#306 The Top 10 Atrial Fibrillation Triggers
Dr. John Day
Dr. Day is a cardiologist specializing in heart rhythm abnormalities at St. Mark’s Hospital in Salt Lake City, Utah. He graduated from Johns Hopkins Medical School and completed his residency and fellowships in cardiology and cardiac electrophysiology at Stanford University. He is the former president of the Heart Rhythm Society and the Utah chapter of the American College of Cardiology.
The Top 10 Atrial Fibrillation Triggers
A few years back, my good friend, Mellanie True Hills, the founder of the StopAF.org website, teamed up with researchers from the University of California at San Francisco in an effort to better understand atrial fibrillation triggers. What they found in their investigation was that people who are healthier usually have definitive triggers, while people who are less healthy might not even require a trigger to push their heart out of rhythm. They also found that while just about everyone has different triggers, some triggers are far more common than others.
There’s an important distinction to make here between causes and triggers. It’s important to understand both, but the long-term factors that put people at greater risk of AFib, also known as substrate causes (like bad genetics, being overweight, high blood pressure, etc.), aren’t always the same things that prompt a specific incident of AFib. Here, a wildfire analogy might be helpful: Any spark can trigger a single blaze, but the chances of having lots of fires in a season are greatly increased by conditions that accumulate over time, including drought, insect infestation and the growth of underbrush.
The top three atrial fibrillation triggers according to Mellanie True Hills study? Alcohol, caffeine and exercise—in that order. While all of these factors may be part of the combination of causes that pushes people toward AFib, it would be very rare for any of these factors alone to be the sole cause. But once someone is at that precipice, alcohol, caffeine and exercise can be powerful inciting events that can send their heart into chaos.And that shouldn’t come as a big surprise, particularly when it comes to that first trigger; any emergency room doctor can share many stories of high school or college students who have presented with AFib after binge drinking.
Alcohol use doesn’t just increase the risk of AFib. It also increases the risk of countless other diseases, including cancer. And while there are some studies that have demonstrated that a small amount of alcohol can offer some health benefits, when it comes to all-cause mortality those benefits are outweighed by the increased risk of other health-related harms, according to a 2018 study in the prestigious British medical journal The Lancet, that pulled no punches. “The conclusions of the study are clear and unambiguous: alcohol is a colossal global health issue,” the authors wrote, adding that there was strong support for a guideline published by the chief medical officer of the United Kingdom, who found there is “no safe level of alcohol consumption.
Caffeine is a powerful stimulant that can have a significant impact on our hearts. Fortunately, for most people with AFib, caffeine isn’t a problem. Indeed, studies have shown that the caffeine that comes from chocolate, coffee, and tea don’t trigger AFib for most people. However, for some people, like the 28% of the 1,298 people participating in Mellanie True Hills’ study, caffeine is indeed an important trigger for Afib attacks.
Exercise is the most natural way in the world to shift our hearts into a higher gear, so it’s no shock that, if your heart is already prone to beating erratically, a quick burst of exercise could push it over the edge. In general though, it is extreme levels of exercise, exercising at levels beyond where you have trained, or exercising in a dehydrated or electrolyte depleted state in someone that is already prone to AFib attacks that trigger AFib episodes.
Most of my patients are shocked when they learn that people who run marathons, competitively cycle, or do Ironman triathlons are five times more likely to develop atrial fibrillation. What is particularly perplexing, however, is that studies have not tended to show higher rates of arrhythmias in athletes who participate in other strenuous forms of exercise, such as boxing, wrestling and weight-lifting. There is something particular about endurance sports that increases the risk of AFib. (One exception to this may be football. Among former NFL athletes, the risk of AFib is six times higher, although this may be due to the use of performance-enhancing substances or the weight these athletes put on to compete at a professional level.)
Also, it bears noting that while aggressively competing in endurance sports might put you at a greater risk of AFib, participation in these activities certainly does not guarantee you’ll get AFib. It is reassuring to note that recreational participation in endurance sports, even if it is a marathon or triathlon, doesn’t seem to put you at risk of AFib.
After alcohol, caffeine, and exercise, the second tier of AFib triggers include lack of sleep, dehydration, large meals, and stress and anxiety. The impact of poor sleep on AFib has been well documented. Even small interruptions of sleep quality and duration can increase the risk of atrial fibrillation by 18 percent, and people who experience insomnia are 30 to 40 percent more likely to develop atrial fibrillation. People who do not reach deep levels of sleep—the sort of sleep that is key to recovery—have an 18 percent increased risk of atrial fibrillation, and it worsens each time they wake up at night. It’s even worse for people with sleep disorders such as sleep apnea; they have a 200 to 400 percent increased risk of AFib over individuals without a sleep breathing disorder. And the problem is compounded once AFib actually develops; the presence of an abnormal rhythm can increase the risk of poor sleep quality, or short sleep, by three to four times. It’s a vicious cycle.
5. Dehydration/Electrolyte Imbalance
Even simple incidences of dehydration can tip the balance of the electrically charged ions potassium, sodium, calcium and magnesium, which play critical roles in ensuring your body holds onto enough water to function and help direct the electrical impulses that keep your heart beating. That, of course, makes levels of electrolytes that are too high or too low a potential danger—especially to people who might already be prone to atrial fibrillation for other reasons. One study from researchers in The Netherlands showed that low levels of potassium could quadruple the chances of AFib in some individuals. Those experiencing magnesium deficiency are also at considerable risk.
6. Large Meals/Specific Food Triggers
Why would food a large meal or a specific food be a trigger of an AFib attack? Perhaps because gastrointestinal problems, including stretching your stomach from a large meal, are known to stimulate the vagus nerve, which connects your gut, brain and heart. We don’t understand this connection in depth, but our research has shown that gastrointestinal distress, like from a large meal, are associated with atrial fibrillation. Also, when those gastrointestinal issues have resolved, the AFib usually settles down as well.
