Atrial Fibrillation
An irregular, often fast heartbeat caused by chaotic electrical signals in the top chambers of the heart. It can feel like fluttering or nothing at all. It affects about 2–4% of Australians and raises the risk of stroke about fivefold, but blood thinners cut that risk by about two-thirds.
Symptoms
- A fluttering, racing, pounding or irregular heartbeat (palpitations).
- Breathlessness, tiredness, feeling dizzy or light-headed, or doing less than you used to.
- Chest discomfort.
- Often no symptoms at all; it’s found on a pulse check, ECG or smartwatch alert.
Causes and risk factors
- Getting older: AF becomes much more common with age.
- High blood pressure, heart disease, heart valve problems and heart failure.
- Excess weight, heavy alcohol use, smoking and sleep apnoea.
- Diabetes, kidney disease and an overactive thyroid.
- Triggers for an episode can include major surgery, serious infection or a big night of drinking.
How it’s diagnosed
- An ECG (heart tracing) while the AF is happening confirms it.
- If it comes and goes, a 24-hour or longer heart monitor can catch it.
- A smartwatch can flag a possible irregular rhythm, but a doctor needs to confirm it.
- An echocardiogram (heart ultrasound) and blood tests, including thyroid, look for causes.
- Your doctor uses a stroke risk score (based on age, blood pressure, diabetes, heart failure, past stroke and vascular disease) to decide on a blood thinner.
The AF ladder
Three jobs at once: prevent stroke, control symptoms, and treat what’s driving the AF. Stroke prevention depends on your risk score, not on how often you feel the AF.
- Step 1 · Self-careCut alcohol, lose weight, treat the driversDrink much less (or stop), lose weight if needed, get blood pressure controlled and sleep apnoea treated, stay active.
- Works
- Stopping drinking: AF came back in 53% vs 73% over 6 months in regular drinkers. Losing 10% or more of body weight: 45% were free of AF symptoms at 4 years without procedures or rhythm tablets, vs 13% who lost under 3%
- Cost
- Free
- How long
- Ongoing
- Watch for
- Very intense endurance exercise can itself raise AF risk; moderate is the sweet spot.
Your heart’s electrician recommends fewer beers and more walks.
- Step 2 · PrescriptionBlood thinners (apixaban, rivaroxaban, dabigatran, warfarin)Daily tablets that prevent clots forming in the heart, for people whose stroke risk score is raised.
- Works
- Warfarin cuts stroke by about two-thirds. The newer ones prevent about a fifth more strokes than warfarin and cause about half as many bleeds in the brain
- Cost
- Under the $25 PBS co-payment; $7.70 concession
- How long
- Long term, even if the AF seems to settle
- Watch for
- Bleeding: tell your dentist and every doctor. Don’t skip doses. Warfarin needs regular blood tests and has many food and drug interactions.
The single most important AF medicine, and it does nothing for your symptoms. That’s how you know it’s working quietly.
- Step 3 · PrescriptionRate control (beta blockers and others)Tablets that slow the heart down so it pumps more efficiently, even if the rhythm stays irregular.
- Works
- Ease breathlessness and palpitations for many people; the usual first approach for symptoms
- Cost
- Under the $25 PBS co-payment
- How long
- Long term
- Watch for
- Tiredness, dizziness, cold hands. Don’t stop beta blockers suddenly.
Not fixing the rhythm, just turning the drummer’s tempo down.
- Step 4 · Prescription or hospitalRhythm control: tablets or cardioversionMedicines to keep a normal rhythm, or cardioversion: a controlled electric shock under a short anaesthetic to reset it.
- Works
- Can restore normal rhythm and relieve symptoms, but AF often returns over time, so tablets or ablation may follow
- Cost
- Tablets under the $25 PBS co-payment; cardioversion free in public hospitals
- How long
- Varies
- Watch for
- Some rhythm tablets need ECG and blood test monitoring. Blood thinners are needed around cardioversion.
Control-alt-delete for the heart. Sometimes it needs doing again.
- Step 5 · SpecialistCatheter ablationA cardiologist threads thin tubes through a vein in the groin to the heart and scars or zaps the spots that set off AF.
- Works
- Reduces AF episodes and symptoms for many people; some need a second procedure
- Cost
- Free in the public system (waits apply); private out-of-pocket costs vary
- How long
- One procedure, a few days to recover
- Watch for
- Rare but serious complications. You may still need a blood thinner afterwards, depending on your stroke risk.
Rewiring, not just turning it off and on again.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Aspirin for stroke prevention in AFIn older trials it cut strokes by only about a fifth, much less than a blood thinner, and still causes bleeding. Guidelines now prefer a proper blood thinner.
- Fish oil capsulesA big Cochrane review found little or no effect on heart rhythm problems, heart attacks or strokes.
- Stopping your blood thinner because you feel fineStroke risk comes from the AF, not how it feels. Never stop without talking to your doctor.
What you can do
- Learn to check your pulse at your wrist: irregular is worth an ECG.
- Cut right back on alcohol; many people find their AF episodes drop.
- Get your blood pressure under control and ask about sleep apnoea if you snore.
- Take your blood thinner at the same time every day, and carry a medicines list.
- Tell your dentist and any doctor or pharmacist that you take a blood thinner.
See your GP if
- You notice palpitations, an irregular pulse or a smartwatch alert
- You’re more breathless or tired than usual
- You’re on treatment and your symptoms are coming back
- You’re on a blood thinner and bruising more or have blood in your urine
Call 000 (Australia) or your local emergency number for a fast or irregular heartbeat with chest pain, fainting, severe breathlessness or confusion. Also for signs of stroke: face drooping, an arm that won’t lift, slurred speech, or sudden vision loss, even if they pass. From a mobile, 112 works in most countries.
On a blood thinner? Get urgent help for black or bloody poo, vomiting blood, a bleed that won’t stop, or any head injury.
Common questions
Is atrial fibrillation dangerous?
It’s not usually immediately life-threatening, but it raises the risk of stroke about fivefold and can weaken the heart over time if it’s ongoing. Treatment lowers both risks.
If my AF comes and goes, do I still need a blood thinner?
Usually, if your stroke risk score is raised. AF that comes and goes still raises stroke risk, so the decision is based on your score, not on how often you feel it.
Can my smartwatch diagnose AF?
It can flag a possible irregular rhythm, which is useful. A doctor still needs to confirm it with an ECG before treatment.
Can AF be cured?
Some people stay free of it for years after treating triggers, losing weight, cutting alcohol or having ablation. For many it’s a long-term condition that can be well controlled.
Helpful resources
- Stroke Foundation: Signs of strokeThe F.A.S.T. test and other warning signs, worth knowing for you and your family. Free, Australia.
- NHS: Atrial fibrillationClear guide to symptoms, tests and treatments, including what to expect from cardioversion and ablation. UK.
Evidence and more information
- Healthdirect: Atrial fibrillation
- NHS: Atrial fibrillation
- HSE Ireland: Complications of atrial fibrillation
- Hart et al: Antithrombotic therapy to prevent stroke in AF (Annals of Internal Medicine, 2007)
- Ruff et al: Newer blood thinners vs warfarin, meta-analysis (Lancet, 2014)
- Alcohol abstinence in drinkers with AF (NEJM, 2020)
- LEGACY study: Weight loss and AF (JACC, 2015)
- Cochrane review of omega-3 supplements and heart disease (summary)
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