath.

What about people who have a controlled heart rate? Does the AFib also affect shortness of breath when someone has a controlled heart rate as well? What are the ways that that could happen? One example is due to the atrial fibrillation by itself, and the loss of normal atrial contraction. In atrial fibrillation, the upper chambers of your heart, or atria, is just quivering, it’s not really squeezing properly the way the upper chambers of the heart normally should. So your heart loses some of that efficiency and that certainly can contribute to some shortness of breath. The ‘atrial kick’, which is the normal contraction of the atrium, can improve cardiac output (the amount of blood your heart squeezes per minute) by around 20-30%. You can understand that the loss of normal atrial contraction during atrial fibrillation makes a significant affect on your heart function and efficiency, when can then lead to shortness of breath.

3. Elevated Pressures Inside of a Person’s Heart and/or Lungs During Atrial Fibrillation Causes Shortness of Breath and can lead to fluid retention.

Also, when people are in atrial fibrillation consistently, very commonly the pressures inside of their heart can be elevated compared to someone who is not in atrial fibrillation. This can be partly caused to the lack of normal atrial contraction as discussed above. Those elevated pressures then get transmitted to the next nearest organ, which are the lungs. That’s when people start getting fluid in their lungs, or with another type of diagnosis typically called congestive heart failure. So that extra pressure when patients are having atrial fibrillation can then transmit to your lungs, leading to excess fluid in your lungs and then cause shortness of breath.

Overview


Atrial fibrillation

When the heart beats normally, its muscular walls tighten and squeeze (contract) to force blood out and around the body.

They then relax so the heart can fill with blood again. This process is repeated every time the heart beats.

In atrial fibrillation, the heart’s upper chambers (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions. This reduces the heart’s efficiency and performance.

Atrial fibrillation happens when abnormal electrical impulses suddenly start firing in the atria.

These impulses override the heart’s natural pacemaker, which can no longer control the rhythm of the heart. This causes you to have a highly irregular pulse rate.

The cause is not fully understood, but it tends to affect certain groups of people, such as those over 65.

It may be triggered by certain situations, such as drinking too much alcohol or smoking.

Atrial fibrillation can be defined in various ways, depending on the degree to which it affects you.

For example:

  • paroxysmal atrial fibrillation – episodes come and go, and usually stop within 48 hours without any treatment
  • persistent atrial fibrillation – each episode lasts for longer than 7 days (or less when it’s treated)
  • long-standing persistent atrial fibrillation – where you have had continuous atrial fibrillation for a year or longer
  • permanent atrial fibrillation – where atrial fibrillation is present all the time

Are there reversible causes of atrial fibrillation?

Atrial fibrillation (commonly known as AFib) is the most common heart rhythm disorder in the United States and affects approximately 5.5 million people. Symptoms include heart palpitations, shortness of breath, fatigue, light-headedness, dizziness, and sometimes passing out.

On its own, atrial fibrillation is not generally a life threatening condition, but it can cause stroke or congestive heart failure if left untreated. It can also be extremely limiting to a person’s lifestyle due to fatigue, shortness of breath, and palpitations.

Atrial fibrillation can be caused by many things, and some of those causes are reversible, which means a patient’s symptoms can improve or stop entirely without additional heart rhythm medications or a surgical procedure.

Reversible lifestyle causes

Atrial fibrillation can be caused by high blood pressure, obesity, sleep apnea, elevated blood sugar, or alcohol intake. While some of these causes are also medical conditions, they can all be impacted by a patient’s lifestyle.

Obesity, high blood pressure, sleep apnea, and elevated blood sugar (typically caused by type II diabetes that is not well controlled) can all be improved by losing weight through diet and exercise. As those conditions improve, a patient’s atrial fibrillation symptoms will often improve as well.

There is a strong correlation between excess alcohol intake and atrial fibrillation. In patients with this lifestyle cause, reducing or eliminating alcohol intake can have a big impact on the frequency or severity of their atrial fibrillation symptoms.

