Atrial Fibrillation
Treatment Overview
Treating atrial fibrillation is important for several reasons. An irregular, rapidly beating heart can weaken the heart muscle and cause it to dilate or stretch out. This can increase your risk of developing heart failure or having chest pain or even a heart attack. Also, atrial fibrillation can greatly increase your risk of having a stroke.
Many people are able to live full and active lives while being treated for atrial fibrillation. To stay healthy, you will probably need to take medications, including an anticoagulant or aspirin, medications to slow heart rate, or possibly rhythm control medications.
Initial treatment
If atrial fibrillation is causing your heart to pump dangerously fast or your blood pressure to drop dramatically, you will probably be taken to the hospital for treatment to restore your blood pressure and heart rate to normal. If atrial fibrillation is not causing severe symptoms, you may be treated on an outpatient basis. Treatment for people who have just started having episodes of atrial fibrillation usually includes trying to convert the heart to a normal rhythm. Sometimes anticoagulant medications are used to prevent clots and stroke.
- If you have had atrial fibrillation for less than 48 hours, your doctor may perform a procedure called cardioversion, using either medication or a low-voltage electrical shock (electrical cardioversion), to return the irregular heartbeat to a normal rhythm (normal sinus rhythm).
- If atrial fibrillation has lasted for more than 48 hours, attempting cardioversion could cause a stroke. In this case, you may need to take the anticoagulant medication warfarin (such as Coumadin) for several weeks before your doctor tries cardioversion. Taking anticoagulants reduces the chance that a clot might travel from the heart to the brain after cardioversion.
- If you are not sure how long you have had atrial fibrillation, you are also at risk of having a clot in your heart. If you are not having severe symptoms, such as fainting, your doctor will probably also recommend that you take anticoagulants for several weeks before cardioversion to prevent a stroke.
- If you have severe symptoms and you are not sure how long you have had atrial fibrillation, your doctor may try to restore your heart to a normal rhythm immediately. In this case, your doctor will use a transesophageal echocardiogram to determine whether you have a clot in your heart that could cause a stroke. The results of this test will determine what your doctor does next:
- If the heart is clear of clots, cardioversion can be attempted. Anticoagulants are used after to prevent strokes.
- If there is a clot in the heart, you doctor will prescribe anticoagulants before trying cardioversion.
Cardioversion usually works to restore a normal sinus rhythm. However, in many cases the heart rhythm goes back to atrial fibrillation.
Ongoing treatment
When atrial fibrillation comes on suddenly, lasts a short time, and goes away on its own, it is called paroxysmal atrial fibrillation. Typically, episodes of paroxysmal atrial fibrillation come on more often and last longer over time.
Having paroxysmal atrial fibrillation can raise your risk of stroke. If you are at an average to high risk of having a stroke, your doctor may prescribe long-term use of an anticoagulant medication, warfarin (such as Coumadin), to reduce this risk. You may be at average to high risk of stroke if you are older than 75 or have a history of heart disease, high blood pressure, diabetes, or stroke. If you are at low risk of having a stroke or you cannot take warfarin, you may need to take aspirin daily.
You may also need to take rhythm control medications (antiarrhythmics) to try to prevent paroxysmal atrial fibrillation from recurring.
Doctors may recommend the "pill in the pocket" approach for people with paroxysmal atrial fibrillation. With this approach, you can take a single dose of an antiarrhythmic drug when you feel palpitations instead of taking the medication every day. For some people, this stops atrial fibrillation episodes. It may also reduce medication side effects and the need to be seen in the emergency room or be hospitalized.7
Over time, episodes of atrial fibrillation typically last longer and often do not go away on their own. This is called persistent atrial fibrillation. When you have had atrial fibrillation for a long time, it is more difficult to return your heart to a normal rhythm (also called a normal sinus rhythm). When cardioversion is not an option or does not work, medications are usually given to control the heart rate and prevent stroke.
Rate control medications. Rate control medications are used if your heart rate is too fast. These medications include beta-blockers, calcium channel blockers, and/or digoxin. They usually do not return your heart to a normal rhythm—in other words, your heartbeat will still be irregular. However, these medications can keep your heart from beating at a dangerously fast rate. Most people tolerate an irregular heart rhythm if the rate is kept between 60 and 100 beats per minute.
Research studies have changed the way persistent atrial fibrillation is treated in many cases. The studies found that traditionally prescribed rhythm control medications were expensive, often had side effects, and did not produce better results than rate control medications in the large group of people studied. This group included older people at risk for stroke who did not have severe symptoms.8
Rhythm control medications.Rhythm control medications (antiarrhythmics) are still considered valuable for the treatment of atrial fibrillation, however. If symptoms persist despite rate control medications and in certain other cases, rhythm control medications are often prescribed. These medications help return the heart to its normal rhythm and keep atrial fibrillation from returning.
