Atrial fibrillation (AF) can profoundly impact the foot and lower limb through its cardiovascular, circulatory, and systemic complications, with podiatrists playing a crucial role in early detection, risk reduction, and patient management.
How Atrial Fibrillation Impacts the Foot and Lower Limb
Atrial fibrillation is the most common cardiac arrhythmia, characterized by rapid and irregular heart rhythms. While primarily a cardiac problem, AF’s downstream consequences frequently manifest in the lower limbs.
- Impaired Circulation and Peripheral Arterial Disease (PAD): AF increases the risk of peripheral arterial disease due to shared underlying conditions like atherosclerosis and systemic vascular inflammation. Up to 21% of patients with AF demonstrate PAD when screened with ankle-brachial index (ABI), significantly higher than the general population. PAD leads to poor blood flow, leg and foot pain, intermittent claudication, numbness, slow wound healing, and—in severe cases—gangrene or limb ischemia.
- Arterial Embolism and Acute Limb Ischemia: AF increases the risk of blood clot formation in the atria. Emboli can travel to distal arteries, causing acute occlusion—most commonly in the legs. Patients may present with sudden foot pain, pallor, paresthesia, pulselessness, and risk of irreversible muscle and tissue damage if not treated rapidly. Case reports highlight limb-threatening embolic events directly linked to AF, requiring emergency intervention to restore blood flow and prevent amputation.
- Venous Complications and Edema: AF-induced heart failure results in fluid accumulation, leading to swelling of feet, ankles, and lower legs. This can cause discomfort, skin changes (e.g., stasis dermatitis), and increased susceptibility to ulcers and infection. Chronic edema can exacerbate existing lower limb conditions and hinder podiatric interventions.
- Chronic Lower Limb Symptoms: Signs associated with AF include muscle fatigue, weakness, and lower extremity swelling. These symptoms may limit mobility and reduce quality of life, especially in older adults or those with comorbid diabetes or PAD.
Mechanisms Connecting AF With Lower Limb Pathology
Several underlying mechanisms link AF to foot and lower limb pathology.
- Atherosclerosis: Both AF and PAD frequently occur due to atherosclerosis—a chronic process involving vessel inflammation, lipid accumulation, and structural change. Systemic atherosclerosis raises the risk for both cardiac arrhythmia and vascular insufficiency in the extremities.
- Thromboembolism: Rapid irregular heartbeat in AF leads to stasis of blood in the atria, promoting clot formation. These clots may embolize to peripheral arteries supplying the legs, producing acute ischemic episodes with potentially catastrophic outcomes.
- Heart Failure: The inability of the heart to efficiently pump blood because of AF leads to venous congestion and fluid leak into the tissues, commonly seen as lower limb edema.
- Impaired Perfusion and Healing: Chronic low cardiac output, coupled with PAD, deprives foot and leg tissues of adequate oxygen and nutrients, impairing wound healing, increasing infection risk, and worsening diabetic foot outcomes
Clinical Presentation in the Foot and Lower Limb
AF’s manifestations in the lower limbs can be subtle or dramatic:
- Sudden onset of calf pain, pallor, and paresthesia (sensory disturbances) may signal acute embolic arterial occlusion
- Chronic symptoms include fatigue, chronic leg pain, intermittent claudication, and persistent swelling.
- Ulcers, delayed healing, and recurrent infection are frequent in patients with coexisting AF and PAD.
- Irregular pulse and diminished pedal pulses may be noted during routine foot examination.
The Role of Podiatrists
Podiatrists play an essential interdisciplinary role in the management of patients with AF, often serving as the first point of contact for those with undiagnosed cardiac arrhythmia.
Early Detection and Opportunistic Screening
- Pulse Checks: Podiatrists can detect irregular pedal pulses during routine vascular assessments of the foot. Simple palpation or use of Doppler ultrasound for 30 seconds can identify rhythm disturbances suggestive of AF.
- Targeting High-Risk Populations: Patients with diabetes, advancing age, or known vascular disease are at elevated risk of AF and PAD. Podiatrists routinely encounter these groups in clinical practice, allowing opportunistic screening during foot checks.
- Technology-Assisted Screening: Initiatives in some healthcare systems have integrated digital single-lead ECG testing into podiatry clinics, allowing prompt diagnosis and referral for cardiac evaluation if AF is suspected.
Risk Factor Modification and Prevention
- Addressing Comorbidities: Podiatrists support management of risk factors such as diabetes, hypertension, obesity, and peripheral arterial disease—modifying the underlying pathways that contribute to AF and lower limb vascular events.
- Patient Education: Education on the signs and symptoms of acute ischemia and chronic vascular insufficiency is fundamental. Podiatrists teach patients to recognize new or worsening lower limb symptoms requiring medical attention.
Multidisciplinary Referral and Care Coordination
- Referral Pathways: When an irregular lower limb pulse is detected, podiatrists initiate timely referral to cardiac or vascular specialists for formal diagnostic evaluation and intervention.
- Interdisciplinary Communication: Integrated care ensures that podiatric findings prompt comprehensive cardiac assessment and anticoagulation therapy, reducing risk of recurrence and long-term complications.
Lower Limb Preservation and Advanced Management
- Monitoring and Wound Care: Patients with AF, especially those on anticoagulant therapy, may have delayed healing and increased risk of bleeding. Podiatrists play an ongoing role in wound management, infection control, and limb preservation, particularly in those with chronic foot ulcers.
- Surveillance for Edema and Tissue Health: Routine assessment for chronic fluid accumulation, skin breakdown, and infection helps reduce the risk of lower limb complications secondary to AF-induced heart failure.
Practical Examples and Evidence of Podiatric Involvement
Real-world initiatives have demonstrated how podiatrists can contribute to AF detection and improved patient outcomes.
- In the United Kingdom, podiatry departments have embraced technology, implementing opportunistic AF screening during routine appointments and referring patients for further cardiac evaluation when irregular pulses are identified.
- Studies have shown that integration of point-of-care testing and robust referral pathways enhances the early diagnosis of AF and reduces major adverse events such as stroke and limb loss.
Atrial fibrillation has far-reaching consequences for foot and lower limb health, contributing to arterial embolism, PAD, chronic edema, impaired healing, and increased risk of amputation. Podiatrists occupy a pivotal role through opportunistic screening, education, risk modification, and care coordination—helping to bridge the gap between systemic cardiac disease and limb preservation. Through vigilance and collaborative care, podiatrists serve as a frontline defense against the silent threats of AF in the lower limb.