When is afib an emergency?


You’ve Been Diagnosed with Atrial Fibrillation. Now What?

UNC AFib Care Network’s Transitions of Care Clinic

Because coordination of care is so important, UNC AFib Care Network offers the AFib Transitions of Care clinics.

“These clinics serve as landing spots for patients who went to the ER or urgent care clinic with symptoms of AFib,” Armbruster says. “Patients with AFib can be discharged from the ER with follow-up in the AFib transitions clinic as soon as the following day.”

The provider in the clinic acts as a navigator for these patients to address any acute AFib issues, coordinate care among their primary care team and ensure they have a follow-up plan to address the risk factors and conditions that contribute to their AFib.

In addition, they make sure newly diagnosed patients have an individualized care plan. An important part of this plan is to make sure patients understand what AFib is and is not.

Common symptoms of AFib are:

  • Fatigue or lack of energy
  • Dizziness, lightheadedness or fainting
  • Chest pain, pressure or tightness
  • Shortness of breath
  • Heart pounding or racing
  • Increased urination
  • Trouble completing daily activities

“A lot of patients have symptoms and they get scared. They think they’re having a heart attack or another serious problem, so we educate them on what is common to experience with AFib,” Armbruster says. “Then we help them develop an individualized action plan for when they have AFib symptoms with their next AFib episode.”

Managing Your AFib

Armbruster says the first step to managing an AFib episode is to know your symptoms.

“Everybody experiences AFib differently. Some have no symptoms at all, and some people are completely debilitated and can’t get out of bed when they have an episode,” Armbruster says.

Understanding your specific symptoms will help you determine the severity of the episode.

“If during your typical episode, you’re a little short of breath when you walk or a little more tired than usual, you know that when you experience those symptoms that it’s most likely due to your AFib,” she says. “And if you’re having a typical episode, there’s no need to panic. If you feel OK, you can manage your episode at home.”

To do this, Armbruster teaches patients strategies to get through an episode, such as deep breathing exercises or taking an additional dose of medication for rapid heart rate. Examples of prescribed medications that slow down the heart rate are beta blockers (metoprolol, propranolol) and calcium channel blockers (diltiazem, verapamil).

She also teaches patients how to take their pulse.

“By doing a simple manual pulse check, you can not only figure out how fast your heart rate is going, you can also detect if there are irregularities in your pulse,” Armbruster says. “If you’re feeling symptoms, you can check your pulse and if it’s irregular, you are likely having an AFib episode. If it’s not irregular, you’re probably not in AFib and your symptoms may be caused by something else.”

Some patients purchase a commercial device to help monitor their heart rate or heart rhythm, such as a Fitbit or an Apple Watch. However, it is important to also learn how to do a manual pulse check because these devices can sometimes be unreliable.

Armbruster says that being able to calculate your heart rate also helps with your treatment plan, because you can know when to take medication for your AFib.

AFib patients are often prescribed oral blood-thinning medications to reduce their stroke risk and medications to control their heart rate. Some patients take medications daily, while others take them only as needed if they experience rapid heart rate with an AFib episode.

“Many patients take medications daily and supplement with additional doses as needed, but patients should only do this if they have been instructed to do so by their provider,” Armbruster says. “By doing these things at home to control your episodes, hopefully you can stay out of the hospital and avoid the ER.”

When to Call the Doctor or 911

If an AFib episode lasts 24 to 48 hours with no break or if symptoms worsen, call your physician, Armbruster says.

Call 911 or go to the emergency room immediately if you experience any symptoms of a stroke, which are sudden weakness or numbness or difficulty speaking or seeing. You should also seek emergency care if you pass out or feel like you’re going to pass out, if you have significant shortness of breath or severe lightheadedness or if you feel weak, cold or clammy.

Although patients with AFib can develop chest pain with an AFib episode, chest pain that persists for more than five to 10 minutes and is not clearly associated with an AFib episode can also be from a heart attack. Seek urgent medical attention.

“The bottom line is: Listen to your body,” Armbruster says.

If you’re concerned about AFib, talk to your doctor or contact the UNC AFib Care Network, which offers a quarterly support group at the UNC Wellness Center for patients and family members.

