Treatment

Several approaches are used to treat Atrial Fibrillation, including daily medications, implantation of medical devices (such as pacemakers), conducting surgical and non-surgical procedures, or a combination of these treatments. Regardless of the method, the goals of AF treatment are to:

• restore a normal heart rhythm.
• reduce and control the rapid heart rate.
• reduce the risk of stroke.

Methods of treatment can be placed into two categories: suppressive therapies and curative therapies. Suppressive therapies work to suppress or control the symptoms of AF. Curative therapies are designed to eliminate the cause of the condition and have the potential to cure it.

After the condition is diagnosed, a physician works with the patient to develop a treatment plan that best addresses the symptoms the patient is experiencing, the type of AF and the lifestyle of the patient. Current treatment options include:

Suppressive therapies

Cardioversion
Occasionally, it is necessary to immediately treat a heart that is in Atrial Fibrillation and restore its normal, sinus rhythm. To do so, a physician may perform a cardioversion in one of two ways:

Electrical cardioversion – While under anesthesia, the patient receives an electrical shock that is delivered through a defibrillator, placed on the chest. The electrical shock stops the heart for a split second and when it begins to beat again, normal rhythm may be restored.

Cardioversion with drugs – Antiarrhythmics – a class of medications – are often used to suppress irregular rhythms of the heart. Occasionally, the physician may administer an antiarrhythmic drug prior to attempting an electrical cardioversion – especially in cases where electrical cardioversion has been unsuccessful in the past. In these cases, antiarrhythmic medications may improve the success of the electrical cardioversion procedure.

Although cardioversion immediately restores sinus rhythm in more than 95 percent of patients, results are not always permanent. More than half of the patients who receive cardioversion revert back to an abnormal, quivering heartbeat.

Medication
When a heart is in Atrial Fibrillation, it beats both frequently and irregularly. The heart beats frequently, because the heart is beating at a faster rate than normal. It beats irregularly because the beats do not occur in an organized, consistent fashion; they are arrhythmic.

For Atrial Fibrillation, medications may be used as a primary mode of treatment or in combination with other treatments. Three types of medications can be prescribed, depending on the patient’s condition, which address the frequency of the heartbeat, irregularity of the heartbeat, or thin the blood to prevent thomboembolic events such as stroke:

Rate control medications – Rate control medications are designed to regulate the speed at which a heart beats and are frequently prescribed first to control the dangerously fast rhythm. Rate control medications will usually not regulate an irregular heartbeat, but can reduce the heart rate to 60 to 100 beats per minute.

Antiarrhythmics – Antiarrhythmic medications are designed to regulate the rhythm of the heart. When the heart beats in an irregular, disorganized fashion, antiarrhythmics can be prescribed to restore a consistent sinus rhythm.

Anticoagulants – Anticoagulant medicines are commonly prescribed for people with AF to help reduce the risk of stroke. Because blood is not completely pumped out of a heart with AF, it can pool in the chambers, causing clots to form. The clots can dislodge and travel to the brain, causing a stroke. Anticoagulants increase the time it takes for blood to clot and prevent existing clots from growing by thinning the blood.

Medical devices
If medications used to suppress symptoms slow the heart rate too much or if a patient’s AF episodes are sporadic, a implantable medical device may be used to help regulate the heartbeat. A device such as an implantable cardioverter defibrillator (ICD) can be used to treat symptoms of AF with low-dose electrical energy.

Pacemakers may also be used regulate the heartbeat. A pacemaker is implanted near the collarbone and a wire is extended from it to the heart. If the pacemaker detects an abnormally slow or nonexistent rhythm, it transmits an electrical impulse to simulate the heartbeat.

Curative therapies

Ablation
If a physician determines a patient’s AF can not be managed with medicines or cardioversion, he or she may recommend cardiac ablation. Use of ablation to treat AF is an option that some physicians will use in their practice. It is the physician that decides if the use of ablation is appropriate treatment for the patient. 

A physician typically recommends ablation for patients:

• with paroxysmal or chronic AF.
• whose AF is resistant to medications.
• who experience continued symptoms after treatment with medications.
• who experience complications with medications.

The intent of cardiac ablation is to ablate, or destroy, abnormal tissue areas of the heart, which can repair the heart’s electrical system and return it to a normal rhythm. While specific procedures and techniques vary, ablation may be placed in two categories:

Catheter ablation
During catheter ablation, a physician threads several electrode catheters – special long, flexible tubes with wires – through a large vein in the groin and up into the heart. Some of these, called diagnostic catheters, are used to study the arrhythmia and locate its origin. Once the physician determines exactly where abnormal tissue in the heart is located, it can be ablated using an ablation catheter.

To ablate the abnormal tissue, the physician removes the diagnostic catheters and inserts the ablation catheter, positioning it on or very close to the abnormal tissue. Radio-frequency energy is delivered through the ablation catheter into the abnormal tissue. The small area of heart tissue under the tip of the ablation catheter is heated or frozen by this energy, creating a tiny scar or lesion. As a result, this tissue is no longer capable of conducting or sustaining the arrhythmia.

When the physician has successfully ablated all the abnormal tissue, the catheters are removed and the insertion site is closed.

Click to learn more about AF and catheter ablation

Surgical Ablation
Traditionally, surgical ablation required open heart surgery and general anesthesia. While highly effective, surgical ablation procedures can be more invasive than other ablation procedures, requiring that an incision be made in the chest.

Surgical ablation procedures typically incorporate a traditional method, also called the Cox-Maze Procedure, in which incisions are made in cardiac tissue, or use an energy source to ablate the tissue.

In a traditional procedure, physicians make a precise pattern of incisions inside the right and left atria and suture the incisions back together. This creates lesions of scar tissue that stop abnormal electrical activity from passing through the heart. Patients must be placed on a heart-lung bypass machine or are ‘on-pump’ throughout the procedure.

Surgical ablation procedures that use energy sources are much like catheter ablation; they use high-frequency energies to ablate tissue. In some of these procedures, it is not necessary to place the patient on a heart-lung bypass machine. These procedures are also known as ‘off-pump’ procedures.

All surgical ablation procedures require an incision be made in the patient’s chest to access the heart. Incisions are either open-chest — a large incision is made over the sternum and the chest is ‘opened’— or closed-chest – one or more incisions are made on the side of the chest and the heart is accessed through the ribcage.

Surgical ablation can be performed on AF patients already receiving cardiac valve replacement or repair, or coronary artery bypass, because a surgeon already has access to the patient’s heart. These procedures are referred to as concomitant – something that occurs at the same time as another thing.

Click to learn more about AF and surgical ablation

Published: January 1, 2007