Atrial fibrillation: the heart health timebomb ticking away

Linked to one in five strokes, many of us are in the dark about the signs of this heart abnormality – and what can be done to treat it

When the Welsh rugby star Alun Wyn Jones went for his first ECG in July last year, it was purely a “box ticking” procedure. An electrocardiogram is standard for any medical exam for players in France, and Jones had recently joined Toulon.
But within minutes of his heartbeat being charted, instead of the regular, zig zag lines an elite sportsman might expect to see on the graph, the 38 year old’s were “all over the place”.
“It looked like one of my kids had been let loose scribbling with the crayons. My heartbeat was like a galloping horse with six legs. It was all over the shop, clearly not a normal reading,” says Jones.
The father of three girls, aged nine, six and 16 months, was shocked to learn he had atrial fibrillation (AF or AFib). There was no known family history of the condition, yet it certainly explained the performance-affecting tiredness which led to his ultimate retirement, in the summer of 2023. “I’d noticed the fatigue and tried to train my way out of it, one of the worst things I could have done.”
AFib is the most common heart rhythm abnormality, it causes the heart to beat irregularly and often abnormally quickly. A normal heart rate should be regular, and between 60 and 100 beats a minute when you’re resting. AF is a type of arrhythmia, an abnormality in the heart’s electrical system which sends out signals that cause the heart to beat. In AF the electrical signals in the top chambers (atria) of your heart do not get sent out properly,  they quiver or twitch (fibrillation) which causes your heart to beat randomly and not pump blood as well as it should.
According to the British Heart Foundation (BHF), over 1.5 million people have been diagnosed with AFib in the UK, and it’s estimated at least another 270,000 over 65s have undiagnosed (or silent) AFib. Because the likelihood of AFib increases with age and we’re all living longer, the numbers are predicted to increase dramatically in coming years. The condition makes people five times more likely to have a stroke.
The cause of atrial fibrillation is not always known, but damage to the heart is the most common cause. “The incidence of AF increases with age, due to changes in the structure and the electrics of the upper chamber of the heart, known as the left atrium,” says Dr Neil Srinivasan, a consultant cardiologist and electrophysiologist and host of the Doctor Next Door podcast. “Hypertension and heart disease are more prevalent as we get older and can be a trigger.” He also points to obesity and sedentary lifestyles – clearly neither were contributing factors to Jone’s condition. But AF, Dr Srinivasan notes, is extremely common in endurance athletes, “I see it all the time in cyclists and marathon runners.”
For the general public, says the specialist, men have a 1.5 to two times higher age-adjusted incidence of AFib than women. “By 40 years and older it’s estimated that 2.3 per cent of the population have it,” says Dr Srinivasan. “By 65 years and older it’s 5.9 per cent, and by 85 years and older this rises to 28.5 per cent.” While age is the biggest factor, and Jones believes his intense training may have contributed, sometimes there might be no “cause”. Lifestyle factors can play a role.
“Binge drinking, or daily drinking with no alcohol-free days is a significant risk,” says Dr Srinivasan, who recommends sticking to the government guidelines of up to 14 weekly units, spread across three or more days. Caffeine, smoking, recreational drugs, stress and even spicy foods are listed on the BHF website as potential triggers. 
And there were studies during the pandemic which showed Covid increased the risk for the onset of AF in hospitalised patients. “We certainly saw an upspike – across all ages – in AF related to Covid,” says Dr Srinivasan. “Covid was a multi-system disease which caused havoc with the body’s normal regulatory systems and also the autonomic nervous system (fight and flight system). Some AF is thought to be triggered by abnormalities in the body’s autonomic nervous system, particularly the vagal (vagus nerve) inputs into the heart. 
“This may be one of the reasons why athletes get AF, because they often have high vagal tone [an active vagus nerve]. Covid also also affected the heart muscle itself, causing inflammatory scarring in some patients. These effects certainly resulted in more AF cases during the pandemic. 
Jones was told his condition had likely begun 18 months previously, but many of the AF symptoms he experienced, such as fatigue or occasional heart palpitations, can be attributed to the stresses of modern life.
“It’s easy to dismiss symptoms because they’re so general, a lot of people work hard and have stressful jobs,” says Jones. “There’s also a stigma when it comes to heart issues, I didn’t want to be constantly talking about it, yet I feel a responsibility to be open so others can be more aware and get help. Men are notoriously terrible for avoiding doctors, but please don’t put it off. It might save your life.”
Along with palpitations and fatigue, Dr Srinivasan says a warning sign can be the inability to do the exercise you normally would, for example feeling more breathless up stairs or hills, or noticing your heart rate seems unusually fast.
Other than having an irregular heartbeat, Dr Srinivasan also flags there is a significant association between AF and erectile dysfunction (ED). “One study found that 57 per cent of AFib patients have ED, and another found that the risk of ED increases with age in people with AFib.”
However, it’s not all depressing news. Evidence suggests that new ED is uncommon in AFib patients, and it might not be the AF causing the ED, but the beta-blockers used in treatment.
AFib is a contributing factor to one in five strokes – the main risk of the condition, Dr Srinivasan explains, though high risk patients can be protected by anticoagulation drugs (blood thinners to prevent clotting). “We now have excellent once daily or twice daily medications that can prevent strokes, that do not require blood test monitoring”. 
“In itself, AF is not a dangerous heart condition. It doesn’t cause heart attacks and doesn’t make you have a shorter life,” he reassures. 
“The main problem – for sufferers of any age – is the random and often fast heart rate of AF, meaning your heart rate is wrong for the activity you’re doing, leading to inadequate blood flow to the muscles. In some people AF can cause heart failure and leaking of the heart valves, but there is good data to show that early correction of AF to maintain a normal rhythm staves off these complications and can increase life expectancy.”
Initially, if symptoms are manageable, regular monitoring alone might be enough. The condition is often progressive, however. Sometimes tablets can help maintain a normal heartbeat either regularly or as a “pill-in-the-pocket strategy” says Dr Srinivasan.
Direct current (DC) cardioversion might be offered – as it was to Jones – in patients with persistent AFib. This uses small electrical shocks delivered through pads stuck to the chest, to restore a regular heartbeat. “The success rate of both tablets and cardioversion to maintain a normal rhythm is around 20-40 per cent, at best, over a one-year period,” says Srinivasan. 
Catheter ablation might be the next step, an invasive procedure, this involves taking two to three fine tubes from the groin into the heart and applying heat or cooling energy to the cardiac tissue to treat the heart rhythm. It has a success rate of around 70 per cent in the first procedure, rising to 80-90 per cent with subsequent ones if needed. 
It is important to detect AFib early to prevent strokes and manage symptoms. In the early stage of the disease patients may go in and out of AF intermittently (paroxysmal AFib) which, with the right treatment, can prolong the time it takes to become persistent AFib.
Neither the BHF nor Dr Srinivasan recommend going for regular ECGs to detect AFib, as unless people have symptoms at that time it won’t show up. Far better is continuous monitoring, and that’s where smart technology comes in. Smart watches like Garmin and Apple or Oura rings have tracking abilities. The best piece of kit on the market, and the only one the BHF recommends is the KardiaMobile, which Jones uses to send clinically validated results to his physician. 
“For less than a hundred pounds it’s just a useful piece of kit for anyone, like having a thermometer, or pulse oxidator at home,“ says Jones. “I don’t track myself to find problems, I track my heart because I’ve got the ability to track it. More of us should pay attention to our health because prevention is always better than cure.”
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