At The Hospital

AFib: Common Treatment Procedures

AFib at the Hospital

Many people diagnosed with AFib live long, full and active lives, and it’s possible to receive treatment for a single episode of atrial fibrillation and recover without needing to have a surgical procedure. Some people manage their atrial fibrillation symptoms with their healthcare provider by taking a medication, and others may either take medications for a while and then have a procedure or they may opt for having a procedure right away.

Procedures in a hospital can range from a fairly simple cardioversion, which can have a quick recovery time, to complex treatments requiring an open heart surgical procedure for persistent, chronic atrial fibrillation.

Although AFib can be stressful for anyone whose symptoms continually or periodically flare up, you may also discover that once you find a way to manage your condition or find a procedure that works to correct the problem, you regain a sense of normalcy in your life. With the right treatment, many people are able to relieve symptoms.

On the pages below, you’ll find tips and insight about treatment with procedures to relieve AFib.

Interview Transcript

Announcer: Is it bad enough to go to the emergency room or isn’t it? You’re listening to ER or Not on The Scope.

Interviewer: All right. It’s time for ER or Not. You get to play along and decide whether or not something that’s happened is worth going to the emergency room or not. With Dr. Troy Madsen, he’s an emergency room physician at University of Utah Health. Sitting around kind of minding your own business and all of a sudden you noticed like your heart’s beating really fast, it’s racing. ER or not?

Dr. Madsen: Yeah. Well, this is a good question because we see this quite often in the ER. And the medical term for it is palpitations when you just have that feeling like your heart’s racing or maybe it’s skipping a beat. So I’d say it kind of depends on the other symptoms you’re having with it and how long this lasts.

If it’s something that lasts for a few seconds, it goes away, you could probably just follow up with your doctor. But if it’s something where it just will not go away, let’s say you feel down and you feel your pulse and it’s going really fast, if you’re having other symptoms like you’re light-headed, passing out, absolutely I’d get right into the ER.

Interviewer: All right. In the instance where you just see your doctor where if it’s just for a quick moment, what could possibly be going on there?

Dr. Madsen: So one of the most common things we see when people say they have palpitations or they just have this feeling like it’s skipping a beat or speeding up, we’ll often see what are called premature ventricular complexes or PVC’s. All that means is the lower part of the heart that squeezes the blood out, can beat a little bit early. Typically, it’s not a problem.

If that happens, a lot of people have that especially when they exercise. If it’s bothersome, a cardiologist can do an oblation where they find the spot that’s causing that premature beat and get rid of it. But usually, it’s not a serious thing where you need to rush right into the ER and get that diagnosed.

Interviewer: And it’s usually something that just kind of happens once in a while?

Dr. Madsen: For some people, it happens more frequently. Others, may never even notice it when it’s happening, you know. In some cases, people do feel it. They may notice it more when they exercise or they’re walking, so it varies from person to person.

Interviewer: All right. And in the case of where you would go to the ER if it was continual and it lasted for a while, what could that be an indication of?

Dr. Madsen: Yes. So that could sometimes be an indication of more serious things. The most serious thing being ventricular tachycardia where your heart is just racing. And that can be a life-threatening thing. Some people may have heart conditions that set them up for that that make them more likely to have that happen. That’s something where sometimes we even need to shock the heart to get it back into a normal rhythm.

Another thing we commonly see especially in older people is atrial fibrillation. Now, this is where the top of the heart, the atria, goes really, really fast. And in the bottom of the heart then senses some of those fast beats from the top and then conducts that at also a very fast rate. It also sometimes can be life-threatening because it will drop your blood pressure but in most cases, people come into the ER. Their blood pressure’s okay. We can give them medications to slow their heart down or we can also, if we have to, give them a little bit of sedation and shock the heart back into a normal rhythm.

So if your heart’s racing and it just lasts a short period of time, otherwise, you feel okay, I think you’re okay just to see your doctor. If it’s something that’s going on for longer than a minute or two or it keeps coming back or you’re having other symptoms with it, absolutely, you have reason to get to the ER.

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Atrial fibrillation is the most common arrhythmia requiring treatment in the United States. Approximately 2.2 million individuals in this country have atrial fibrillation.

What causes atrial fibrillation?

Atrial fibrillation is associated with many cardiac conditions, including cardiomyopathy, coronary artery disease, valvular heart disease, ventricular hypertrophy and other associated conditions. Atrial fibrillation has been associated with hyperthyroidism, acute alcohol intoxication, changes in the autonomic nervous system and is common after cardiac surgery. The most common condition associated with atrial fibrillation is high blood pressure. Some people have atrial fibrillation with no obvious source or associated condition. This is more frequent in younger people and it is called “lone” atrial fibrillation. It is likely that people who have this form of atrial fibrillation have had some inflammatory process or trauma to the atrium. Some people have a focal source that originates from the pulmonary veins.