Reducing atrial fibrillation symptoms through diet and exercise

We recommend a consistent healthy diet by eating the right foods and tracking calories regularly, plus getting 30 minutes of aerobic exercise five days per week for healthy weight loss. Considering the , patients who lose greater than 10% of their body weight could see a 60% reduction in the need for stronger treatments, such as heart rhythm medications or ablation procedures.

Extreme weight loss or the use of stimulants to lose weight can be harmful to your overall health and actually cause or worsen symptoms of atrial fibrillation. In some rare cases, surgery may be needed for a patient to lose weight and improve these modifiable health conditions.

Reversible medical causes

Hyperthyroidism, or elevated thyroid levels, is also strongly correlated with atrial fibrillation, especially if left untreated. A simple lab test can check thyroid levels. In many cases, when hyperthyroidism is well controlled through medication or other treatment, a patient’s atrial fibrillation can be eliminated completely.

When treatment is still necessary

Some patients will still require treatment for atrial fibrillation, either through stronger heart rhythm medications, daily use of blood thinners, electrical cardioversion to shock the heart back into proper rhythm, or an ablation procedure. This may include patients whose atrial fibrillation is so severe they are unable to take the necessary action to modify lifestyle factors prior to treatment or patients for whom modifying lifestyle factors did not improve their atrial fibrillation.

However, even for patients who require additional treatment, losing weight through diet and exercise can increase the effectiveness of treatments and help improve their atrial fibrillation. Treating atrial fibrillation medically can improve overall symptoms, but for long-term prevention of atrial fibrillation, it’s still critical for patients to do their part in reducing lifestyle factors that may cause it.

If you are experiencing symptoms of atrial fibrillation, contact the Oklahoma Heart Hospital today for an appointment with one of our physicians to discuss your treatment options.

Breathing Easier: Life With Afib

Michele Straube was in her early 20s when she started to feel short of breath and dizzy every time she climbed stairs or rode a bike. “I got winded after one flight of steps,” she said. “I got dizzy if I stood for any period of time, and I couldn’t walk uphill and talk at the same time.”

Straube is one of 2.6 million Americans who have atrial fibrillation, or afib, a rapid and irregular heartbeat. The condition occurs when the heart’s two upper chambers (the atria) beat out of rhythm with the two lower chambers (the ventricles), causing poor blood flow to the body and raising the risk for stroke or heart failure.

According to the Mayo Clinic, the heart rate in a patient with afib ranges between 100 and 175 beats per minute, as opposed to a normal range of 60 to 100 beats. Symptoms typically include heart palpitations, or a fluttering sensation, shortness of breath, weakness, and a drop in blood pressure. Patients may experience constant symptoms (known as chronic afib), occasional episodes (paroxysmal afib), or no symptoms at all.

“There’s a lot of variation within afib itself,” said Marcie Berger, MD, FACC, a cardiac electrophysiologist at Froedtert Memorial Lutheran Hospital and The Medical College of Wisconsin in Milwaukee.

Afib is diagnosed using an electrocardiogram to measure the heart’s electrical impulses or an echocardiogram to detect structural heart problems. There are also portable heart monitors that are worn to record a patient’s heartbeats over an extended period of time.

Heart abnormalities, high blood pressure, hyperthyroidism, and sleep apnea can cause afib. A person’s risk of developing the condition increases based on family history, alcohol consumption, obesity, and, in particular, age. “It’s much more common as people get older,” said J. David Burkhardt, MD, an electrophysiologist at the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin. The odds of developing afib go up for people over the age of 60, and 10 percent of people over 80 have it.

Treatment “is based on your symptoms and whether they occur chronically or once in a while,” said Dr. Berger. The goal is to either reset the patient’s heart to its normal rhythm (known as cardioversion) or, if that’s not possible, to regulate the heart rate within the normal range.

