Sunday, December 8, 2013

Atrial Fibrillation Treatment

Afib Treatment

Atrial fibrillation is the most common sustained cardiac arrhythmia. The number of patients with afib continues to grow but fortunately, so does the treatment options. You have learned in our previous sections about the normal rhythm of your heart, what afib is and consequences it may have. We will now focus on the treatment options available for patients with afib.

Medical Therapy for afib                           

In treating someone with atrial fibrillation it is important to always focus on the three main problems it may cause:
- Strokes
- Symptoms - consequently decreased quality of life
- congestive heart failure

The treatment for atrial fibrillation is always individualized, tailored to a patient’s  needs, risk factors for stroke and congestive heart failure and most importantly how much afib has affected your quality of life. The treatment is also dependent upon whether a patient has paroxysmal, persistent or permanent atrial fibrillation.

In treating a patient with afib I always follow a step-wise approach.

Step 1 - Stroke Prevention

 - Determine the patient's stroke risk and based on that choose the most appropriate stroke prevention option.
Every patient with afib has an increased risk of having a stroke. Strokes happen when blood clots form inside the left atrium and if dislodged travel to the brain where they can cut off circulation.

Your risk of stroke is dependent upon what other risk factors you have. The risk factors for stroke in patients with afib are:
- Congestive Heart Failure
- Hypertension
- Age greater than 65
- Diabetes
- Prior Stroke or TIA
- History of heart attacks or blockages in the neck or leg arteries

The appropriate treatment to decrease your risk of stroke will be dependent on how high your risk is. Your physician will also take into consideration along with you how high your risk of bleeding from blood thinners is.

Low risk patients: for many patients aspirin might be the only treatment needed.

Moderate or high risk patients: blood thinners (such as coumadin, dabigatran, apixaban or rivaroxaban)

Treatment is always individualized and should be carefully discussed with your physician.

Another emerging option for stroke prevention (not currently commercially available) as an alternative to blood thinners is atrial appendage closure.

Please see more details about stroke prevention on our section about stroke. And always remember that this booklet is supposed to be informational only and that treatment is individualized and should be discussed with your physician.

Step 2 - Improve Quality of Life - Reducing the symptoms caused by Afib

Determine how symptomatic a patient is and based on that determine if rate or rhythm control is the most appropriate option.


 Rate control strategyRhythm Control strategy

Patients with atrial fibrillation can be extremely symptomatic while some have no symptoms at all. Some patients have few spells a year, while others have many spells a week. Others are in afib all the time. These are the factors that will determine the treatment.

Patients with paroxysmal afib

Spells that stop spontaneously, typically lasting less than 24 hours.

Depending on the number and severity of the spells the treatment will consist of:
-beta blockers or calcium channel blockers: medications that are used to slow down your heart during spells of afib.
- anti-arrhythmic drugs: if a patient continues to have symptomatic spells frequently, these drugs are indicated to decrease the number of spells. When these drugs are used we call it a rhythm control strategy.  There are many anti-arrhythmic drugs available. Oftentimes treatment by a physician specialized in treating rhythm disorders is necessary.
- Atrial fibrillation ablation: afib ablation is the best option for patients that have failed or have not tolerated  medications.  Afib ablation  is the only treatment options for patients with afib that is potentially curative. We have an entire section dedicated to atrial fibrillation ablation.

Electrophysiology Lab
Atrial Fibrillation ablations are performed in the Electrophysiology Laboratory

Patients with Persistent Afib

Patients that stay in afib constantly and have to be treated to return to normal rhythm.

In patients with persistent atrial fibrillation the first step is to decide what is the most appropriate treatment options, rate or rhythm control.

Rhythm control is the right option for you if you have symptoms believed to be secondary to afib, such as fatigue, shortness of breath, dizziness, etc. Most patients are able to tell right away when they went into afib and for these patients it is relatively easy to decide the treatment of choice.
- Cardioversion plus anti-arrhythmic drugs: for patients with persistent atrial fibrillation to return back to normal rhythm, we typically need to perform a cardioversion. A procedure where the patient is sedated for a brief period of time and then a shock is delivered to stop the afib. After that medications have to be used to keep the patient in normal rhythm.

- Afib ablation: ablation can also be performed for patients with persistent atrial fibrillation.

Rate control is the best option for patient that are asymptomatic or just mildly symptomatic. For these patients the treatment consists of using medications to control the heart rate. It is always important to remember that treatment to reduce the risk of stroke concurrently is necessary.

Step 3 - Prevention of Congestive Heart Failure

For patients that stay in afib, it is very important to make sure that the heart rates are well controlled at all times, both at rest and during exertion. Some patients have such fast heart rates during afib that with time the heart can become weak – and develop congestive heart failure. It is always one of the goals of our therapy to prevent congestive Heart Failure.

The majority of patients will have their heart rates well controlled with medications. A small number of patients have afib that does not respond to any of the available medications and require other interventions. Another option for these patients is to undergo AV nodal ablation with implantation of pacemaker. This option is nowadays used as a last resort, or when patients are not candidates for afib ablation or medications.

Jose Osorio, MD

Cardiac Electrophysiologist

St Vincent's Hospital

Birmingham, Al

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