Keeping in Mind Signs and Symptoms That May Point to Atrial Fibrillation

Why it’s important to understand atrial fibrillation, which is a leading cause of stroke 1

Illustrations by Thomas Hedger

Dr. David McManus is a cardiologist at UMass Memorial Medical Center. When his father, Floyd, underwent cataract surgery–a common operation for older patients–his anesthesiologist had his eye trained on his vitals.2 It’s a crucial role played by anesthesiologists in even routine surgeries: ensuring that a patient’s heart rate and breathing, though they’ll slow under anesthesia, remain safely regular.3 In the case of Floyd, the anesthesiologist noticed an irregular heart rhythm.

And that anesthesiologist played a key role in identifying a serious condition for Floyd. After the cataract surgery, Floyd was found to have atrial fibrillation (AFib) – a heart condition which can lead to blood clots, and even stroke, among other complications.4 He and his son, Dr. McManus, consulted his internist, chose a cardiologist, and began managing the condition. Who would have thought that cataract surgery could potentially play a role in identifying another unrelated condition?

It was eventually a quick diagnosis, but it came after multiple doctor’s visits. Dr. McManus, a cardiologist who specializes in electrophysiology, recalls noticing that his father was occasionally short of breath, but he’d brush it off.

“People have commented that here I am, a cardiologist focusing on AFib, and I can’t even find it in my own dad,” Dr. McManus jokes.

Irony aside, Floyd's case points to one of the complexities of AFib. Both AFib and its symptoms can be intermittent, which can make identifying it during a routine exam difficult.5 In some cases, AFib can have no signs or symptoms at all.6 Yet sometimes, AFib can be found in a few moments via pulse palpation during a check-up.4,7 Some symptoms of AFib include heart palpitations, pain and pressure in the chest, fatigue, shortness of breath, lightheadedness, dizziness, and rapid or pounding pulse.6

Typically, an anesthesiologist’s intervention isn’t and shouldn’t be necessary to find AFib. Ideally, it would be detected during a routine primary-care checkup. “My father’s case is a great example of how more awareness needs to be raised around the identification of AFib in appropriate patients,” Dr. McManus notes.

“Patients may present with symptoms of palpitations, or the sensation of a racing or irregular heartbeat,” says Dr. Andrea Russo, the Director of Cardiac Electrophysiology and Arrhythmia Services at Cooper University Health Care in Camden, New Jersey and President-Elect of the Heart Rhythm Society. “But if symptoms are intermittent [and not likely to be detected in the clinic,] patients may receive monitoring at home using mobile telemetry or an event recorder. The home monitor allows patients to record their heart rhythm at the time when symptoms occur.”

Awareness that something doesn’t feel right, combined with a doctor’s assessment—which will likely involve an electrocardiogram–and the potential for home monitoring, can be important in the diagnosis of AFib.8,9

Research on AFib diagnosis, and the health-care industry’s approach to it, is ongoing and evolving, but we do know about the risks of AFib. Importantly, people with AFib are five-times more likely to experience a stroke than those with regular heartbeats.8

In a patient with AFib, the upper chambers of the heart beat irregularly.4 This means that the heart cannot effectively move blood into the ventricles. This may lead to pooling of blood in the heart, and a clot may form. If that blood clot then enters the bloodstream and gets stuck in an artery that leads to the brain, it can cause a life-threatening or debilitating stroke.4

For 2018, approximately 7.5 million people were projected to be affected by AFib in the United States,10 according to an article in the American Journal of Cardiology. This article also projected that number could grow to an estimated 12 million people by 2030.10 Additionally, the Centers for Disease Control and Prevention (CDC) estimated that about nine percent of people aged 65 years or older have AFib.6 Given the expected growing number of people with AFib, this could mean there may be more people at a higher risk of stroke as a result.6

“I’ve heard some people describe a fluttering sensation or a rapid pulse. I’ve heard others say it feels like a fish flip-flopping out of water in their chest, or like a hummingbird flopping around inside trying to get out.“Dr. David McManus, Cardiologist

For those at higher risk of AFib, there is a potential need for more public education on the connection between the condition and stroke, and the importance of diagnosis in appropriate patients. A statement made by the American Heart Association earlier this year in Circulation pointed out the need for future studies focusing on AFib burden.11

“There really is no one symptom of AFib,” says Dr. McManus. “I’ve heard some people describe a fluttering sensation or a rapid pulse. I’ve heard others say it feels like a fish flip-flopping out of water in their chest, or like a hummingbird flopping around inside trying to get out. That’s what a doctor would call a palpitation. But some patients that have AFib don’t feel any of these things.”

