Heart Views

: 2004  |  Volume : 5  |  Issue : 3  |  Page : 40--46

Arrhythmia-Provoking Factors and Symptoms at the Onset of Paroxysmal Atrial Fibrillation: A Study Based on Interviews with 100 Patients Seeking Hospital Assistance

Anders Hansson, Bjarne Madsen-Hardig, S Bertil Olsson 
 Department of Cardiology, University Hospital, Lund, Sweden

Correspondence Address:
Anders Hansson
Department of Cardiology, University Hospital, Lund


Background: Surprisingly little information on symptoms of paroxysmal atrial fibrillation is available in the scientific literature. Using questionnaires, we have analyzed the symptoms associated with arrhythmia attacks. Methods: One hundred randomly-selected patients with idiopathic paroxysmal atrial fibrillation filled in a structured questionnaire. Results: Psychic stress was the most common factor triggering arrhythmia (54%), followed by physical exertion (42%), tiredness (41%) coffee (25%) and infections (22%). Thirty-four patients cited alcohol, 26 in the form of red wine, 16 as white wine and 26 as spirits. Among these 34, red wine and spirits produced significantly more episodes of arrhythmia than white wine (p = 0.01 and 0.005 respectively). Symptoms during arrhythmia were palpitations during (88%), reduced physical ability (87%), palpitations at rest (86%), shortness of breath during exertion (70%) and anxiety (59%). Significant differences between sexes were noted regarding swollen legs (women 21%, men 6%, p = 0.027), nausea (women 36%, men 13%, p = 0.012) and anxiety (females 79%, males 51%, p =0.014). Conclusion: Psychic stress was the commonest triggering factor in hospitalized patients with paroxysmal atrial fibrillation. Red wine and spirits were more proarrhythmic than white wine. Symptoms in women in connection with attacks of arrhythmia vary somewhat from those in men.

How to cite this article:
Hansson A, Madsen-Hardig B, Olsson S B. Arrhythmia-Provoking Factors and Symptoms at the Onset of Paroxysmal Atrial Fibrillation: A Study Based on Interviews with 100 Patients Seeking Hospital Assistance.Heart Views 2004;5:40-46

How to cite this URL:
Hansson A, Madsen-Hardig B, Olsson S B. Arrhythmia-Provoking Factors and Symptoms at the Onset of Paroxysmal Atrial Fibrillation: A Study Based on Interviews with 100 Patients Seeking Hospital Assistance. Heart Views [serial online] 2004 [cited 2020 Aug 11 ];5:40-46
Available from: http://www.heartviews.org/text.asp?2004/5/3/40/64555

Full Text


Atrial fibrillation (AF) is divided into three different forms: paroxysmal, persistent and permanent [1] . Even if the pathological, electrical and physiological phenomena leading to AF have been described in more detail, the mechanisms underlying these changes remain largely unknown. The relative occurrences of paroxysmal atrial fibrillation (PAF) and other forms of this arrhythmia in the population are also not well known. In a paper based on hospital observations, 35% of all fibrillation was described as being of paroxysmal type [2] . Even though AF is common, surprisingly limited information about possible triggering factors and symptoms at the onset of arrhythmia in larger groups of patients is available [3] . Our aim in this investigation was to throw light on the factors believed by patients to have caused their arrhythmia and on the symptoms experienced at the onset of attacks of AF.


A group of one hundred patients who had ECG-verified PAF and whose symptoms prompted hospital care were asked to fill in a structured questionnaire consisting of 58 questions covering arrhythmia-triggering factors, time of onset of the attack, and symptoms during attack. All patients completed the data by personal interviews by one of the authors. The vast majority of all patients were recruited during two periods of a total of 14 months. In some questions, extra information could be supplied by the patients in their own words. All patients had earlier attacks of AF, which stopped either spontaneously or following medication. Most of them had been treated in hospital for the arrhythmia.

