Young people do get Atrial fibrillation. This rhythm abnormality has been considered a scourge of the aged. Atrial fibrillation is in fact the most common cardiac rhythm disorder. It has not been getting the attention it deserves for a long time. It can often be without any symptoms in its early stages and physicians have not been able to place this rhythm disorder in the context of overall heart health in the elderly.
Now we know that atrial fibrillation can impact life significantly. It can be an unrecognised source for strokes. It can cause progressive breathlessness and a situation called heart failure. Heart failure is diagnosed when the heart is not able to pump enough blood for the requirements of the body - the muscles which keep us moving, the brain which keeps us alert, the intestines which help us digest the food we eat and then the vital organs like the kidneys and liver and the heart itself. If the heart is already having any disease - from previous heart attacks or heart muscle disease of any cause, for example, atrial fibrillation can offset the balance very quickly and make life miserable.
One of the reasons why the management of atrial fibrillation took a back seat is because there has not been much clarity on how to manage this rhythm disorder. Physicians and surgeons often get around managing this rhythm disorder by treating what is easily treatable - like opening up blocked arteries in the heart or replacing damaged valves. In the elderly, the risk of stroke because of atrial fibrillation can be somewhat mitigated by taking blood thinners.
However, when atrial fibrillation happens in the young, the patient as well as the physician is deeply concerned. We would want to make this rhythm disorder go away as quickly as it came. The risk of long term atrial fibrillation cannot be understated in a patient in his forties who has decades of productive life in front of him. Patients who continue to have atrial fibrillation are at risk of stroke, heart failure and heart attacks; much more than a healthy person of the same age. In addition, there is an additional risk from various other illnesses commonly associated with this rhythm disorder. These include high blood pressure, diabetes, renal failure, obesity and sleep disordered breathing (sleep apnea) and respiratory illnesses.
Why do young people get atrial fibrillation? But, why do some old people get this problem and not all of them? AF was considered a disease affecting mostly people in their eighth decade - beyond their 70th birthday. Ageing is associated with fibrosis - progressive damage of the muscle cells lining the atria - the upper chambers of the heart. There is also dilatation of the chambers and this makes the electrical conduction in the atrium go haywire. Instead of organised electrical activation where adjacent muscle cells are sequentially activated the damaged muscles result in new channels and by-routes for electrical activity resulting in grossly disordered and chaotic electrical activity. What results is that the muscle cells get repeatedly activated - often more than 250 times per minute in a totally disordered way. The atria instead of contracting nearly once per every second will no longer have orderly contraction - but just fibrillate - quiver like a bag of worms.
In India most lifestyle diseases start much earlier - so we see patients in their late fifties and early sixties with atrial fibrillation. These patients often have various associated illnesses like obesity, disordered breathing patterns during sleep, high blood pressure or ‘insulin resistance’ which is a precursor to diabetes. All these disorders are associated with hormonal and chemical changes (including activation of dormant genes) which are ultimately damaging to the muscle cells of the atrial chambers.
When AF happens in the young we look out for all the other diseases mentioned above. We often find there is obesity disordered respiration during sleep or poorly managed hypertension. The increasing incidence of AF in the young is clearly related to the growing prevalence of lifestyle diseases, poor diet and habits and stress. Young AF can be an early manifestation of some disease which ultimately affects the heart muscle in general ( cardiomyopathy). There are many genetic abnormalities of the conduction system of the heart - which can manifest with slow or fast heart rates and sometimes increased risk of sudden death. Early onset of atrial fibrillation means the doctor should rule out such diseases and keep the patient in follow-up to see if he develops other signs of a progressive heart condition which can result in heart failure or death.
Luckily, most young patients with AF have some correctable risk factors. The unlucky ones in this regard are those rare patients who inherit genes for AF. They often have young relatives with AF. Even in these patients medications and lifestyle changes have a positive benefit. In India, we find that obesity increases the risk of AF. There is associated hypertrophy of the muscle chambers of the heart with obesity and there is also increased sleep apnea in obese patients. High-intensity sports is known to cause paroxysms of AF. Endurance athletes like marathon runners have a higher incidence of AF compared to the general population. At the other end, in our population sedentary lifestyle, and lack of physical activity are associated with ‘insulin resistance’, poor muscle mass, increased body fat and a predilection for young age atrial fibrillation.
So what does a specialist doctor do when he encounters a young patient with atrial fibrillation? The first is to rule out structural heart disease like severe valve disease or heart muscle disease. Next would be to look for a more simple rhythm disorder called supra ventricular tachycardia ( SVT ) which can be easily treated permanently and which will avoid further AF. High blood pressure and hormonal diseases like hyperthyroidism and tumours of the adrenal glands are looked for. We investigate sleep apnea and secondary causes of obesity if the patient is overweight or obese. Genetic tests are rarely advised. The management of atrial fibrillation will largely depend on the underlying cause, the frequency and severity of the illness and a nuanced judgement on the use of specific medications or interventions. Not all patients require long term medicines or invasive procedures and in some cases, getting a long lasting cure - no recurrence of atrial fibrillation - is not possible.
Most young patients with AF have various comorbidities as mentioned previously. A few patients, especially with poor control of associated conditions or poor lifestyle have progression of the disease. The AF may become a permanent feature - all ECGs show the abnormal rhythm whether one has any symptoms from it or not. Such patients especially are at risk of stroke, heart failure and other complications from atrial fibrillation.
Can you prevent atrial fibrillation? The best way to prevent AF is to identify who is at risk and to give optimal care for them. This includes avoiding or reversing weight gain or obesity, maintaining good physical activity, eating a heart healthy diet. Among other things the strongest recommendation is for weight loss - A 10% weight loss is a reasonable goal which I suggest to patients who are overweight. While losing weight a protein-rich diet and physical activity to maintain optimal muscle mass may be beneficial. Regular physical activity of moderate intensity is associated with less risk of AF. Aerobic exercise regimens and Yoga have been shown to reduce the incidence of AF episodes. The importance of very good control of blood pressure cannot be understated. It's important that physicians target BP lowering aggressively and specific anti blood pressure medications may have additional benefits. Reduced salt consumption and compliance to medications is vital in preventing long-term recurrence. Treating sleep-disordered breathing ( sleep apnea) is an important strategy because sleep apnea is a strong risk factor for atrial fibrillation. Response to medications is also improved if sleep apnea is corrected. The information on diet and activity are from observational studies and what is good for the heart is good for atrial fibrillation.
A low-calorie, fibre-rich diet high on vegetables and fruits and less on sugary food including juices and processed food. A “Mediterranean diet’ rich in locally sourced vegetables and olive oil may reduce the risk of AF.
Studies on fish-derived omega 3 fatty acids or vitamin D did not show significant benefits in large studies. Abstinence from alcohol is beneficial in persons who are used to moderate consumption, while alcohol binges have been definitely associated with an increased risk of new onset and recurrent atrial fibrillation. Alcohol is considered the most common precipitant of discrete AF episodes. Smoking is considered a risk factor and smoking cessation is strongly advised to prevent AF and other heart conditions. It is generally recommended without much evidence, that caffeine intake can increase the risk of atrial fibrillation. However, most studies have not shown a clear detrimental effect.
(Dr. Anees Thajudeen is a Senior Consultant in the Department of Cardiology and Electrophysiology at KIMSHEALTH Trivandrum)
