COMMENTARY

Asymptomatic Atrial Fibrillation: Should We Intervene, and if so, How?

Christopher DeSimone, MD, PhD; Martin van Zyl, MB, BCh

Disclosures

April 22, 2020

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Martin van Zyl, MB, BCh: Hello, and welcome to the Mayo Clinic Medscape video series. I am Martin van Zyl, cardiology fellow at Mayo Clinic. Today we will be discussing a very important and underrecognized problem: asymptomatic atrial fibrillation. I am joined by my colleague, Dr Christopher DeSimone, assistant professor of medicine and expert in this area. Welcome, Chris.

Christopher DeSimone, MD, PhD: Thank you for having me today. This is an important topic and one that, as an electrophysiologist, I love to discuss because it gives us an opportunity to help our patients in significant ways.

van Zyl: Tell us about asymptomatic atrial fibrillation and why it is potentially such a big problem.

DeSimone: First, we need to determine whether the patient is really asymptomatic based on the clinical history and the feeling you get from the patient. When they are in atrial fibrillation, are they truly having no symptoms? How has atrial fibrillation affected the patient's lifestyle?

Second, what prompted the patient to seek help for atrial fibrillation? Everyone is wearing gadgets—Fitbits, Apple Watches, and such—and they will think, "Oh, I am in atrial fibrillation. Let me go see my doctor." I think it is going to become more and more prevalent, particularly as the population ages.

Atrial fibrillation will have major implications for the patient's lifestyle. It will potentially cause symptoms. It also will put them at higher risk for stroke and heart failure. Helping to improve patients' quality of life and protecting them from those other comorbidities is very important.

van Zyl: What is your approach to the patient with asymptomatic atrial fibrillation?

DeSimone: First, really listen to the patient. See them face-to-face, figure out what brought them in. Sometimes it could be something as simple as, "I was having a colonoscopy and they saw atrial fibrillation on my ECG, and I just wanted to figure out what to do about this." Then I ask what type of symptoms they are having Sometimes they aren't aware of any symptoms, but I press them and ask about what is going on in their lives, how active they are, and what are they not able to do that they did in the past.

Sometimes a patient says, "I think I am just getting older and I am not able to do what I used to." That makes me wonder whether age is really the cause or if it's the atrial fibrillation. I want to know how the patient feels when they are in sinus rhythm compared with the atrial fibrillation, to which they may have become accustomed .

van Zyl: Would there be a scenario where you would actually want to intervene in someone who has asymptomatic atrial fibrillation?

DeSimone: I would intervene if a patient had a reduced ejection fraction or if the patient had symptoms of heart failure. Some patients notice leg or ankle swelling, or they have been treated a couple times for the "flu" or "pneumonia" but have not gotten better with antibiotics. Then you examine them to see if they are starting to present with mild heart failure symptoms.

Sometimes you will see patients in the hospital with a decompensated heart failure episode. I would intervene in that case because atrial fibrillation may be driving that. A caveat: If you have heart failure and have higher pressures in the left atrium of the heart, this could be akin to going into atrial fibrillation.

van Zyl: How do you intervene? What is your approach to the patient with heart failure and "asymptomatic" atrial fibrillation?

DeSimone: Usually these patients will have been in atrial fibrillation for quite some time when they come to you. You may not be able to define when it started or stopped. Usually I will use our best drug, amiodarone, and I will put the patient on that for a couple of days or even a week, bring them back, and cardiovert them, get them into sinus rhythm. In 3 months' time, I will repeat the echocardiogram and the ECG and ask them how they are feeling symptomatically. I want to see whether we can improve the heart failure once we have controlled the atrial fibrillation, and whether that is the key. I believe that merits a more aggressive approach to treating "asymptomatic" atrial fibrillation and helping the patients.

van Zyl: Thank you so much for your insights on this important problem, and thanks to our audience for joining us on theheart.org | Medscape Cardiology.

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