Atrial Fibrillation

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Treatment

Treatment of atrial fibrillation is complex and depends on whether the patient is currently experiencing symptoms, how long the patient has been in atrial fibrillation, the overall health of the patient, and the size and function of the heart's chambers.

Stable Patients
In stable patients, several general approaches may be taken. Those who are experiencing palpitations can be treated with certain medications that "slow" conduction of electrical impulses through the AV node and down into the ventricles.

Such medications include the following:

• Beta-blockers slow the heart rate. Several in use include: atenolol (Tenormin®), bisoprolol (Zebeta®), carvedilol (Coreg®), metoprolol (Lopressor®, Toprol XL®), nadolol (Corgard®), propranolol (Inderal®, Inderal® LA), and timolol (Blockadren®). These medications may initially be given intravenously. Long-term, they are usually taken in pill form once or twice a day.
• Calcium channel blockers have multiple effects on the heart. Two of these agents can be used to slow the heart rate in patients with atrial fibrillation: diltiazem (Cardizem®) and verapamil (Calan®, Calan SR®, Covera® HS, Isoptin®, Isoptin SR®, Veralan®). There are long-acting forms available that can be taken only once or twice a day.
• Digoxin (Lanoxin®) is often used to treat patients with heart failure, since it can stimulate the left ventricle to contract and pump blood a little more vigorously. Digoxin also slows electrical conduction through the AV node and can thus decrease the rate at which electrical impulses are conducted from the atria to the ventricles.

Blood thinners
Patients at risk for developing a blood clot in the left atrium are usually treated with blood thinners. Those who may already have a blood clot in the left atrium can be treated with blood thinners that help prevent the formation of more blood clots and allow the body to dissolve any formed blood clot. These patients usually receive heparin when admitted to the hospital. The older form of heparin, unfractionated heparin, is usually administered via continuous intravenous infusion, and frequent blood tests (PPT, prothrombin-proconvertin test) are performed to monitor how "thin" the heparin is making the blood. Some doctors use one of the newer heparin preparations, low-molecular-weight heparin, to thin the blood. These preparations are injected in the skin (usually in the abdomen) twice a day, and repeated monitoring is not required. Some doctors may use these medications after discharge from the hospital. Such medications include enoxaparin (Lovenox®), dalteparin (Fragmin®), and nadroparin (Fraxiparin®)

Patients who require long-term "blood thinning" are treated with the medication warfarin (Coumadin®). Patients treated long term with warfarin require periodic monitoring with an INR test of the blood to assess if the blood is "thinned" to the correct degree. In patients with atrial fibrillation, most doctors aim for an INR value in the range of 2.0 - 3.0.

Cardioversion through medication
Although long-term treatment with warfarin may decrease the chances of having a stroke, it is generally felt that a more ideal approach to prevent stroke is to try to "convert" the heart rhythm from atrial fibrillation back into sinus rhythm. Not every patient can be successfully converted back into sinus rhythm. These patients include those who have been in atrial fibrillation for a long period of time and those who are found to have very enlarged (dilated) atria.

Patients can be converted into sinus rhythm through the administration of certain medications or by electrically "shocking" the heart. One of the newer medicines frequently being used to try to convert atrial fibrillation back into sinus rhythm is called ibutilide (Corvert®). This medication is administered intravenously for 10 minutes. If necessary, a second ten-minute infusion of the medication can be administered. