Atrial Fibrillation

How does the normal heart rhythm function?

The normal heart rhythm, referred to as sinus rhythm, is a regular rhythm with the heart rate being regulated by the level of physical activity or stress. The normal heart rhythm originates from a natural pacemaker which is located in the right upper chamber of the heart. The natural pacemaker, known as the sinus node, fires off electrical impulses at regular intervals, akin to a ‘switch’ at the top of the heart going on and off at regular intervals. The electrical activity then spreads to the rest of the heart. In response to the spread of these electrical impulses, the heart beats at regular intervals.

What is atrial fibrillation?

In patients with atrial fibrillation, the normal organized heart rhythm described above is replaced by a chaotic, irregular and often rapid heart rhythm. In the absence of treatment, the heart rate is commonly disproportionately high for the level of activity in patients with atrial fibrillation.

The fast and irregular heart rhythm in patients with atrial fibrillation may cause palpitations (an uncomfortable sensation of a fast irregular heartbeat). Furthermore, because the heart does not pump blood in an effective way, atrial fibrillation may cause a reduction in exercise capacity, difficulty in breathing when exercising, and fatigue. These symptoms can be debilitating and have a significant impact on quality of life.

In patients with atrial fibrillation, the rhythm abnormality maybe continuous (persistent atrial fibrillation) or may be intermittent, which transient self-terminating episodes occurring with a recurrent pattern (paroxysmal atrial fibrillation). These episodes may last anywhere from a few seconds to a number of hours.

What are the treatment options for atrial fibrillation?

Treatment of atrial fibrillation focuses on two main areas. The first is prevention of stroke, with anticoagulant (blood thinning) medications and the second is eliminating symptoms with the aim of improving quality of life.

Preventing stroke in atrial fibrillation patients

The decision to start blood thinners is based on the specific risk profile for stroke in a patient with atrial fibrillation. Amongst patients who do not have any risk factors, blood thinning medications may not be necessary. In the presence of one or more of the risk factors below, your physician may recommend treatment with blood thinning medications:

  • Age above 65 years
  • History of heart failure
  • High blood pressure
  • Diabetes
  • Previous stroke or transient ischaemic attack (TIA)
  • Disease in the heart arteries or other major arteries
  • Female sex*

*Only counts if one of the other risk factors are present

Treatment of symptoms of atrial fibrillation

Available options for treating symptoms of atrial fibrillation include performing a procedure with the aim of curing the heart rhythm abnormality, referred to as a catheter ablation procedure, or treatment with medications. Medications to suppress atrial fibrillation may be used as single medications or as combinations of medications. The choice of medication is often determined by the side effect profile.

There are a number of important considerations when deciding between a catheter ablation procedure or medications to treat atrial fibrillation. For patients with paroxysmal (intermittent) atrial fibrillation, in the majority of cases, patient choice is at the centre of the decision. A patient’s decision to have a catheter ablation procedure may be influenced by the fact that regular medications do not fit with a patient’s lifestyle, the patient experiences unpleasant side effects associated with medications, or medications are not effective. The role of catheter ablation as a first-line treatment has expanded progressively in recent years.

Amongst patients with atrial fibrillation that is present all the time (persistent atrial fibrillation), the decision to undertake a catheter ablation procedure may involve additional considerations (in addition to patient choice). The decision commonly involves consideration of the amount of time the heart has been in continuous atrial fibrillation, and potentially the findings of a heart scan (echocardiogram or cardiac MRI scan). Overall, the physician will take multiple factors into account, including the patient’s own preferences and the overall clinical picture, before coming to a decision.

