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Treatments and drugs
By Mayo Clinic staff
In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. If the condition that triggered your atrial fibrillation can be treated, you might not have any more heart rhythm problems — or at least not for quite some time. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.
The treatment option best for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the goals of treating atrial fibrillation are to:
- Reset the rhythm or control the rate
- Prevent blood clots
The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need a more invasive treatment, such as surgery or medical procedures using catheters.
Resetting your heart's rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it. Cardioversion can be done in two ways:
- Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm. This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic or a similar one to try to prevent more spells of atrial fibrillation
- Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily. When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed during anesthesia.
Before cardioversion, you may be given a blood-thinning medication, such as warfarin (Coumadin), for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 24 hours, you'll need to take warfarin for at least four to six weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm. Warfarin is a powerful medication that can have dangerous side effects if not taken exactly as directed by your doctor. If you have any concerns about taking warfarin, talk to your doctor.
Or, instead of taking warfarin, you may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion. In transesophageal echocardiography, a tube is passed down your esophagus and detailed ultrasound images are made of your heart. You'll be sedated during the test.
Maintaining a normal heart rhythm
After electrical cardioversion, anti-arrhythmic medications often are prescribed to help prevent future episodes of atrial fibrillation. Commonly used medications include:
- Amiodarone (Cordarone, Pacerone)
- Propafenone (Rythmol)
- Sotalol (Betapace)
- Dofetilide (Tikosyn)
Although these drugs can help maintain a normal heart rhythm in many people, they can cause side effects, including:
- Nausea
- Dizziness
- Fatigue
Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, the chance of another episode of atrial fibrillation is high.
Heart rate control
Sometimes atrial fibrillation can't be converted to a normal heart rhythm. Then the goal is to slow the heart rate to between 60 and 100 beats a minute (rate control). Heart rate control can be achieved two ways:
- Medications. Traditionally, doctors have prescribed the medication digoxin (Lanoxin). It can control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers.
-
Atrioventricular (AV) node ablation. If medications don't work, or you have side effects, AV node ablation may be another option. The procedure involves applying radio frequency energy to the pathway connecting the upper and lower chambers of your heart (AV node) through a long, thin tube (catheter) to destroy this small area of tissue.
The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though, and anticoagulant medication is still required. A pacemaker is then implanted to establish a normal rhythm. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke, because your heart rhythm is still atrial fibrillation.
Other surgical and catheter procedures
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:
-
Radiofrequency catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.
Radiofrequency energy directed to these hot spots through a catheter inserted in an artery near your collarbone or leg may be used to destroy these hot spots, scarring the tissue so the erratic electrical signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices. In some cases, other types of catheters that can freeze the heart tissue (cryotherapy) are used.
- Surgical maze procedure. The maze procedure is often done during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy can also be used to create the scars, and there are several variations of the surgical maze technique. The procedure has a high success rate, but because it usually requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair. Some people need a pacemaker implanted after the procedure.
Preventing blood clots
Most people who have atrial fibrillation or who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher if other heart disease is present along with atrial fibrillation. Your doctor may prescribe blood-thinning medications (anticoagulants) such as warfarin (Coumadin) in addition to medications designed to treat your irregular heartbeat. Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal. If you're prescribed warfarin, carefully follow your doctor's instructions on taking it. Warfarin is a powerful medication that can have dangerous side effects.
- Atrial fibrillation. American Heart Association. http://www.americanheart.org/presenter.jhtml?identifier=4451. Accessed Jan. 20, 2009.
- Atrial fibrillation and flutter. Heart Rhythm Society. http://www.hrspatients.org/patients/heart_disorders/atrial_fibrillation/default.asp. Accessed Jan. 20, 2009.
- Atrial fibrillation. National Heart Lung and Blood Institute. http://www.nhlbi.nih.gov/health/dci/Diseases/af/af_all.html. Accessed Jan. 20, 2009.
- Thomas MC, et al. Blood pressure control and the risk of incident atrial fibrillation. American Journal of Hypertension. 2008;21:1111.
- ACC/AHA/ESC Writing Committee members. 2006 guidelines for the management of patients with atrial fibrillation. Europace. 2006;8:651.
- Singer DE, et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:546S.
- Podrid PJ. Patient information: Cardioversion. http://www.uptodate.com/index. Accessed Jan. 20, 2009.
- Cappato R, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111:1100.
- Voeller RK, et al. The effects of the Cox maze procedure on atrial function. Journal of Thoracic and Cardiovascular Surgery. 2008;136:1257.
- FDA approves first ablation catheters for the treatment of atrial fibrillation. U.S. Food and Drug Administration. http://www.fda.gov/bbs/topics/NEWS/2009/NEW01953.html. Accessed Feb. 6, 2009.
