Can atrial fibrillation (AF) cause a cough?

Can Atrial Fibrillation Cause a Cough?

Atrial fibrillation itself does not directly cause cough, but cough can occur as a manifestation of heart failure—the most common complication of AF—or as a side effect of ACE inhibitors used to treat AF-related heart failure.

Understanding the Relationship Between AF and Cough

AF Does Not Directly Cause Cough

The most recent and comprehensive AF guidelines from the European Society of Cardiology (2024) list the typical symptoms of AF as palpitations, fatigue, dyspnea, and non-specific symptoms, but cough is notably absent from the symptom profile 1. The documented symptoms of AF include cardiac-specific manifestations like palpitations and non-specific symptoms such as fatigue, but respiratory symptoms like cough are not recognized as direct manifestations of the arrhythmia itself 1.

The Indirect Connection: Heart Failure as the Bridge

Heart failure represents the most common non-fatal outcome in AF patients, occurring in approximately half of patients over time, with a 4-5-fold increased risk compared to those without AF 1. This connection is critical because:

• Pulmonary edema from congestive heart failure can present with cough as the sole manifestation 1
• Cough occasionally serves as the presenting complaint of heart failure, whether cardiogenic or noncardiogenic 1
• The concept that "AF begets HF and HF begets AF" is well-established, with both conditions sharing common pathophysiological mechanisms 1

ACE Inhibitor-Related Cough: A Common Confounding Factor

ACE inhibitor-induced cough represents the most common reason for withdrawal of these drugs, occurring in 5-10% of white patients and up to 50% in Chinese patients 1. This is particularly relevant because:

• ACE inhibitors are standard therapy for heart failure patients, many of whom have concurrent AF 1
• The cough is characteristically nonproductive with a persistent "tickle" in the throat 1
• It typically appears within the first months of therapy and disappears within 1-2 weeks of discontinuation 1
• Other causes of cough, especially pulmonary congestion from heart failure, must always be excluded before attributing cough to the ACE inhibitor 1

Clinical Algorithm for Evaluating Cough in AF Patients

Step 1: Assess for Heart Failure

• Evaluate for dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema 1
• Obtain chest X-ray looking for pulmonary congestion or edema 1
• Check NT-proBNP or BNP levels (elevated in heart failure) 1
• Perform echocardiography to assess left ventricular function and left atrial size 1

Step 2: Review Medications

• Identify if patient is taking ACE inhibitors (captopril, enalapril, lisinopril, ramipril, etc.) 1
• Determine timing of cough onset relative to medication initiation 1
• Consider that beta-blockers and calcium channel blockers do not cause cough 1

Step 3: Exclude Other Causes

• Rule out pulmonary embolism (occurs in nearly half of patients with documented PE and can present as cough) 1
• Assess for respiratory infections, chronic lung disease, or other pulmonary pathology 1
• Consider uncommon causes only after excluding common etiologies 1

Management Approach

If Heart Failure is Present:

• Optimize heart failure therapy with diuretics to reduce pulmonary congestion 1
• Consider rhythm control strategy for AF, as restoration of sinus rhythm may improve cardiac output and reduce heart failure symptoms 1
• The cough should improve as pulmonary congestion resolves 1

If ACE Inhibitor-Related:

• Encourage continuation if cough is mild, given the long-term mortality benefits of ACE inhibitors in heart failure 1
• Only withdraw if cough proves persistent and troublesome 1
• Switch to angiotensin receptor blocker (ARB) as alternative, though extreme caution is advised as some patients develop angioedema with ARBs after ACEI-related angioedema 1
• Demonstrate that cough disappears after drug withdrawal and recurs with rechallenge before definitively attributing to ACE inhibitor 1

Critical Pitfalls to Avoid

• Do not assume cough is from ACE inhibitors without first excluding pulmonary congestion from heart failure 1
• Do not overlook pulmonary embolism, which can present with cough and occurs more frequently in AF patients due to thromboembolic risk 1
• Do not discontinue ACE inhibitors prematurely, as many patients can tolerate mild cough given the substantial mortality benefit 1
• Recognize that in studies of ACE inhibitor cough, the symptom often did not recur with rechallenge, suggesting it was coincidental 1