Cardioversion can be done with drugs called anti-arrhythmics, which are given as pills or intravenously. They’re usually administered in the hospital so the patient’s heart rate can be monitored. The drugs’ success rate is only around 50 percent, and they can cause serious side effects, as Berger points out.

“These drugs are tough, and a lot of people are excluded from taking them if they have kidney or other heart diseases,” said Berger. “They can be difficult to tolerate and cause problems with the liver and lungs.”

Another option is electrical cardioversion, in which an electrical shock is delivered to reset the heart’s rhythm back to normal.

If resetting the heartbeat isn’t possible, there are medications and surgery known as catheter ablation to try to control heart rate. The medications, however, are most effective when the patient is at rest, and they often have to be taken in combination with other drugs to avoid complications.

Ablation surgery, which prevents electrical impulses to be sent from the heart’s upper chambers to the lower, “is a nice procedure when it works,” according to Berger. “But there are serious complications such as stroke risk or bleeding around the heart. It’s a more important option for people with chronic afib who have tried medication but it’s not working for them.”

That was the case for Straube, who first took drugs to control her afib before symptoms began to resurface. Surgery is not an option for every patient and success rates vary, but Straube says it was the only way for her “to get pre-afib life back.”

Besides resetting or regulating the heart rate, the other important part of treating afib is to reduce the stroke risk associated with the condition.

“A stroke prevention strategy is required for everyone,” said Burkhardt. “Depending on how high a person’s stroke risk is, they may just have to take an aspirin everyday, or they may have to take more potent blood thinners.”

Ultimately, “the goal of any afib treatment is to get the patient back to normal,” he said, “and doing all the activities they were doing before diagnosis.”

Case:

A 72-year-old man with hypertension and paroxysmal atrial fibrillation presents to the emergency department having experienced worsening shortness of breath during the last week.

On physical examination, his heart rate is 65 beats per minute, blood pressure is 145/82 mm Hg, and oxygen saturation on room air is 94%. Further examination reveals that he has significant jugular venous pressure, S3, S4, and crackles in both lung bases. He also has trace bilateral lower extremity edema and an apical holosystolic murmur.

A bedside echocardiogram is performed in the emergency department and reveals a left ventricular ejection fraction of 65%, mild to moderate left ventricular hypertrophy, moderate mitral regurgitation, and pulmonary artery systolic pressure estimated at 52 mm Hg. His electrocardiogram is consistent with left ventricular hypertrophy.

Concerned a pulmonary embolism may be present, the emergency department physician orders a pulmonary computed tomographic angiogram, which was negative for a pulmonary embolism. The patient is currently receiving metoprolol succinate, amiodarone, furosemide, and warfarin.

What is the next best step?

A. Start nifedipine

B. Start ambrisentan and tadalafil

C. Change the oral furosemide to an intravenous administration and increase the dose

D. Refer the patient for a right heart catheterization

What is atrial fibrillation?

The treatment of A-Fib aims to improve symptoms and reduce the risk of complications. For some people, converting the heart back to a normal rhythm is the best option.

For others, the doctor deems it better to leave the irregular rhythm in place and prescribe medication to control a high heart rate and prevent the formation of blood clots.

In addition to recommending a healthy lifestyle, a doctor will determine the most appropriate treatment depending on symptoms, other conditions they have, and overall health.

Medications

For AFib, medications are used to control the heart rate, prevent clots from forming. Sometimes medications or a procedure is used to try to restore a regular rhythm.

Preventing clots

When a doctor thinks the best option is to let someone stay in AFib, they may prescribe anticoagulant medications, or blood-thinners. These medications make it harder for blood to clot.

However, stopping bleeding becomes more difficult in a person who takes these medications. The doctor will weigh the risk of developing a clot against the risk of falling and causing a bleed in the brain.

Share on PinterestThe surgeon might install a pacemaker to moderate heart rhythm.

