Most of the AF we see occurs in older patients - usually those above the age of 60 and therefore much of what we know about AF comes from studies involving older patients. What we are however beginning to realise is that AF can occur in younger patients too and perhaps this group of patients represents a group that we do need to study and research a lot more because what we understand about the causes of AF and the disease course may not be extrapolatable to younger patients.
The prevalence of AF in the young is significantly lower - in the order of 0.5%. Whilst we blame age and comorbidities such as diabetes, hypertension and obesity in the elderly, the same comorbidities are not seen to such a great extent in the younger patient. In these patients there are thought to be three main possible causes which are always worth thinking about.
The propensity for AF could have been inherited
The AF could be the first manifestation of silent cardiac disease (i.e if the heart muscle were in someway abnormal (very difficult to test for unless it looks abnormal) then it is more likely to be irritable
There may be an abnormality of the ionic channels within the heart which regulate the electrical currents within the heart. This is termed a channelopathy. Common channelopathies include Brugada syndrome, Long Qt syndrome etc.
I was very interested in understanding what we already know about AF in the young and i found an interesting paper on this subject published by Wutzler et al in 2016. A reference for this paper will be available on my website.
Wutzler et al studied 124 patients who were below the age of 35 years when they first presented with their AF and followed them up for an average of 4 years to see what happened to them. They noted some interesting findings:
57% of this group of patients did have some comorbidities or underlying structural heart disease. 20% of patients had an underlying cardiomyopathy. So the first important message is that it is important to see a cardiologist and for him to look hard for an underlying cardiomyopathy and address any comorbidities.
None of these patients had a stroke during the follow-up but it is also worth noting that 36% of the study group were already taking an anticoagulant. Hence the second point is that until we have more data, it is recommended that patients who have comorbidities or structural heart disease should still take an anticoagulant.
No-one dropped down dead suddenly so it appears at least from this study that AF in young patients does not confer an increased risk of sudden cardiac death.
All the patients who had a cardiomyopathy were noted to have it at the beginning of the study. None of the patients developed it during the course of the study. Additionally none of the patients were subsequently diagnosed with a channelopathy either.
Almost 57% of patients in this study were also found to have an incidental SVT when they underwent more detailed electrophysiological studies. Most of them had been referred for AF ablation but during the study found to have extra electrical pathways which are why SVTs happen. Very interestingly, when the SVT pathway was ablated (rather than AF ablation), no further heart rhythm disturbances were noted during follow-up suggesting that in some way the SVT was also responsible for the AF.
This is a very small study but hopefully the findings will help inform scientists to design bigger studies but in summary, the findings from this study are that young patients with AF are not uncommon, need thorough investigation by a cardiologist and ideally an electrophysiologist (including electrophysiological studies to look for extra pathways) and should be anticoagulated if they are found to have structural heart disease or significant comorbidities. In addition it is always a good idea for all patients to address any lifestyle issues to try and become healthier people.
I hope you found this video useful and I'd be very grateful if you would consider sharing it with anyone who may benefit.
A. Wutzler et al. AF in young patients. Clin. Cardiol. 39, 4, 229–233 (2016) 233
Keywords: AF; AFib; Atrial fibrillation; AFib in young; cardiomyopathy; Brugada syndrome; SVT