We have also had many patients report to us over the years that sugar, fast foods, foods with caffeine, processed foods, fried foods, or really spicy foods have also been atrial fibrillation triggers—not just contributors to the rising risk of getting AFib in the first place. Once again, all of these triggers probably had something to do with vagus nerve stimulation or glucose fluctuations. Surprisingly, in 30 years of seeing AFib patients, I have yet to hear a patient report to me that broccoli or kale triggered an AFib attack.
What kinds of challenges can create stress that triggers AFib? A research group in Denmark concluded that the severely stressful experience of losing a partner increased the risk of atrial fibrillation for an entire year. Another international group of researchers found that divorced men had a higher incidence of death associated with atrial fibrillation. And a group from Sweden revealed a potential dose-response relationship between work-related stress, like getting fired from a job, and atrial fibrillation. In fact, the Swedish researchers found, just the experience of having a job with high psychological demands and with little control over your work situation could increase your AFib risk by 50 percent.
When Yale University researcher and electrophysiologist Dr. Rachel Lampert correlated the way her patients were feeling emotionally to see if she could predict whether or not they would go into AFib that day, the results were absolutely startling. In a study published in the Journal of the American College of Cardiology in 2014, she noted that feelings of sadness, anger, stress, impatience, and anxiety increase the risk of an AFib attack up to 500 percent in the same day. Happiness, meanwhile, appears to be protective. If you are feeling happy you are 85 percent less likely to have your heart go out of rhythm today, according to Lampert’s research.
8. Laying on Your Left Side
I must admit that I was a bit surprised to see that sleeping on your left side was an atrial fibrillation trigger for so many people. As you may or may not know, lying on the left side of the body is a position which pulls your heart against your chest wall due to gravity. And while this gravitational pull to your chest wall certainly makes palpitations more noticeable, perhaps in some people it is also an atrial fibrillation trigger. If you want to read more about laying on your left side and arrhythmia, here is a great article I wrote a few years ago on the subject.
9. Cold Beverages and Foods
Another culprit that might be a potent trigger: very cold foods. That’s what a research team from California learned when they reviewed the case of a young adult man who drank one of those sugary “slushed ice” drinks, the type of which you commonly find at gas station convenience stores. Just about everyone who has tried one of these drinks knows the sensation of “brain freeze,” an intense, rapid-onset headache also known as sphenopalatine ganglioneuralgia, that is caused by sudden temperature changes to the carotid artery and anterior cerebral artery, which are located near the back of the throat, and which feed blood to the brain. The man immediately began to suffer from both atrial fibrillation and brain freeze at the same time.
Researchers have theorized that the vagus nerve may be similarly stimulated. This doesn’t mean we need to avoid cold foods; we just need to be mindful of how we consume them. When it comes to smoothies, slow and steady wins the race.
10. Not Exercising
Regular daily exercise in general isn’t risky at all—in fact, it’s exceptionally protective against AFib and just about every other chronic medical problem. To put things into perspective, for every thousand patients we see with atrial fibrillation, perhaps one may be at risk for atrial fibrillation due to overexercising. The biggest problem, by far, is that most patients aren’t exercising enough. There is far greater risk to not exercising enough than to exercising too much. People who live sedentary lifestyles are at significant risk of AFib, not to mention all of the other health consequences of not getting enough exercise.
Next Steps if You Have AFib Triggers
If you have clear and identifiable triggers, and can easily avoid them, then that is your best option to prevent AFib attacks. But please remember that triggers alone probably won’t incite an AFib event unless you are already prone to AFib attacks from things like bad genetics, carrying too much weight, high blood pressure, etc. And your best best to beat AFib is to not only avoid the triggers but to also address the underlying causes which put your at risk for AFib in the first place.
If you suffer from AFib you need to see a cardiac electrophysiologist or “EP.” An EP physician is a board certified cardiologist who has done an extra two years of a training arrhythmia management. If you live in the US and don’t have an EP, please feel free to call my office at 801-266- 3418 to set up an in-person or video visit.
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About the Photo
This is a picture of the beautiful Desolation Lake in the Wasatch Mountains at approximately 9,000 feet above sea level near my home. At least a couple times a week in the summer and fall, I’ll hike up to the lake. In the winter and spring, I’ll backcountry ski in this area.
Disclaimer Policy: This website is intended to give general information and does not provide medical advice. This website does not create a doctor-patient relationship between you and Dr. John Day. If you have a medical problem, immediately contact your healthcare provider. Information on this website is not intended to diagnose or treat any condition. Dr. John Day is not responsible for any losses, damages or claims that may result from your medical decisions.
Excellent, as always. I am wondering if you could address the affects of living at higher altitude (as you do) with regards to Afib. I live at about 6,500 feet next door in Colorado and exercise up to 11,000 feet. Anecdotally, my wife and I were at a dinner (pre-Covid) with two other couples. All were very active and in their 50’s and 60’s. Two had been competitive cyclists. One swam competitively in college. One played basketball. Five of the six had experienced arrhythmia issues in their 50’s. Two had had ablations. Two others had been diagnosed and been offered ablations. When the US Olympic training center in Colorado Springs opened many years ago they found an inordinately high number of young athletes were experiencing Afib for the first time. Many of those had never trained at higher altitude. A few years ago LA Dodger pitcher Kenley Jensen, who had been diagnosed with Afib, was taken to a hospital in Denver and sent back to LA when he went into Afib before a game with the Rockies. I’d love to hear your take on this aspect that does not get mentioned often.