Patients who previously had myocardial infarction, pericarditis, diseases of the thyroid or diabetes were not included since these diseases may be the underlying cause of the arrhythmia [4],[5],[6],[7],[8],[9],[10] . Our group of patients thus had idiopathic PAF. Permission for the investigation was obtained from the local Ethical Committee and all patients were informed about the investigation, both orally and in writing.


Data were compared using Fisher's Exact Test and Mann Whitney U-test. Values of p Material

One hundred completed questionnaires were filled in by 72 men and 28 women. Twenty-four of these, had on some occasion, been treated for hypertension. The median (range) age of the entire group was 59.9 (22.4-79.2) years. Patients with previous histories of hypertension were significantly older than those without, 65.0 (46.6-78.6) years as against 58.6 (22.4-79.2) years respectively. The women in the group were significantly older than the men 67.9 (54.1-78.6) years and 58.2 (22.4-79.2) years respectively, p = 0.02 [Figure 1]. Since patients with hypertension differed from the others only with regards to age, the ensuing analyses were made without respect to its incidence. Seventy six of all patients were given antiarrhythmic drugs, sotalol being the most common. Twenty four of the patients were not taking any antiarrhythmic pharmacological treatment [Table 1].

Attacks of arrhythmia

Seventy-two patients believed that their attacks usually started at about the same time of day, typically starting in the evenings or at night [Figure 2]. The time of onset appeared not to depend on sex. For most patients (64%), attacks typically lasted less than one day, while a further 17% gave 1-7 days. No attack lasted more than one week.

Thirty-five percent of the entire group woke up with episodes of fibrillation. 34% stated that attacks began with psychic stress, as defined by the patients. Thirty one percent of the episodes started during rest and 22% of the attacks followed physical exertion. Twenty-five percent could not think of any special factor initiating attacks. No differences in the onset of attacks between men and women could be established. Eighty-five percent of the group succeeded in identifying some sort of triggering-factor [Table 2]. The most common of these was psychic stress followed by physical exertion, tiredness, and infection. As regards foodstuffs, 25% thought that coffee was the triggering-factor. Those who cited sympathetic tone anamnesis with stress as the triggering-factor usually stated that the onset of arrhythmia was in the evening or at night.

Alcohol was named as a triggering-factor by 34 patients, red wine in 26 cases, spirits in 26 and white wine in 16 cases. Some patients named more than one kind of alcohol as a triggering factor. Two of those who reacted to red wine did not drink spirits and hence could not say whether spirits also triggered the arrhythmia. In the alcohol-triggered group, red wine and spirits triggered more episodes of arrhythmia than white wine (p = 0.01 and p = 0.05 respectively). There were no significant differences in the arrhythmia-provoking effects of spirits and red wine nor between men and women [Table 2], [Figure 3]. Time delay between onset of trigger and subsequent onset of the AF episode was not explored in the questionnaire.

Foodstuffs such as onion, nuts, chocolate and ice-cream were cited as agents producing fibrillation by a few patients [Table 2].

Seventy-four percent considered that the episodes of AF they experienced affected their lifestyles, while 26% thought this was not the case. Among answers in their own words, a common reply was that they did not dare to exercise as much as they would have liked (13 patients). Eight patients did not dare to travel. Sixty-six percent stated that their episodes of AF affected their relatives, while 32% answered this question in the negative. In their own words, they remarked that the main problem was their relatives' uneasiness.

During attacks of AF, the most common symptoms were palpitations in connection with strain, reduced physical performance, palpitations when at rest, breathlessness during exertion and anxiety . Females showed significantly higher frequencies of swollen legs (p = 0.02), indisposition (p = 0.012) and anxiety (p = 0.014) than males.


Although PAF is one of the most common heart-disturbances causing patients to seek medical care in hospitals, surprisingly little information is available about the factors which trigger it and the symptoms associated with the onset of arrhythmia in larger groups of patients. This study has therefore been undertaken to determine which factors patients consider responsible for triggering arrhythmia and the symptoms that occur in connection with episodes of arrhythmia.

