Atrial Fibrillation and Cough: Clinical Evaluation and Management

Introduction to Atrial Fibrillation and Cough

The European Society of Cardiology guidelines (2024) list typical symptoms of atrial fibrillation as palpitations, fatigue, dyspnea, and non-specific symptoms, but cough is notably absent from the symptom profile 1, 2
Heart failure represents the most common non-fatal outcome in atrial fibrillation patients, occurring in approximately half of patients over time, with a 4-5-fold increased risk compared to those without atrial fibrillation 1, 2

Pulmonary edema from congestive heart failure can present with cough as the sole manifestation 3
Cough occasionally serves as the presenting complaint of heart failure, whether cardiogenic or noncardiogenic 3
The concept that "atrial fibrillation begets heart failure and heart failure begets atrial fibrillation" is well-established, with both conditions sharing common pathophysiological mechanisms 4

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 5
ACE inhibitors are standard therapy for heart failure patients, many of whom have concurrent atrial fibrillation 5

Evaluate for dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema to assess for heart failure 1
Obtain chest X-ray looking for pulmonary congestion or edema to assess for heart failure 3
Check NT-proBNP or BNP levels (elevated in heart failure) to assess for heart failure 2
Perform echocardiography to assess left ventricular function and left atrial size 1, 2

Optimize heart failure therapy with diuretics to reduce pulmonary congestion if heart failure is present 5
Consider rhythm control strategy for atrial fibrillation, as restoration of sinus rhythm may improve cardiac output and reduce heart failure symptoms 4
If ACE inhibitor-related cough, encourage continuation if cough is mild, given the long-term mortality benefits of ACE inhibitors in heart failure 5
Switch to angiotensin receptor blocker (ARB) as alternative if ACE inhibitor-related cough is persistent and troublesome, though extreme caution is advised 5

Do not assume cough is from ACE inhibitors without first excluding pulmonary congestion from heart failure 5, 6
Do not overlook pulmonary embolism, which can present with cough and occurs more frequently in atrial fibrillation patients due to thromboembolic risk 3
Do not discontinue ACE inhibitors prematurely, as many patients can tolerate mild cough given the substantial mortality benefit 5