Anticoagulant medications. Most people with atrial fibrillation should take warfarin (such as Coumadin), an anticoagulation medication, to prevent blood clots that can lead to a stroke. Numerous studies have shown that warfarin prevents stroke and saves lives in people who have an average to high risk of stroke.9 If you have high blood pressure, diabetes, heart failure, or a history of transient ischemic attack (TIA) or stroke, you may be at average to high risk of stroke. Talk to your doctor about whether you should take warfarin.
For people with a low risk of stroke or those who cannot take warfarin, daily aspirin may be recommended.
If you are age 55 or older and have atrial fibrillation, you can find your risk of having a stroke in the next 5 years using this Interactive Tool: What Is Your Risk for a Stroke if You Have Atrial Fibrillation?
For information about whether to take anticoagulants, see:
For instructions on how to take anticoagulants, see:
If you take warfarin, don't suddenly change your intake of foods that are rich in vitamin K. Vitamin K can interfere with the action of anticoagulants, making it more likely that your blood will clot. For more information, see:
Treatment if the condition gets worse
For some people with atrial fibrillation, medications to slow the heart rate or control its rhythm do not work. These people continue to have a rapid, irregular heart rate. In these cases, doctors sometimes recommend a nonsurgical procedure called catheter ablation or a surgical procedure called the maze procedure. Experts suggest that these procedures should be performed in a medical center where the staff has experience with the procedures.
Catheter ablation
Catheter ablation for atrial fibrillation is relatively new and is still being studied. Catheter ablation destroys the heart tissue that causes atrial fibrillation and keeps atrial fibrillation going after it starts. Thin wires are inserted into a vein in the groin and guided into the heart. The wires have an attachment at the tip. The attachment sends out radiofrequency energy, which creates heat. This heat destroys the tissue that causes atrial fibrillation or the tissue that keeps it happening.
Catheter ablation is most successful at treating paroxysmal atrial fibrillation. In people with persistent or chronic atrial fibrillation, the success rate is lower. Catheter ablation is an invasive procedure and has some serious risks. Catheter ablation should only be done in people who have tried other treatments but continue to have serious symptoms. As the procedure becomes more effective and safe, doctors may use it as one of the first treatments for atrial fibrillation.
Ablation procedures either try to cure atrial fibrillation (focal ablation, circumferential ablation, or pulmonary vein ablation) or try to control your symptoms (nodal ablation).
Ablation to cure atrial fibrillation. Focal, circumferential, and pulmonary vein catheter ablation are used to try to cure atrial fibrillation. Focal ablation, also known as targeted ablation, is used to destroy the specific areas that are firing off abnormal electrical impulses and causing atrial fibrillation. Circumferential ablation is used to destroy the tissue that lets atrial fibrillation continue. Sometimes a doctor uses both focal and circumferential ablation.
Sometimes, abnormal impulses come from inside a pulmonary vein and cause atrial fibrillation. (The pulmonary veins bring blood back from the lungs to the heart.) Catheter ablation in the pulmonary vein can block these impulses and prevent atrial fibrillation from happening.
A pacemaker device is usually not needed when only specific areas are destroyed.
Ablation to control symptoms of atrial fibrillation. Nodal catheter ablation may be used to control symptoms of atrial fibrillation when the cause cannot be stopped. Nodal catheter ablation destroys your atrioventricular (AV) node and blocks electrical signals to your lower heart chambers (ventricles). After nodal catheter ablation, you will need a permanent pacemaker to regulate your heart rhythm. Nodal ablation can control your heart rate and reduce your symptoms, but it does not prevent or cure atrial fibrillation. So you will probably need to take the anticoagulant warfarin (Coumadin, for example).
Maze procedure
A surgical procedure to cure atrial fibrillation is called the maze procedure. The maze procedure is usually done during open-heart surgery. The procedure creates scar tissue that blocks excess electrical impulses from traveling through your heart. Because of the risks involved with open-heart surgery, this procedure is used only in people who have severe symptoms and are having heart surgery for other reasons. Doctors are developing less invasive surgical maze techniques. These may be less painful and easier to recover from.
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| Author: | Robin Parks, MS | Last Updated: January 18, 2007 |
| Medical Review: | Caroline S. Rhoads, MD - Internal Medicine Laurence Epstein, MD - Cardiac Electrophysiologist | |
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