Dear Dr. Gott: I was recently diagnosed with atrial fibrillation. My family practitioner sent me to a cardiologist at my request for a second opinion.

My GP suggested I start warfarin and have an angiogram. The cardiologist says, "A-fib isn't something that calls for an angiogram" and put me on warfarin and diltiazem. He is now telling me that I can do one of two things: have a trans-oesophageal echocardiography followed by cardioversion (his preference), or I can stay on the medication for the rest of my life.

I have no symptoms except for a fast pulse and some shortness of breath upon exertion. I am a 78-year-old retired nurse. I have no physical problems other than osteoarthritis. I also take losartan for high blood pressure, which is now stable at 120/80.

What is you opinion on how I should proceed? Which physician should I listen to?

Reply: Atrial fibrillation is a heart disorder that causes an abnormally rapid, irregular heart rate; therefore, I believe your cardiologist is the best choice for treatment. Symptoms may not be noticeable in some sufferers but may include decreased blood pressure, chest pain, shortness of breath, weakness, lightheadedness, confusion, fatigue, fainting and palpitations. If symptoms come and go, the condition is known as paroxysmal atrial fibrillation, whereas consistent symptoms denote chronic a-fib.

There are several possible causes. The risk of developing this condition increases with age. Heart failure, coronary-artery disease, high blood pressure, heart attack, certain medications, heart-valve defects, hyperthyroidism, heart surgery and infections (especially of the heart) are common causes.

In some cases, no cause can be found. This is known as lone atrial fibrillation, and serious complications are rare.

Heart failure, stroke and blood clots are common complications of untreated a-fib, especially if other heart abnormalities are involved.

Treatment is first aimed at any underlying condition that might have caused the atrial fibrillation, and resetting the heart's rhythm back to normal and preventing blood clots from forming.

The primary therapy is cardioversion. This can be done with medications or by shocking the heart with electricity. The cause, severity and how long the condition has been present all play a factor in which therapy is used.

To reduce the risk of stroke and blood clots, anticoagulant medications such as warfarin are often prescribed for several weeks before the cardioversion is attempted and sometimes for several weeks afterward.

Another option is trans-oesophageal echocardiography, which is similar to an ultrasound of the heart except that the image is achieved by looking through the oesophagus instead of the chest. In this way, a clearer image is available because the ribs are not in the way.

Once a normal rhythm is achieved, medication may be prescribed to maintain it.

If this doesn't work, the cardiologist may recommend ablation, a procedure used to destroy the specific area within the heart that is causing the abnormal signals. It is also important to quit smoking, eat a low-fat, low-salt diet to reduce cholesterol and high blood pressure, and reduce alcohol intake to no more than one drink per day for women and two for men. Increased exercise can also help. Caffeine and other stimulants, such as those found in cold medicines, should also be avoided.