Atrial Fibrillation – also known as AFib or AF – is the most common arrhythmia in the world. Conservatively, 3-5 million Americans suffer from it today. AF accounts for approximately 1/3 of hospitalizations for cardiac rhythm disturbances and increases the risk of stroke 5-fold. More than $16 billion are spent annually to manage complications from AF. And, it is expected that the number of patients suffering from AF will triple in the next 30 years.
Here is what patient’s say about their experience with atrial fibrillation: “ My heart flip-flops, skips beats, and feels like it’s banging against my chest wall, especially if I’m carrying stuff up my stairs or bending down.”
What happens during Atrial Fibrillation?
Normally, your heart contracts and relaxes to a regular beat. During AF, the upper chambers of the heart (the atria) beat irregularly (quiver or fibrillate). This results in an irregular pulse which leads to symptoms.
Common symptoms during Atrial Fibrillation
Some patients have no symptoms at all. In these situations, their condition is only diagnosed during a routine medical examination. Still, others may present with 1 or more of the following symptoms:
- Rapid and irregular heartbeat
- Fluttering or thumping in the chest
- Shortness of breath and anxiety
- Fatigue when exercising
- Chest pain or pressure
Are there different types of Atrial Fibrillation?
Medical practitioners describe AF in the following fashion:
- Paroxysmal AF is when the heart returns to a normal rhythm on its own. People who have this form of AF typically have symptoms that last a few minutes to a few hours. Episodes of AF may only occur several times a year. Over time, this form often progresses to more persistent forms of AF.
- Persistent AF is when the episode lasts continuously for more than 7 days. Typically, an intervention is required to stop the arrhythmia since the heart often is unable to return to a normal rhythm on its own.
- Long-standing persistent AF occurs when a patient has been in atrial fibrillation for greater than 1 year. Again, the arrhythmia will only stop with an intervention.
- Permanent AF is a label used for patients in whom attempts at returning the patient to a normal rhythm have failed or a decision has been made to allow the patient to remain in AF indefinitely.
The natural history of AF is that it progressively becomes more persistent. Of course, the most devastating event associated with AF is the risk of stroke. A stroke is 5 times more likely in patients with AF than those without AF.
How do I get diagnosed?
If you are experiencing palpitations or note that your heart rate is irregular, you need to present to your physician for a thorough evaluation to determine whether you have atrial fibrillation. A thorough evaluation includes a detailed history and physical exam and a 12-lead EKG. Sometimes patients will undergo additional monitoring. Often, patients will be referred to a cardiologist or electrophysiologist (a cardiologist that specializes in heart rhythm disorders) for further evaluation.
Management of Atrial Fibrillation focuses on two treatment goals – (1) preventing symptoms and (2) preventing strokes. Possible goals include:
- Restoration of normal rhythm with or without medications
- Managing elevated heart rates while in AF
- Preventing blood clots from forming
- Controlling associated risk factors
- Preventing the possible development of congestive heart failure
How do I determine my stroke risk?
Several additional risk factors have been identified that contribute to the risk of stroke in patients with AF:
- C – cardiomyopathy (weak heart muscle with an ejection fraction < 35%)
- H – hypertension
- A2 – age > 75 years old
- D – diabetes
- S2 – history of stroke or transient ischemic attack (TIA)
- V – history of vascular disease
- A – age > 65 – 74 years old
- Sc – Sex (female)
A patient is given 1 point for each risk factor except for those marked with a subscript 2 (get 2 points). If you have > 1 point, you should be considered for one of the blood thinning medications (known as anticoagulants) mentioned below. Patients with a score of 0 may be considered for no anticoagulation.
Medications for Atrial Fibrillation
Medications are either geared to prevent strokes, control heart rate, or control the rhythm of the heart. Lists included here are not meant to be comprehensive. We encourage you to contact our office for the latest advancements in the medical management of AF.
How do I prevent a stroke?
Stroke prevention is achieved by taking a medication that prevents the formation of clots – collectively known as anticoagulants. For over 50 years, the only effective medication available was warfarin (Coumadin®). However, there are 3 new agents available that offer similar protection without the fuss that surrounds warfarin such as frequent blood monitoring or being concerned about diet or other medication interactions
- dabigatran (Pradaxa®)
- rivaroxaban (Xarelto®)
- apixaban (Eliquis®)
In low risk patients, aspirin has been used; however, its use is falling out of favor since better agents are now available.
Important precautions when taking blood thinning medication
- Call your healthcare provider right away if you have any usual bleeding or bruising
- If you forget to take your daily anticoagulant dose don’t take an extra dose to “catch up”! Follow your healthcare provider’s directions of what to do if you miss a dose.