For patients, particularly aged 65 and older with conditions including (but not limited to) diabetes, high blood pressure, coronary artery disease, or other heart conditions, it’s important to understand the potential signs of AFib and to talk with their doctor about any concerning symptoms.6,12 To help reduce some risk factors, doctor recommendations may include lifestyle changes, such as regular physical activity and heart-healthy eating patterns.

Outside the doctor’s office, patients may begin to access to their own health monitors, some of which are being built into smartwatches. This new technology may have potential, but at this early stage it’s important to note that it’s not yet clear just how helpful these devices will be when it comes to diagnosis.

Dr. McManus stresses the importance of AFib being kept in mind during routine check-ups, particularly amongst the at-risk population, such as those over 65. His father’s case illustrates the importance, for both patients and care providers, of raising awareness about the condition. “This is a very personal thing for me...and so I’m hopeful of ongoing innovative research, which has the potential to help patients.”

  • Pulse PalpationA health-care practitioner can check the rhythm and regularity of your pulse by placing and holding their fingers somewhere that an artery is near the skin’s surface, such as the neck or inner wrist. ECGs are used to confirm the heart rhythm.13,14

  • AuscultationAuscultation refers to a stethoscope exam that allows a doctor to listen to the sounds of the body, such as your heartbeat and breathing.13,14

  • ElectrocardiogramAn electrocardiogram (ECG) uses small electrode patches, placed on your skin, to record the electrical impulses that pass through your heart. ECGs help your doctor to track your heart rhythm. ECG is used to confirm AFib.15,16

Floyd’s outcome was fortunate—but there’s more work, research, and education that needs to come for health-care providers and patients alike. No one has all the solutions when it comes to the identification of AFib, but as the American population ages, this could be an important area of focus.

Through the Matter of Moments, Recognizing AFib-Stroke Risk initiative, the BMS-Pfizer Alliance aims to elevate awareness of the AFib-stroke connection and the importance of AFib diagnosis in patients at higher risk, such as patients 65 years and older.

Dr. McManus provides paid consultation services to the BMS-Pfizer Alliance for separate activities.

The Heart Rhythm Society has received funding grants from the BMS-Pfizer Alliance.

  1. National Stroke Association. AFib-Stroke Connection. Accessed November 2018. Available at: http://www.stroke.org/understand-stroke/preventing-stroke/afib-stroke-connection
  2. National Institute of Health. Facts About Cataract. Accessed November 2019. Available at: https://nei.nih.gov/health/cataract/cataract_facts
  3. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. Accessed November 2018.
  4. National Heart Lung and Blood Institute. Atrial Fibrillation. Accessed November 2018. Available at: https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation
  5. Stahrenberg, Raoul, M.D., et al. Enhanced Detection of Paroxysmal Atrial Fibrillation by Early and Prolonged Continuous Holter Monitoring in Patients With Cerebral Ischemia Presenting in Sinus Rhythm. Stroke. Accessed December 2018. Available at: https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.110.591958?download=true
  6. CDC, Atrial Fibrillation Fact Sheet. Accessed November 2018. Available at: https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm.
  7. MedlinePlus. Atrial Fibrillation or Flutter. Accessed December 2018. Available at: https://medlineplus.gov/ency/article/000184.htm
  8. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Available at: https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Anticoag-10-14/GuidelinesAndBackground/1%20January%20ACC%20AHA%20HRS%202014%20Afib%20Guidelines.pdf?la=en
  9. Circulation. Shea, Julia B., MS, RNCS et al. A Patient’s Guide to Living with Atrial Fibrillation. Accessed November 2018. Available at: https://www.ahajournals.org/doi/abs/10.1161/circulationaha.108.780577.
  10. Colilla S, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112:1142–1147.
  11. Circulation. Atrial Fibrillation Burden: Moving Beyond Atrial Fibrillation as a Binary Entity: A Scientific Statement From the American. Accessed December 2018. Available at: https://www.ahajournals.org/doi/abs/10.1161/cir.0000000000000568
  12. Heart Rhythm Society. Risk Factors for Atrial Fibrillation (AFib). Accessed November 2018. Available at: https://www.hrsonline.org/Patient-Resources/Heart-Diseases-Disorders/Atrial-Fibrillation-AFib/Risk-Factors-for-AFib
  13. MedlinePlus. Auscultation. Accessed December 2018. Available at: https://medlineplus.gov/ency/article/002226.htm
  14. MedlinePlus. Pulse. Accessed December 2018. Available at: https://medlineplus.gov/ency/article/003399.htm
  15. MedlinePlus. Electrocariogram. Accessed December 2018. Available at: https://medlineplus.gov/ency/article/003868.htm
  16. National Heart Lung and Blood Institute. Electrocardiogram. Accessed December 2018. Available at https://www.nhlbi.nih.gov/health-topics/electrocardiogram