Is atrial fibrillation associated with a heart attack or stroke?

Atrial fibrillation is a very rapid irregular rhythm in the top two chambers of the heart. If one were to look at the heart as it were fibrillating, it would look like a bowl of Jell-O quivering.

Atrial fibrillation can be associated with a heart attack or a stroke. A heart attack is when an artery supplying blood to the heart blocks off, causing damage to the heart muscle. A stroke occurs when an area of the brain does not get enough blood supply, in some cases due to a blocked artery supplying blood to the brain. This leads to brain damage and neurologic dysfunction.

Atrial fibrillation is a common cause of stroke in the elderly and up to 30% of the strokes in individuals over the age of 75 are due to atrial fibrillation. The reason that atrial fibrillation can be associated with, or cause, a stroke is because blood clots tend to form in the upper chambers, so-called atria, of the heart and these blood clots can break off and travel throughout the body, plugging up blood vessels. 25% of the blood goes to the brain in most cases, it is common that a blood clot, if it travels, will travel to the brain. It can also travel to the heart and clog up a vessel creating a heart attack or it can travel to any other area of the body causing a blocking in an artery–to the leg, for example, in the eye or any other organ.

The risk of blood clots caused by atrial fibrillation increases with the following conditions:

  1. Hypertension
  2. Heart failure
  3. Diabetes
  4. Increasing age

Will atrial fibrillation ever go away?

Yes. One form of atrial fibrillation that is treatable is so-called paroxysmal atrial fibrillation. This form of atrial fibrillation is more common in younger people and in people without serious underlying structural heart disease. In fact, this form of atrial fibrillation often occurs without any other underlying heart disease present. This paroxysmal form occurs when episodes of atrial fibrillation come for a short period of time and go away suddenly, to return later. This form is often associated with frequent extra beats in the atrium.

In the electrophysiology laboratory, much the same kind of a place as a cardiac catheterization laboratory, catheters with electrodes on the tips can be placed into the heart to “map” the initiation of atrial fibrillation. The technology in this regard is advancing rapidly. Much of this form of atrial fibrillation originates from the pulmonary veins so the procedure is quite involved. It requires “transeptal puncture” to get the catheters to the left side of the heart. When the source is identified, an application of radiofrequency energy, or more recently, ultrasonic energy, is delivered to eliminate the spot creating the problem. For this form of atrial fibrillation, the success rate has been reported to be as high as 80 percent.

There are several important concerns using this number as a benchmark:

  1. The procedure is really still new and somewhat experimental.
  2. Not all electrophysiologists and not all centers have the expertise to perform this.
  3. The longterm success rate is not clear because the follow-up has been in terms of months rather than years.
  4. There may be multiple spots that trigger atrial fibrillation and they might not all be obvious at the time of the evaluation.
  5. There are some potential risks of this procedure: one risk includes so-called pulmonary vein stenosis.

If multiple applications of energy are delivered into the site that triggers atrial fibrillation and if these sites are from the pulmonary vein, then it is possible to cause blockage of the pulmonary vein and this is a very dangerous situation. I would not want to dissuade you from therapy since this therapy can be curative, but there are significant risks such that it would make sense to consider other therapies first to keep the rates low or to suppress episodes of atrial fibrillation.

Atrial fibrillation also can be cured by a surgical procedure known as a MAZE procedure. Percutaneous approaches in the electrophysiology laboratory have been tried to recreate this MAZE procedure to cure atrial fibrillation in people who have it more chronically, or persistently, than a person who has paroxysmal atrial fibrillation.

Atrial fibrillation can also go away on its own in some people. It tends to do this when there is a specific trigger such as coronary artery bypass surgery, hyperthyroidism, pericarditis, alcohol intoxication (or other stimulants such as some of the over-the-counter supplements and even caffeine), other acute illnesses that cause extreme vomiting and some conditions that lead to overexertion.

Is it safe to work out with this condition?