- Always tell your physician, dentist, and pharmacist that you have been prescribed an anticoagulant medication
- Remember that other medications, and sometime supplements, can impact the effectiveness of these medications – either rendering the anticoagulant ineffective or overly effective
What if I am high risk for stroke but not a candidate for anticoagulation?
Unfortunately, not every patient is able to take blood thinning medication safely. A patient may have experienced a prior bleed while taking a blood thinner or is at risk for following. Until recently, these patients had no alternative but to accept the risk of stroke. However, we now have minimally-invasive procedures aimed to close a structure known as the left atrial appendage (LAA) which is the culprit for blood clots 90% of the time. Thin flexible tubes are inserted into blood vessels in the leg and possibly into the sack surrounding the heart. These thin tubes serve as a method to deliver either a stitch (Lariat®)that closes the LAA from the outside of the heart or a seal (Watchman™) that sits inside the heart to seal off the entrance to the LAA. Patients typically spend one evening in the hospital and go home the next day. Recovery is short with patients up and walking within hours of the procedure.
Heart rate controlling medications
Beta blockers, calcium channel blockers, and/or digoxin are often used to help prevent the heart from racing while in AF. Adequate heart rate control will frequently result in symptom improvement. Examples of these types medications include:
Heart rhythm controlling medications
Sometimes medications are required to maintain a normal rhythm and prevent the recurrence of AF. Collectively, these medications are known as anti-arrhythmic drugs. These medications require close monitoring by your healthcare provider if prescribed:
- Flecainide (Tambecor®)
- Propafenone (Rythmol®)
- Sotalal (Betapace®)
- Dofetilide (Tikosyn®)
- Amiodarone (Pacerone® or Cordarone®)
- Dronedarone (Multaq®)
The decision to use electrical cardioversion
A cardioversion is an outpatient procedure which allows for the immediate restoration of normal rhythm. The procedure is painless and involves going to sleep for 2-3 minutes while a quick current of electricity is sent through the heart resulting in a normal heart beat. It is the “reset button” for the heart. Sometimes, a patient will need to undergo a transesophageal echocardiogram (TEE) prior to the procedure to confirm that no blood clots are sitting in the heart. A TEE is also an outpatient procedure where the patient swallows a thin ultrasound probe similar to an endoscopy. Pictures of the heart are taken and then the probe is removed.
Atrial Fibrillation catheter ablation
By far, the most effective method in preventing recurrence of AF is by catheter ablation. Ablation is typically reserved for symptomatic patients with recurrent AF who are intolerant of one of the rhythm controlling medications mentioned above or do not wish to subject themselves to the potential side-effects from these medications.
A catheter ablation is a minimally invasive procedure performed by a heart rhythm specialist known as an electrophysiologist. The procedure is akin to having a cardiac catheterization or angiogram in that a patient lies on a table. Very thin spaghetti – like catheters are inserted into the body via the blood vessels in the leg. An electrically sensitive catheter is used to identify areas of the heart that are electrically malfunctioning. These catheters either heat or cool the heart tissue to destroy these malfunctioning areas. In the appropriate patient, the success rate of preventing AF recurrence is typically 70%. About 1 out or every 3 to 4 patients will need to have the procedure done twice. In these patients, the success rate can be as high as 80-85%. Recovery is short with patients walking within hours of the procedure. Patients will typically spend 1 evening in the hospital and go home the next day.
Can Atrial Fibrillation be cured?
The jury is still out on this question. At this time, there is no definitive cure for AF. However, catheter ablation is the closest tool we have to preventing the long-term recurrence of AF.
AV-node ablation with pacemaker implantation
This strategy is reserved for highly-symptomatic patients whose heart rate cannot be controlled by medications and who are not candidates for an AF catheter ablation. In these situations, the only way to prevent the heart from continuously racing is to disconnect the normal wiring of the heart (the AV node) and have a pacemaker take over the job of assuring that the heart beats at a normal rate. Patients often note an immediate improvement in symptoms after having this procedure.
At First Coast Heart & Vascular Center, we pride ourselves in offering comprehensive management for patients with Atrial Fibrillation. Our skilled cardiologists and electrophysiologists are able to offer contemporary medical management options. For symptomatic patients not responding and/or tolerating medical therapy, Dr. Neil Sanghvi and Dr. Dinesh Pubbi are able to perform an Atrial Fibrillation catheter ablation using state-of-the-art equipment found at several local hospitals. And, for patients unable to take anticoagulation, our physicians can evaluate you to determine whether you are a candidate for a left atrial appendage closure device.