What provokes arrhythmia?

From observations of heart-rate in sinus rhythm shortly before its onset, it has been suggested that PAF can be classified into sympathetically-mediated and vagal forms [11] . Earlier studies have shown a degree of daily variation in the onset of AF. Thus, attacks are more common in the morning and at night [12] , but higher frequency has also been reported during daytime [13] . A possible explanation is that arrhythmia often starts in younger patients at night and in older ones during the day [14] . A weekly variation has also been reported, with fewer attacks on Saturdays [12] . An annual variation with fewer attacks during the last months of the year has also been reported [12] .

In our study, the 72 patients who thought that their attacks of arrhythmia usually occurred at about the same time of day timed its occurrence in the evening or at night. Hence, a large fraction of those investigated should have vagal PAF since this often starts at night [11] . Despite this, the majority of the patients considered that the triggering-factor was some kind of situation in which increased levels of catecholamines can be discerned. Even those with positive stress-related anamnesis (triggered by physical exertion and psychic stress) often had attacks starting in the evening or at night. However, this does not imply an absolute correlation in time, but rather the probable existence of a certain latent period between stress and the onset of arrhythmia. In earlier studies, it has been proposed that attacks of PAF are often due to variations in the tonus of the autonomic nervous system. Arrhythmia is stimulated particularly when an initial adrenergic increase is followed by an abrupt change to vagal dominance [15] .

Alcohol has long been considered to play an etiological role in PAF, a correlation underlined in the expression "holiday heart" [11] . Since temporary enhanced alcohol consumption is frequent, it is difficult to prove a direct correlation [8],[16] . Episodes of AF have been triggered by the acute effects of alcohol on atrial refractoriness and conduction, but also by the effects of chronic misuse of alcohol leading to subclinical heart dysfunction [17] . Other mechanisms have also been discussed [18] . Every third patient in our study considered alcohol to be a triggering-factor, but white wine was blamed less than red wine and spirits. Why arrhythmia should be triggered less frequently by white wine than by red wine or spirits remains unclear.

It is now generally accepted that most attacks of PAF are induced by ectopic impulses originating in the pulmonary veins [19],[20] . Both automaticity and triggered automaticity in these cells have been demonstrated in experimental conditions [19],[20] . The influence of the autonomic nervous system, alcohol and other factors inducing arrhythmia on this mechanism is, however, uncertain.

Symptoms at the onset of fibrillation

A number of patients with PAF are asymptomatic [21] , but in general patients with this form of arrhythmia show more symptoms than those with permanent AF [22] . Studies with telephone-transmitted ECG have shown a sensitivity of symptomatic registrations of up to 89% with PAF [23] . Thus, there is good correlation between the symptoms and ECG-verified AF.

The limited amount of literature on the symptomology of PAF includes Quality of Life investigations, Case Reports and quantification of a few symptoms [24] . Investigations based on "Quality of Life" forms have earlier shown that patients with PAF have lower scores for physical function, emotional function, vitality and general health [24] . The symptoms commonly reported include palpitations, giddiness, dyspnea, tachycardia, perspiration, chest pains, coldness, anxiety [23],[24],[25] , tiredness, weakness, indisposition, vomiting and epigastric discomfort [26] .

The most frequent symptoms in periods of AF reported by our group of patients included palpitations, reduced physical performance, palpitations when at rest, breathlessness when exerting oneself and anxiety. In an earlier report, the most pronounced symptoms were palpitations and anxiety as well as giddiness [24] . That females showed significantly higher frequencies of swollen legs, indisposition and anxiety than males has not previously been reported. These differences can possibly be accounted for since earlier studies have reported that attacks of AF in women last longer and cause higher heart-rates [27] . We could not, however, establish any significant differences in the lengths of attacks between men and women in our study.

Swollen legs maybe due to right-sided cardiac failure in some patients. That most patients experience definite symptoms following acute but transient attacks of AF maybe due to increased activity of the sympathetic nervous system triggered by an attack of AF [28] . It is plausible to assume that the autonomic nervous system plays a considerable part in both the genesis of and the symptoms observed during a period of AF [24] .


The data for this study was taken at a hospital and is thus not representative of all patients with PAF. The symptoms of our patients are so far advanced that hospitalization or a visit to a hospital was required. Ongoing treatment may have modified patients' recollections of anamnestic factors. The data was not obtained consecutively, but randomness was favored by lack of a systemic inclusion mechanism.

Patients with hypertension are not excluded, even if subtle diastolic changes in the left ventricle and hence the left atrial performance could be caused by hypertension [29] .

Although symptoms associated with the onset of PAF may be age related, our material is too limited to allow exploration of this relationship.


Most of the patients in a group being treated at a hospital for PAF consider psychic stress to be the factor triggering their arrhythmia. Red wine and spirits seems more prone to trigger attacks of AF than white wine. The symptoms of PAF are many and occur frequently. In women, PAF leads to significantly higher frequencies of swollen legs, indisposition and anxiety than in men.

Acknowledgements: The Swedish Heart and Lung Foundation and the Franke & Margareta Bergqvist Foundation supported this study.

Competing interests: None.