Dr Mahida’s publications on atrial fibrillation

  • Yamashita S, Tokuda M, Matsuo S, Mahida S, Sato H, Oseto H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Kato M, Tanigawa S, Miyanaga S, Sugimoto K, Yoshimura M, Yamane. Risk of Coronary Sinus Stenosis After Epicardial Radiofrequency Ablation for Mitral Isthmus Linear Ablation. Circ Arrhythm Electrophysiol 2020 Jul 27. doi: 10.1161/CIRCEP.120.008388. Online ahead of print.
  • Derval N, Takigawa M, Frontera A, Mahida S, Konstantinos V, Denis A, Duchateau J, Pillois X, Yamashita S, Berte B, Thompson N, Hooks D, Pambrun T, Sacher F, Hocini M, Bordachar P, Jaïs P, Haïssaguerre M. Characterization of Complex Atrial Tachycardia in Patients With Previous Atrial Interventions Using High-Resolution Mapping. JACC Clin Electrophysiol. 2020 Jul;6(7):815-826. doi: 10.1016/j.jacep.2020.03.004. Epub 2020 May 27.
  • Ding WY, Williams E, Das M, Tovmassian L, Tayebjee M, Haywood G, Martin C, Rajappan K, Bates M, Temple IP, Reichlin T, Chen Z, Balasubramaniam R, Ronayne C, Clarkson N, Mahida S, Sticherling C, Gupta D. Cryoballoon pulmonary vein isolation as first line treatment for typical atrial flutter (CRAFT): study protocol for a randomised controlled trial. J Interv Card Electrophysiol. 2020 May 8. doi: 10.1007/s10840-020-00746-6. Online ahead of print.PMID: 32385774
  • Bartoletti S, Mann M, Gupta A, Khan AM, Sahni A, El-Kadri M, Modi S, Waktare J, Mahida S, Hall M, Snowdon R, Todd D, Gupta D. Same-day discharge in selected patients undergoing atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019 Nov;42(11):1448-1455. doi: 10.1111/pace.13807. Epub 2019 Oct 13.
  • Yamashita S, Tokuda M, Matsuo S, Mahida S, Hachisuka EO, Sato H, Ikewaki H, Oseto H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Kato M, Tanigawa S, Sugimoto K, Yoshimura M, Yamane T. Comparison of atrial arrhythmia recurrence after persistent atrial fibrillation ablation between patients with or without tachycardia-induced cardiomyopathy. J Cardiovasc Electrophysiol. 2019 Nov;30(11):2310-2318. doi: 10.1111/jce.14144.
  • Pearman CM, Redfern J, Williams EA, Snowdon RL, Modi P, Hall MCS, Modi S, Waktare JEP, Mahida S, Todd DM, Mediratta N, Gupta D. Early experience of thoracoscopic vs. catheter ablation for atrial fibrillation. Europace. 2019 Feb 6. doi: 10.1093/europace/euy303.
  • Wynn G, Gupta D, Maille B, Snowdon R, Waktare J, Todd D, Hall M, Mahida S, Modi S. Demonstration of pulmonary vein exit block following pulmonary vein isolation: A novel use for adenosine. J Cardiovasc Electrophysiol. 2018 Sep 19. doi: 10.1111/jce.13744.
  • Yamashita S, Hooks DA, Shah A, Relan J, Cheniti G, Kitamura T, Berte B, Mahida S, Sellal JM, Jefairi NA, Frontera A, Amraoui S, Collotand F, Denis A, Derval N, Sacher F, Cochet H, Dubois R, Hocini M, Haïssaguerre M, Klein G, Jaïs P. Atrial tachycardias: Cause or effect with ablation of persistent atrial fibrillation?. J Cardiovasc Electrophysiol. 2018 Feb;29(2):274-283.
  • Lim HS, Hocini M, Dubois R, Denis A, Derval N, Zellerhoff S, Yamashita S, Berte B, Mahida S, Komatsu Y, Daly M, Jesel L, Pomier C, Meillet V, Amraoui S, Shah AJ, Cochet H, Sacher F, Jaïs P, Haïssaguerre M. Complexity and Distribution of Drivers in Relation to Duration of Persistent Atrial Fibrillation J Am Coll Cardiol. 2017 Mar 14;69(10):1257-1269
  • Tucker NR, Mahida S, Ye J, Abraham EJ, Mina JA, Parsons VA, McLellan MA, Shea MA, Hanley A, Benjamin EJ, Milan DJ, Lin H, Ellinor PT. Gain-of-function mutations in GATA6 lead to atrial fibrillation. Heart Rhythm. 2017 Feb;14(2):284-291. doi: 10.1016/j.hrthm.2016.10.014.