These medications include:

  • warfarin
  • direct-acting oral anticoagulants (DOACs), including rivaroxaban, apixaban, and edoxaban

Elderly people with an increased risk of falling often use aspirin but also have a high risk of forming a clot. Aspirin reduces clotting factor but not to the same extent as other medications, so any bleeding is easier to manage.

People taking warfarin or other anti-clotting agents should advise any medical professional treating them of their current medications, especially if they will be having a procedure or surgery or have been in an accident.

While taking anticoagulants, make sure the doctor knows about any planned or existing pregnancy or any signs of bleeding, such as:

  • very large bruises
  • nausea and light-headedness
  • vomiting blood
  • coughing up blood
  • unusually heavy menstrual flow
  • gums that bleed regularly
  • bloody or black stool
  • blood in the urine
  • sudden back pain that is very severe

Take blood thinners exactly as the doctor advises for the best chance of preventing a clotting-related complication and avoiding excessive thinning of the blood.

Managing heart rate

If the heart rate is high, bringing it down is important to avoid heart failure and reduce the symptoms of A-Fib.

Several medications can help by slowing conduction of the signals that tell the heart to beat.

These include:

  • beta-blockers, such as propranolol, timolol, and atenolol
  • calcium-channel blockers, such as diltiazem and verapamil
  • digoxin

Normalizing heart rhythm

Instead of putting a person on blood thinners and heart rate-controlling medicine, doctors may try to return the heart rhythm to normal using medication.

This is called chemical or pharmacologic cardioversion.

Medications called sodium channel blockers, such as flecainide and quinidine, and potassium channel blockers, such as amiodarone and sotalol, are examples of medications that help to convert A-fib to regular heart rhythm.

Procedures

When a person does not tolerate A-fib medication needed for someone who has an irregular heart rhythm or doesn’t respond to pharmacologic cardioversion, surgical and non-surgical procedures can be used to control the heart rate or try to convert to a regular rhythm to help prevent complications from A-fib.

Options for converting A-fib to a regular rhythm include:

Electrical cardioversion: The surgeon delivers an electric shock to the heart, which briefly resets the abnormal rhythm to a regular beat. Before carrying out cardioversion, they will often perform an echocardiogram by inserting a scope down the throat to produce an image of the heart to make sure no clots are present in the heart.

If they find a clot, a doctor will prescribe anticoagulant medication for several weeks to dissolve it. Cardioversion will then be possible.

Catheter ablation: This destroys the tissue that is causing the irregular rhythm, returning the heart to a regular rhythm. The surgeon may need to repeat this procedure if the A-fib returns.

The surgeon sometimes destroys the area in which the signals travel between the atria and ventricles. This stops the A-fib, but the heart can no longer send a signal to orchestrate a beat. In these instances, the surgeon will then fit a pacemaker.

Surgical ablation: The heart tissue that is causing the irregular rhythm can also be removed in an open-heart surgery called a maze procedure. A surgeon will often carry out this procedure alongside a heart repair.

Pacemaker placement: This device instructs the heart to beat regularly. A surgeon will sometimes place a pacemaker in a person with intermittent A-fib that only occurs intermittently.

When a doctor feels that another condition is responsible for the A-fib, such as hyperthyroidism or sleep apnea, they will treat the underlying condition alongside the arrhythmia.

Atrial fibrillation

The treatment of atrial fibrillation (AF) varies from person to person and depends on:

  • the type of atrial fibrillation
  • symptoms
  • treatment of any underlying cause
  • age
  • overall health

Some people may be treated by their GP, whereas others may be referred to a cardiologist.

Finding an underlying cause

The first step is to try to find out the cause of the atrial fibrillation. If a cause is found, treatment for this may be enough.

For example, medication to correct hyperthyroidism (an overactive thyroid gland) may cure atrial fibrillation.

