SINGAPORE — With his wife due to deliver twins on National Day via a Caesarean section, Mr Ng Wei Jie, 39, is relieved that he had his abnormal heart rhythm treated before embracing fatherhood.

A compliance officer at an insurance company, Mr Ng discovered by chance two years ago that he has a type of heart arrhythmia called atrial fibrillation.

Due to unusual electrocardiogram (ECG) readings during a routine health screening, he was recommended to undergo further tests. He had no obvious symptoms except for the occasional chest tightness and palpitations.

“I was surprised as I didn’t expect to get any illness in my 30s. I was concerned about how it would affect my life,” Mr Ng said.

Last year, he chose to undergo a procedure, known as catheter ablation, to treat his irregular heartbeat after learning that it could lead to a severe stroke even though the symptoms were not affecting his everyday life.

Catheter ablation is one of the treatment options for atrial fibrillation. It involves inserting a long, thin tube (catheter) into the heart, through a blood vessel in the leg, and applying energy — such as radiofrequency or cryotherapy — to targeted areas of heart tissue.

Experts said that strokes in people with atrial fibrillation are more likely to cause serious disability or be fatal. 

Mr Ng said: “Not doing anything about it was not an option for me as I did not want to be a walking timebomb, especially as my wife and I were trying for a child (at the time).

“My wife got pregnant a few months after I underwent the procedure, so I’m glad I went through it and can plan my family’s future with confidence without this hanging over me.”

MOST COMMON TYPE OF ABNORMAL HEART RHYTHM

Assistant Professor Paul Lim, consultant at the department of cardiology in the National Heart Centre Singapore (NHCS), said that atrial fibrillation is the most common abnormal heart rhythm and affects around 2.6 per cent of the Singapore population. 

While it is more commonly seen in older people, affecting more than 10 per cent of those aged 80 and above, the condition is estimated to affect 0.5 per cent of those under 40, he said.

Dr Reginald Liew, senior consultant cardiologist in private practice at The Harley Street Heart and Vascular Centre, said that the actual figure may be higher in younger adults because there has not been enough research looking at atrial fibrillation in the younger population.

Dr Liew, who treated Mr Ng’s atrial fibrillation, said: “Patients can live with atrial fibrillation for many years, even decades, before seeking medical help. (For younger patients under 50), we usually only see those who have had an acute incident, such as a stroke, have symptoms or it was picked it up during health screening or tests for something else.”

Risk factors for atrial fibrillation include alcohol consumption, high body mass index, sleep apnoea, and chronic conditions such as high blood pressure, underlying heart disease or heart defects at birth.

Dr Liew said that it is also possible to have atrial fibrillation without any obvious cause.

Increasingly, studies also show that atrial fibrillation may occur in endurance athletes. This is possibly due to repeated stresses and strain on the atria (the upper heart chambers) during regular strenuous exercise, he said.  

HEALTH RISKS TIED TO ATRIAL FIBRILLATION

Dr Liew described undiagnosed atrial fibrillation as a “ticking timebomb” as people such as Mr Ng are at a higher risk for stroke as well as more severe strokes.

“You might live with it for years without a major incident or you could have a stroke tomorrow,” he said. 

It may also lead to a weakening of the heart muscle over time if the heart rate is fast and not well-controlled, he added.

Explaining how the abnormal heart rhythm can lead to a stroke, Asst Prof Lim from NHCS said that it is associated with blood flow stagnation in the top chambers of the heart and this increases the risk of blood clots forming in the heart.

“If the blood clots leave the heart and travel to the brain, they can fragment into many smaller clots and may cause larger strokes when they disperse,” he explained.

Dr Liew said that the risk of ischaemic stroke among patients with atrial fibrillation is two to seven times that of the general adult population, based on studies. An ischaemic stroke occurs when blood flow is interrupted because of an artery narrowed by atherosclerosis or blocked by a clot.

Atrial fibrillation-related strokes are also more dangerous because they tend to be more severe and are more likely to cause paralysis than any other types of stroke, Dr Liew said.

