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What causes lone AF?

Q - A patient had a sudden episode of palpitations diagnosed 'lone atrial fibrillation'. This reverted spontaneously. What are the causes and prognosis?

A - Lone, or idiopathic, atrial fibrillation (AF) is a diagnosis of exclusion, made in patients where underlying secondary causes have been excluded and the patient has a normal ECG (apart from the AF), chest X-ray and ECG.

True 'lone AF' accounts for some 50 per cent of cases of paroxysmal AF and 15-20 per cent of permanent AF. Common cardiac risk factors include hypertension, diabetes, heart failure and valvular heart disease. Alcohol is a common precipitant of acute AF and commonly spontaneously reverts to sinus rhythm within 24 hours.

In young patients presenting with fast AF, an underlying pre-excitation syndrome such as the Wolff-Parkinson-White syndrome should also be considered, as the use of atrioventricular blocking drugs (for example, digoxin, verapamil) in such cases may be detrimental.

In younger patients (<65) the="" prognosis="" of="" lone="" af="" is="" generally="" good,="" although="" in="" older="" patients="" lone="" af="" may="" still="" be="" associated="" with="" an="" increased="" mortality="" and="" morbidity,="" from="" stroke,="" heart="" failure,="" and="" so="">

Many patients with paroxysmal AF will develop more sustained (persistent and permanent) AF, especially with increasing age.

In the elderly, thyroid disease should also be excluded, especially since overt signs and symptoms may be less obvious. An episode of AF may also frequently occur with non-cardiac disease, including fever, chest infection, pulmonary disease and cancer.

Professor Gregory Lip is professor of cardiovascular medicine at the University Department of Medicine of City Hospital, Birmingham

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