In general, it is not a good idea to workout too vigorously with atrial fibrillation unless you have been carefully evaluated for underlying heart conditions by a doctor. Some people who have atrial fibrillation have significant problems with their heart and with exercise, the heart rate can race tremendously during atrial fibrillation, thereby exacerbating the underlying heart condition and may lead to problems such as very low blood pressure, heart failure or a loss of consciousness.

If the problem of atrial fibrillation has been well managed so that the rate is under control, or the rhythm is under control, it is possible to go back to standard physical activity in many cases. In fact, there are several professional athletes, including basketball players, who have atrial fibrillation present at times.

Is there a common drug therapy?

There are several approaches to atrial fibrillation management with drugs:

  1. Drugs to control the heart rate during atrial fibrillation.
  2. Drugs to keep someone in sinus rhythm.
  3. Drugs to prevent blood clots that can happen from atrial fibrillation.

Let’s consider the first category of drugs: Drugs to control heart rate include medications known as beta-blockers, calcium channel blockers and digoxin. Sometimes these drugs are given intravenously, but they are also available orally and these drugs are used to prevent the heart rate from speeding up too much during atrial fibrillation with exercise and they need to be adjusted so the rate does not get too slow at rest.

The second class of drugs to maintain normal rhythm include so-called antiarrhythmic drugs. Some of these drugs need to be started in the hospital. Some of the older drugs include Quinidine, Procainamide, Disopyramide, Flecainide, Propafenone, Sotalol, Amiodarone and a new drug known as Dofetilide. These drugs are not all approved by the FDA, but all have been used for atrial fibrillation by doctors. Each one has its own set of side effects and benefits. Amiodarone is the most potent, but it has a large number of longterm side effects possible. Flecainide and Propafenone are not to be given to anyone who has an underlying heart condition.

The third types of drugs are blood thinners to prevent stroke and blood clots. These medications include Heparin and Warfarin. With this large compendium of medications, a doctor may select several, depending on the severity of the symptoms, the age of the patient, the presence of underlying heart conditions and response to other medications, the severity of the episodes and other risk factors for stroke.

Can tarantula spider venom treat atrial fibrillation?

Yes, there is something to the use of tarantula spider venom. No drug has yet been developed but a report in the journal Nature on January 4, volume 409, page 35, describes the response of atrial fibrillation to this toxin. It works in a different way than the other medications so far developed and it works on stretch channels in the heart. If this proves to be effective, it may provide insight into causes of atrial fibrillation and the development of potentially new useful therapies.

Can the first symptom of atrial fibrillation be a stroke?

Yes. For some people, atrial fibrillation represents no more than a new, annoying palpitation. For other people, it can be the cause for a stroke but the process might have been unrecognized until that point. The older you are, and the more risk factors you have for stroke, as I mentioned earlier, the greater the chance that without being on a blood thinner, that atrial fibrillation will cause a stroke. With several risk factors present, an older person can have a risk factor for stroke as high as 17 percent each year.

One issue about atrial fibrillation is that there are those that have it and do not even recognize that it is present. Stroke can be caused by atrial fibrillation even in younger individuals and it is one of the potential causes for stroke in which no obvious cause can be diagnosed.

Is Digitalis still used to treat an irregular heartbeat?

Digitalis is one of the treatments used for patients with atrial fibrillation. It comes from the foxglove plant. Digitalis is used mainly to control the rate of the heart during atrial fibrillation. It is not our best drug to control the rate, but may be more useful in elderly, less-active patients and in patients who cannot take a beta-blocker or a calcium channel blocker. It may also be useful in patients who have atrial fibrillation and congestive heart failure. Digitalis at high doses can be potentially toxic and in anyone who has kidney problems, or is taking Quinidine or Verapamil (a calcium channel blocker), the levels of Digitalis can increase substantially.

Can over-the-counter (OTC) drugs cause irregular heartbeats?

Regarding the first question, yes, some over-the-counter drugs can cause irregular heartbeat and some OTC drugs can be associated with atrial fibrillation. The ones of concern are the ones that include adrenalin analogs. Adrenalin is made in the body and it increases the heart rate and blood pressure. Pseudoephedrine is one such compound. This is present in many cold and decongestant preparations.

It is important to recognize that some weight-loss products and some over-the-counter herbal compounds contain an herb known as ma huang. This herb has ephedrine in it. It is important to look at the ingredients in some of these weight loss products or OTC herbal products because this herb can cause irregular heart rhythm and has been associated, in some instances, with sudden death due to cardiac arrest.