  • Yamashita S, Shah AJ, Mahida S, Sellal JM, Berte B, Hooks D, Frontera A, Jefairi NA, Wielandts JY, Lim HS, Amraoui S, Denis A, Derval N, Sacher F, Cochet H, Hocini M, Jaïs P, Haïssaguerre M. Body Surface Mapping to Guide Atrial Fibrillation Ablation Arrhythm Electrophysiol Rev. 2015 Dec;4(3):172-6.
  • Mahida S, Sacher F, Derval N, Berte B, Yamashita S, Hooks D, Denis A, Amraoui S, Hocini M, Haissaguerre M, Jais P. Science Linking Pulmonary Veins and Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2015 May;4(1):40-3.
  • Ma JF, Yang F, Mahida S, Zhao L, Chen X, Zhang ML, Sun Z, Yao Y, Zhang YX, Zheng GY, Dong J, Feng MJ, Zhang R, Sun J, Li S, Wang QS, Cao H, Benjamin EJ, Ellinor PT, Li YG, Tian XL TBX5 mutations contribute to early-onset atrial fibrillation in Chinese and Caucasians. Cardiovascular Research. 2016 Jan 13. pii: cvw003
  • Lim, H Denis A, Middeldorp M, Lau D, Mahajan R, Derval N, Albenque JP, Boveda S, Zellerhoff S, Yamashita S, Mahida S, Berte B, Komatsu Y, Daly M  Jesel L,, Pomier C, Meillet V, Dubois R, Amraoui S , Shah A, Sacher F, Cochet H, Hocini M, Jais  P, Sanders P, Haissaguerre M. Persistent Atrial Fibrillation from the Onset: a Specific Subgroup of Patients with Biatrial Substrate Involvement and Worse Clinical Outcome. JACC Clin Electrophysiol. 2016 Apr;2(2):129-139.
  • Mahida S, Hooks DA, Nentwich K, Ng GA, Grimaldi M, Shin DI, Derval N, Sacher F, Berte, B, Yamashita S, Denis A, Hocini M, Deneke T, Haissaguerre M, Jais, P. nMARQ Ablation for Atrial Fibrillation; Results from a Multicentre Study. J Cardiovasc Electrophysiol. 2015 Jul;26(7):724-9.
  • Lim HS, Zellerhoff S, Derval N, Denis A, Yamashita S, Berte B, Mahida S, Hooks D, Aljefairi N, Shah AJ, Sacher F, Hocini M, Jais P, Haissaguerre M. Noninvasive mapping for atrial fibrillation ablation. Card Electrophysiol Clin. 2015 Mar;7(1):89-98.
  • Mahida S, Berte B, Yamashita S, Derval N, Denis A, Shah A, Amraoui S, Hocini M, Haissaguerre M, Jais P, Sacher F. New Ablation Technologies and Techniques. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):107-12.
  • Mahida S. Genetic Discoveries in Atrial Fibrillation and Implications for Clinical Practice. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):69-75.
  • Mahida S. Expanding Role of SK Channels in Cardiac Electrophysiology. Heart Rhythm. 2014 Mar 25. pii: S1547-5271(14)00337-3.
  • Macri V*, Mahida S*, Zhang ML, Sinner MF, Dolmatova EV, Tucker NR, McLellan M, Shea MA, Milan DJ, Lunetta KL, Benjamin EJ, Ellinor PT. A novel trafficking-defective HCN4 mutation is associated with early-onset atrial fibrillation. Heart Rhythm. 2014 Mar 4. pii: S1547-5271(14)00235-5
  • Lubitz SA, Lunetta KL, Lin H, Arking DE, … Mahida S, …Alonso A, Benjamin EJ, Ellinor PT. Novel genetic markers associate with atrial fibrillation risk in Europeans and Japanese. J Am Coll Cardiol. 2014 Jan 17. pii: S0735-1097(14)00171-5
  • Mahida S Transcription factors and atrial fibrillation. Cardiovasc Res. 2014 Feb 1;101(2):194-202.
  • Mahida S, Ellinor PT. New advances in the genetic basis of atrial fibrillation. J Cardiovasc Electrophysiol. 2012 Dec;23(12):1400-6.
  • Rienstra M, Lubitz SA, Mahida S, Magnani JW, Fontes JD, Sinner MF, Van Gelder IC, Ellinor PT, Benjamin EJ. Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities. Circulation. 2012 Jun 12;125(23):2933-43.
  • Ellinor PT, Lunetta KL, Albert CM, … Mahida S,…, Heckbert SR, Benjamin EJ, Gudnason V, Kääb S. Meta-analysis identifies six new susceptibility loci for atrial fibrillation. Nat Genet. 2012 Apr 29;44(6):670-5.
  • Mahida S, Lubitz SA, Rienstra M, Milan DJ, Ellinor PT. Monogenic atrial fibrillation as pathophysiological paradigms. Cardiovasc Res. 2011 Mar 1;89(4):692-700.

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