1Task Force Rapport: ACC/AHA/ESC Guidelines for the management of patients with atrial fribrillation. Eur Heart J 2001, 22:1852-1923.
2Alpert JS, Petersen P, Godtfredsen J: Atrial fibrillation; Natural history, complications and management. Ann Rev Med 1988, 39:41-52.
3Parkinson J, Campbell M: Paroxysmal auricular fibrillation. A record of 200 patients. Quart J Med 1930, 24:67-100.
4Ostrander LD, Brandt RL, Kjelsberg MO, Epstein FH: Electrocardiographic findings among the adult population of a total natural community, Tecumseh, Michigan. Circulation 1965, 31:888-898.
5Kennel WB, Abbot RD, Savage DD, Mc Namara PM: Coronary heart disease and atrial fibrillation: The Framingham study. Am Heart J 1983, 106:389-396.
6Celik S, Erdol C, Baykan M, Kaplan S, Kasap H: Relation between paroxysmal atrial fibrillation and left ventricular diastolic function in patients with acute myocardial infarction. Am J Cardiol 2001, 88(2):160-162.
7Ristic AD, Maisch B, Hufnagel G, Seferovic PM, Pankuweit S, Ortojic M, Moll R, Olsen E: Arrhythmias in acute pericarditis. An endomyocardial biopsy study. Herz 2000, 25(8):729-733.
8Leather RA, Kerr Charles R: Atrial fibrillation in the absence of overt cardiac disease. In: Atrial Fibrillation. Mechanisms and Management (Edited by: Falk RH, Podrid PJ). New York: Raven Press, Ltd 1992, 93-108.
9Freedberg AS, Papp JG, Williams EMV: The effects of altered thyroid state on atrial intracellular potentials. J Physiol 1970, 207:357-369.
10Levy S: Epidemiology and classification of atrial fibrillation. J Cardiovasc Electrophysiol 1998, 9(8 Suppl):S78-82.
11Coumel P: Neural aspects of paroxysmal atrial fibrillation. In: Atrial Fibrillation. Mechanisms and Management (Edited by: Falk RH, Podrid PJ). New York: Raven Press, Ltd 1992, 109-125.
12Viskin S, Golovner M, Malov N, Fish R, Alroy I, Vila J, Laniado S, Kaplinsky E, Roth A: Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10 000 episodes. Eur Heart J 1999, 20(19):1429-1434.
13Rawles JM, Metcalfe MJ, Jennings K: Time of occurrence, duration, and ventricular rate of paroxysmal atrial fibrillation: the effect of digoxin. Br Heart J 1990, 63(4):225-227.
14Yamashita T, Murakawa Y, Hayami N, Sezahi K, Inone M, Futuri E, Ornata M: Relation between aging and circadian variation of paroxysmal atrial fibrillation. Am J Cardiol 1998, 82(11):1364-1367.
15Bettoni M, Zimmermann M: Autonomic tone variations before the onset of paroxysmal atrial fibrillation. Circulation 2002, 105(23):2753-2759.
16Rich EC, Siebold C, Campion B: Alcoholrelated acute atrial fibrillation: a case control study and review of 40 patients. Arch Intern Med 1985, 145:830-833.
17Ettinger PO, Wu CF, De La Cruzc , Weisse AB, Ahmed SS, Regan TJ: Arrhythmias and the holiday heart: Alcohol associated cardiac rhythm disorders. Am Heart J 1978, 95:555-562.
18Koskinen P, Kupari M: The role of alcohol in atrial fibrillation. In: Atrial Fibrillation Mechanisms and Therapeutic Strategies (Edited by: Olsson SB, Allessie M, Campbell R). Armonk, NY: Futura Publishing Company, Inc 1994, 225-236.
19Chen Y-J, Chen S-A, Chen Y-C, Yeh HI, Chan P, Chang MS, Lin CI: Effects of rapid atrial pacing on the arrhytmogenic activity of single cardiomyocytes from pulmonary veins. Implication in initiation of atrial fibrillation. Circulation 2001, 04:2849-2854.
20Chen Y-J, Chen Y-C, Yeh H-I, Lin C-I, Chen S-A: Electrophysiology and arrhythmogenic activity of single cardiomyocytes from canine superior vena cava. Circulation 2002, 105:2679-2685.
21Neutel J, Smith D, Jankelow D, Pretorius J, Myburgh P: The aeromedical implications of atrial fibrillation. Aviation, Space, and Environmental Medicine 1990, 1036-1038.
22Jung W, Herwig S, Camm J, Dorian P, Newman D, Akhtar M, Wood K, Ayers G, Luderitz B: Are there differences in quality of life measures depending on clinical type of atrial fibrillation? PACE 1998, 21(Part II):890.
23Bhandari A, Anderson J, Gilbert E, Alpert B, Henthorn R, Waldo A, Cullen M, Hawkinson R, Pritchett E: Correlation of symptoms with occurrence of paroxysmal supraventricular tachycardia or atrial fibrillation: a transtelephonic monitoring study. The Flecainide Supraventricular Tachycardia Study Group. Am Heart J 1992, 124(2):381-386.
24Van den Berg M, Hassink R, Tuinenburg A, van Sonderen E, Lefrandt J, de Kam P, van Gelder I, Smit A, Sanderman R, Crijns H: Quality of life in patients with paroxysmal atrial fibrillation and its predictors: importance of the autonomic nervous system. Eur Heart J 2001, 22:247-253.
25Lau CP, Leung WH, Wong CK, Cheng CH: Haemodynamics of induced atrial fibrillation; A comparative assessment with sinus rhythm, atrial and ventricular pacing. Eur Heart J 1990, 11:219-224.
26Schlepper M, Weppner HG, Merie H: Haemodynamic effects of supraventricular tachycardias and their alterations by electrically and verapamil induced termination. Cardiovasc Res 1978, 12:28-33.
27Hnatkova K, Waktare J, Murgatroyd F, Xiahoua G, Camm J, Malik M: Age and gender influences on rate and duration of paroxysmal atrial fibrillation. PACE 1998, 21(Pt II):2455-2458.
28Anderson JL, Gilbert EM, Alpert BL, Henthorn R, Waldo A, Bhandari A, Hawkinson R, Pritchett E: Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy. Circulation 1989, 1557-1570.
29Allessie MA, Boyden PA, Camm AJ, et al.: Pathophysiology and prevention of atrial fibrillation. Circulation 2001, 103:769-777.