AFIB – 4 pillars of treatment

Posted on by Sameer Oza
  1. Anticoagulation
  2. Rate control
  3. Rhythm control
  4. Lifestyle (risk factor) modification

Anticoagulation

Anticoagulation is used to prevent stroke based on the CHA2DS2VaSC score. Patients with a score more than or equal to 2 require anticoagulation based on ACC/AHA/HRS guidelines. In Europe, they anticoagulate for a score of more than or equal to 1. Some common anticoagulants are – warfarin, Pradaxa, Eliquis and Xarelto. If the patient needs anticoagulation but cannot tolerate it due to major bleeds, Watchman or Atriclip may be considered.

Rate control

Rate control is used to slow down the signals from the atria (upper chambers of the heart) from reaching the ventricles (lower chambers of the heart). If the heart rate is not well controlled, the heart being a muscle tires out and leads to cardiomyopathy. Symptoms of congestive heart failure – shortness of breath, swelling of legs, inability to breathe when lying down may ensue. Some common rate control medications are metoprolol (and other beta blockers) and diltiazem (and other calcium channel blockers). Sometimes, if rate control medications are not effective and the patient is not thought to be a candidate for rhythm control, a pacemaker may be placed followed by AV node ablation.

Rhythm control

Rhythm control is when the doctor and patient agree that maintaining normal rhythm (instead of AFIB) is preferable due to symptoms of AFIB. Not all patients need rhythm control as proven in the AFFIRM trial. Rhythm control is recommended in patients who have symptoms of AFIB or have developed cardiomyopathy (weakening of heart muscle) despite adequate rate control. Rhythm control can be achieved with cardioversion, antiarrhythmic drugs, catheter based ablation or surgical ablation.

Short term rhythm control may be achieved with cardioversion (shock delivered to the heart under anesthesia). This is like pressing ctrl+alt+delete on your computer when it is frozen – it resets the heart beat but about 70% of patients will revert to AFIB within a year.

Some commonly used antiarrhythmic drugs are flecainide, propafenone, sotalol, dofetilide, dronedarone and amiodarone. Some antiarrhythmic drugs like sotalol and dofetilide will need to be started in the hospital (usually a 3 day – 2 night stay).

For patients who have failed or not tolerated antiarrhythmic drug therapy OR if patient prefers as a primary therapy, ablation may be an option. Ablation can be done either with a catheter based procedure or surgically.

Lifestyle/risk factor modification

All the above therapies are important. However they do not address the underlying cause of atrial fibrillation.

WHILE ABLATION IS A GOOD TREATMENT WE HAVE TO OFFER YOU, IT IS NOT A CURE. IT IS AN EXPENSIVE BAND-AID IF YOU DO NOT MAKE THE LIFESTYLE CHANGES THAT ARE RECOMMENDED.

Some common lifestyle/risk factors that should be modified concurrent with ablation to make ablation more successful:

  1. Obesity.
  2. Poor sleep quality and sleep apnea.
  3. Alcohol excess (even 1 drink per day is too much once you have AFIB).
  4. Smoking.
  5. High blood pressure.
  6. Overactive thyroid.
  7. Endurance exercise – this one is going to be controversial in Boulder 🙂
  8. Aging – 1 in 4 people develop AFIB by the time they are 80 years old. Can’t do anything about this one? Or can we?