If there is no underlying cause found

If no underlying cause of the atrial fibrillation can be found, the treatment options are:

  • medicines to control atrial fibrillation
  • restoring a normal heart rhythm
  • medicines to reduce the risk of a stroke
  • cardioversion (a controlled electrical shock to reset the heart rhythm)
  • catheter ablation
  • having a pacemaker fitted

You can find out more about each of these below.

Medicines to control atrial fibrillation

Medicines called anti-arrhythmics can control atrial fibrillation by:

  • restoring a normal heart rhythm
  • controlling the rate at which the heart beats

The choice of anti-arrhythmic medicine depends on:

  • the type of atrial fibrillation
  • any other medical conditions you have
  • side effects of the medicine chosen
  • how well the atrial fibrillation responds.

Some people with atrial fibrillation may need more than one anti-arrhythmic medicine to control it.

Restoring a normal heart rhythm

There are a number of drugs that can be used to try to restore a normal heart. The best option for you will be decided by your cardiologist and /or GP.

Commonly, these drugs include:

  • flecainide
  • beta-blockers
  • amiodarone

Dronedarone may also be used for certain people.

It is important you know what side effects to look out for if taking such medication and seek medical advice if you experience any of them.

To find out about side effects, read the patient information leaflet that comes with your medicine for more details.

Medicines to reduce the risk of a stroke

The way the heart beats in atrial fibrillation means that there is a risk of blood clots forming in the heart chambers. If these get into the bloodstream, they can cause a stroke (our complications of atrial fibrillation section has more information on this).

Your doctor will assess your risk to minimise your chance of a stroke. They will consider your age and whether you have a history of any of the following:

  • stroke or blood clots
  • heart valve problems
  • heart failure
  • high blood pressure
  • diabetes
  • heart disease

You will be classed as having a high, moderate or low risk of a stroke and will be given medication according to your risk.

Depending on your level of risk, you may be prescribed warfarin.

New anticoagulants

New anticoagulants such as dabigatran, rivoroxaban and apixaban have been developed which do not require dose changes and continuous blood test monitoring.

The use of these new drugs to reduce the risk of stroke in atrial fibrillation patients is likely to increase with time.

Currently they tend to be reserved for patients who are intolerant of warfarin or are unable to obtain steady levels of blood thinning with warfarin.

Cardioversion

Cardioversion may be tried in some people with atrial fibrillation. The heart is given a controlled electric shock to try to restore a normal rhythm.

The procedure normally takes place in hospital with heavy sedation or anaesthetic and careful monitoring.

In people who have had atrial fibrillation for more than two days, cardioversion is associated with an increased risk of clot formation. If this is the case, warfarin is given for three to four weeks before cardioversion and for at least four weeks afterwards to minimise the chance of having a stroke.

If the cardioversion is successful, warfarin may be stopped. However, some people may need to continue with warfarin if there is a high chance of their atrial fibrillation returning and they have a moderate to high risk of a stroke.

Catheter ablation

Catheter ablation is a procedure that very carefully interrupts abnormal electrical circuits. It is an option if medication has not been effective or tolerated.

Catheters (thin, soft wires) are guided through one of your veins into your heart where they record electrical activity.

When the source of the abnormality is found, an energy source (such as high-frequency radiowaves that generate heat) is transmitted through one of the catheters to destroy the tissue.

This procedure commonly takes two to three hours, so it may be done under general anaesthetic, where you are put to sleep.

Find out more about catheter ablation for atrial fibrillation on the Arrhythmia Alliance website

Having a pacemaker fitted

A pacemaker is a small, battery-operated device that is implanted in your chest, just below your collarbone.

It will not cure, reverse or actively treat your atrial fibrillation.

A pacemaker provides beats where your heart is not supplying its own. If your heart beat is very slow the pacemaker will override this and pace at a set rate. If there are significant pauses between your heart beats beats, the pacemaker will supply a beat, acting as a ‘safety net’.

Having a pacemaker fitted is usually a minor surgical procedure performed under a local anaesthetic (where the area is numbed).

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