Do symptoms go away when the use of the OTC is discontinued?

If an irregular rhythm, or atrial fibrillation, is triggered by an OTC preparation, it may persist for some period of time. But generally, it goes away on its own.

Can you cause permanent damage?

However, once atrial fibrillation starts, and if it is not corrected by intervention and does not go away on its own, over time, the presence of atrial fibrillation in which the rate of the heart is not kept under control means there can be permanent damage to the heart.

Are women more likely than men to have an irregular heartbeat or vice versa?

Actually, with atrial fibrillation, it’s men who have more disease. However, women are more likely to feel their irregular heart rhythm and to have irregular heart beats. Younger people with atrial fibrillation tend to be men and tend to be highly symptomatic with their episodes of atrial fibrillation. Younger women tend to feel extra beats both in the upper and lower chambers of the heart. Older women tend to be more likely than men to have atrial fibrillation where it is reversed at a younger age.

Can underlying conditions make you more prone to an irregular heartbeat?

Yes. While an irregular heart beat can occur independent of any other heart condition, it is worth having the problem checked out because an irregular heart rhythm may be a sign of a concerning underlying heart condition.

Conditions that may increase your risk of an irregular heartbeat:

  • Cardiomyopathy
  • Heart failure
  • Coronary artery disease
  • Valvular heart disease

Can caffeine or intensive exercise enhance a heart arrhythmia?

Caffeine and intense exercise are some of the triggers for irregular heart beats and in particular, atrial fibrillation. It is important to try to relate any irregular heart beat and the presence of atrial fibrillation to what is going on at the time. Because some people will go to a doctor and mention that they drink, for example, a large amount of caffeinated beverages, and have atrial fibrillation. The doctor may restrict them unnecessarily from drinking caffeinated beverages, and there may be no benefit in doing so. On the other hand, if the individual recognizes a relationship between drinking caffeinated beverages and irregular heart rhythms, then it would make perfect sense to abstain from this–similarly, with exercise and alcohol ingestion.

Is tachycardia the same as atrial fibrillation?

Atrial fibrillation is a form of tachycardia. Tachycardia really means a fast heart rhythm. There are many forms of tachycardia. Most people think of tachycardia as a supraventricular tachycardia, but there are many other forms of tachycardia.

Supraventricular tachycardia

Supraventricular tachycardia is a specific rapid rhythm often due to a spot in the top chamber of the heart that is beating rapidly, or it is due to an abnormal electrical pathway that allows for a kind of “short circuiting” of the heart. These pathways can be eliminated by ablation techniques in the electrophysiology laboratory.

Sinus tachycardia

Tachycardia can be a normal response to exercise, this is known as sinus tachycardia. The heart rate will race simply because of the exercise.

Ventricular tachycardia

Another form of tachycardia, a potentially life-threatening form, is known as ventricular tachycardia. It is when the lower chambers of the heart are racing rapidly.

If you are diagnosed and treated for atrial fibrillation and experience fast heart rhythm, can you take additional meds?

Yes, you can take additional medication but is very important to realize that the medicines that are available for atrial fibrillation can interact with each other in a bad way. One reason to take additional medicines would be to try to stop the rhythm. Fleconaide and Propafenone, two antiarrhythmic medications are sometimes prescribed to be taken only when the rhythm occurs. This would be safe as long as these medications are indicated for that specific individual (they would not be for an underlying heart condition) and you should never mix two antiarrhythmic medications. Sometimes medications which are given, are given specifically to keep the heart rate under control. If the heart rate gets faster, it would be appropriate to take a little extra of these medications. It is unlikely that taking a blood thinner, specifically at the time of the onset of atrial fibrillation, would be of any use.

How is atrial fibrillation treated?

What we have discussed today is the problem of a serious condition known as atrial fibrillation. This common medical problem has many different presentations and associations with other conditions. There are new advances in therapies, some of which can cure atrial fibrillation, which are being investigated further.

Medical therapy often requires multiple adjustments until the proper prescription is achieved for any given individual. Any therapy that is used for atrial fibrillation has potential risks and must be prescribed on an individualized basis. A “one-size-fits-all” for atrial fibrillation simply does not work. Newer therapies are being developed at a rapid rate and it is likely that in the next five to ten years, cures for atrial fibrillation will be common and perhaps of lower risk than they are now.

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