People who have had a stroke tend to have a higher risk of a second stroke, which can be more damaging, if not treated properly.

Asst Prof Lim said that while the risk of stroke in younger individuals with atrial fibrillation and no other medical problems is “generally low”, the risk increases with age and with other pre-existing medical conditions, such has diabetes, hypertension, vascular disease or previous stroke.

THE SYMPTOMS

The symptoms for atrial fibrillation may be vague, Dr Liew said, and patients may dismiss them as stress, anxiety or due to excessive caffeine intake.

Especially in younger adults, the most common sign are palpitations, which can feel like sensations of irregular or abnormal heart beats.

“Some people describe feeling their heart ‘flip-flopping’ or feel as though their heart is racing or has slowed down. Other symptoms include fatigue, weakness, dizziness, shortness of breath or reduced ability to exercise. Sometimes, there may be chest pain but each patient is unique and can have different combination of symptoms, Dr Liew said.

Asst Prof Lim said that present international guidelines recommend screening for atrial fibrillation in people aged 65 years or older, with a pulse check or an ECG when they visit their family doctors.

For patients who have suffered a stroke, guidelines recommend extended duration electrocardiogram monitoring to detect atrial fibrillation. This is usually conducted during or after their hospital admission, he said.

Dr Liew said that ultrasound scans may also be used to monitor the condition.

TREATMENT OPTIONS

Asst Prof Lim said that a majority of patients will require treatment to prevent stroke and ensure that their heart does not beat too fast while in atrial fibrillation.

Treatment comprises stroke prevention — blood thinner medications are the mainstay of stroke prevention — and control of heart rate, he said.

The control of heart rate can be achieved by either restoring normal heart rhythm or controlling the heart rate during atrial fibrillation.

“Controlling the heart rate prevents the heart from weakening due to persistent high heart rates. Choosing not to be treated when necessary results in increased risk of stroke and heart failure,” Asst Prof Lim said.

He said that there are several options to restore normal heart rhythm, such as medications or medical procedures such as cardioversion and catheter ablation.

Cardioversion is done by delivering a small amount of energy to the heart muscle in an attempt to stop atrial fibrillation.

Dr Liew said that the latest form of catheter ablation uses cryoablation, which was what Mr Ng chose. It uses extreme cold to freeze the destroy the areas of heart tissue that are causing the irregular heartbeats.

Dr Liew said that he would usually recommend ablation to suitable candidates, especially if they are under the age of 50.

“The alternative is asking someone in their 40s to commit to taking a combination of drugs every day for another 40 or 50 years or to do nothing and gamble with their life every day due to the risk of blood clots and stroke.

“Younger patients with atrial fibrillation also often experience more symptoms or a greater impact on their ability to exercise, so they may prefer to opt for an ablation which has a higher success rate of eliminating their atrial fibrillation, rather than taking lifelong medication,” Dr Liew said.

NHCS offers catheter ablation and Asst Prof Lim said that current evidence has shown that the procedure is more effective than medication in restoring normal heart rhythm to patients, with reduction of symptoms and improved quality of life.

However, even with ablation, some patients may still need to continue taking some medications, he said.

The procedure may also not work or be suitable for some patients, Asst Prof Lim added.

Dr Liew said that the effects of a successful ablation should last “many years, or even decades for someone under 40” but it is not a free pass to live unhealthily.

Patients should still live healthy lifestyles to reduce their risk of other kinds of cardiovascular disease and strokes.

During the ongoing Covid-19 pandemic, people with atrial fibrillation should also take precautions such as self-isolating and seek prompt medical attention when unwell, practise good hand hygiene and safe-distancing, the doctors said.

Asst Prof Lim said that atrial fibrillation itself has not shown to increase the risk of complications with Covid-19, but patients tend to be older and have other heart conditions that may make them suffer more severe disease.

Dr Liew pointed out that mounting evidence shows that Covid-19 patients are at a higher risk of developing blood clots, and anyone who already face an increased risk of blood clots such as atrial fibrillation patients should be taking extra precautions.