Can hypoxia lead to atrial fibrillation (AFib)?

From the Guidelines

Hypoxia leading to atrial fibrillation requires immediate correction of hypoxaemia and acidosis as the initial management strategy. This approach is crucial in preventing further complications and improving patient outcomes, as supported by the European Society of Cardiology guidelines 1. The guidelines recommend correction of hypoxaemia and acidosis as the initial management for patients who develop atrial fibrillation during an acute pulmonary illness or exacerbation of chronic pulmonary disease, with a Class I recommendation and Level C evidence.

Key Considerations

• Correction of hypoxaemia and acidosis is essential in managing atrial fibrillation in patients with pulmonary disease 1.
• Direct current cardioversion (DCC) should be attempted in patients with pulmonary disease who become haemodynamically unstable as a consequence of atrial fibrillation, with a Class I recommendation and Level C evidence 1.
• Non-dihydropyridine calcium channel antagonists, such as diltiazem or verapamil, can be used to control the ventricular rate in patients with obstructive pulmonary disease who develop atrial fibrillation, with a Class IIa recommendation and Level C evidence 1.
• Beta-1 selective blockers, such as bisoprolol, in small doses can be considered as an alternative for ventricular rate control, with a Class IIa recommendation and Level C evidence 1.

Management Strategies

• Oxygen supplementation should be provided to maintain saturation above 92% in patients with hypoxia-induced atrial fibrillation.
• Rate control can be achieved with beta-blockers or calcium channel blockers, while anticoagulation therapy should be considered based on stroke risk assessment using the CHA₂DS₂-VASc score.
• Long-term management should focus on preventing recurrence by addressing the hypoxic trigger, maintaining optimal oxygenation, and potentially using antiarrhythmic medications if episodes persist despite correction of hypoxia.

From the Research

Hypoxia and Atrial Fibrillation

• Hypoxia is associated with atrial fibrillation, as shown in a study published in 2010 2, which found that atrial fibrillation is closely associated with an atrial up-regulation of hypoxic and angiogenic markers.
• The study suggests that fibrosis may lead to an increased O(2) diffusion distance, inducing ischemic signaling and leading to angiogenesis, which may contribute to the development of atrial fibrillation.
• Another study published in 2021 3 emphasizes the importance of prompt diagnosis and management of atrial fibrillation in the emergency department, highlighting the need to consider underlying conditions such as hypoxia.

Management of Atrial Fibrillation

• The management of atrial fibrillation involves rate or rhythm control, as discussed in a study published in 2018 4, which recommends assessing patient clinical stability and evaluating and treating reversible causes.
• The study also suggests that immediate cardioversion is indicated in hemodynamically unstable patients, while rate or rhythm control are options for hemodynamically stable patients.
• A study published in 2015 5 compares the efficacy of calcium channel blockers to β-blockers for acute rate control of atrial fibrillation, suggesting that calcium channel blockers may be more effective in achieving rapid rate control.
• Another study published in 2023 6 investigates heart rate differences between non-dihydropyridine calcium channel blockers and beta-blockers in patients with non-permanent atrial fibrillation, finding that calcium channel blockers are associated with less bradycardia during sinus rhythm.