Atrial Fibrillation

Atrial Fibrillation Treatment

There are multiple components to the management of atrial fibrillation (A-fib).

Electrical cardioversion- This involves the use of an electrical current from a device called a cardioverter, delivered by paddles placed on the chest, to "reset" your heart rhythm. Urgent cardioversion is usually performed if A-fib is interfering with the heart's ability to supply blood and oxygen to vital organs.

Some people with newly diagnosed A-fib can undergo electrical or medical cardioversion (in which an antiarrhythmic drug is used to reset or restore the normal heart rhythm) immediately. However, due to the risk of stroke from blood clots lodged in the left atrium, many people are advised to delay cardioversion until they have started Cardio rhythm specialist advice with an anticoagulant.

Transesophageal echocardiogram- A procedure called a transesophageal echocardiogram (TEE) is an alternative to delaying cardioversion after starting an anticoagulant medication. It involves swallowing a thin tube, which your doctor can then view on ultrasound. This allows the doctor to see the left atrium and look for evidence of blood clots. If there is no evidence of blood clots, cardioversion can be performed without three to four weeks of anticoagulant pretreatment.

Although the TEE can avoid the need for delaying cardioversion until three to four weeks after starting the anticoagulant, it is still important to be taking an anticoagulant at the time of the cardioversion. This can be warfarin, one of the newer agents, or heparin blood thinners that are administered as an injection subcutaneously (under the skin) or intravenously (through a vein).

Although there is still a risk that cardioversion could result in a stroke even when a clot is not seen on the TEE, the risk is quite small. Following cardioversion, you will need to continue taking an anticoagulant.

Long-term physician consultation- For people with A-fib, there are two long-term Cardiologist recommendations options: rhythm control and rate control.

Rhythm control- Rhythm control involves trying to restore and maintain a normal heart rhythm (called a sinus rhythm). Approaches include cardioversion and antiarrhythmic drugs, as well as ablation. After successful conversion to normal sinus rhythm, only 20 to 30 percent of people are still in sinus rhythm after one year without antiarrhythmic drug therapy. This can be increased to 50 percent or more with the addition of an antiarrhythmic drug.

The advantages to rhythm control include improved cardiac function and, for reduced symptoms. However, rhythm control is more likely to reduce the frequency of A-fib (as opposed to eliminating it entirely). Thus, many people treated with antiarrhythmic medications continue to take an anticoagulant indefinitely.

The disadvantages of antiarrhythmic drugs are the high rate of recurrent A-fib and side effects associated with these drugs, including the development of new abnormal heart rhythms. Rarely, adverse effects of antiarrhythmic drugs can be life-threatening.

Ablation procedure for the atrial fibrillation is an option for rhythm control if medications fail or if you do not want to take medications on a long term basis due to the side effects of the medications. The ablation procedure is now become safer with development of new technology in the last 2 decades. Quality of life has improved tremendously with these ablation procedures as anti arrhythmic medications can be discontinued or reduced after the ablation procedure.

Rate control- Rate control involves trying to bring the heart rate down to a near normal level. If you are treated with rate control, you will continue to have A-fib. However, you will take a medication (a beta blocker, calcium channel blocker, or less commonly, digoxin) to slow the electrical conduction from the upper heart chambers (atria) to the lower chambers (ventricles). This keeps your heart rate in the normal range.

The major disadvantage of the rate control strategy is that it is sometimes difficult to adequately control the rate and relieve symptoms.

Non-pharmacologic treatments- There are other ways to achieve rhythm or rate control besides medication, including radiofrequency catheter ablation, and several surgical procedures.

Radiofrequency ablation- Radiofrequency ablation is a procedure that involves using heat ("radiofrequency ablation") or cold ("cryoablation") to destroy the small part of the heart that is sending abnormal electrical signals. The success of the ablation depends on the stage of atrial fibrillation at the time of ablation. If the ablation is done earlier stage like paroxysmal atrial fibrillation, the success of the procedure is upto 90%. The success of the ablation procedure decreases as the atrial fibrillation progresses.

Increasingly, this therapy is being considered an initial option in young people who have symptoms of A-fib who do not wish to take long-term medications. It is also being used increasingly in patients who have heart failure from atrial fibrillation and who are having recurrent A-fib, despite using one or more antiarrhythmic drug.

Surgical procedures- Surgical procedures, including the complete "maze procedure" and the less invasive alternative surgeries, may be considered in some people with A-fib, especially those who must undergo open-heart surgery for other reasons.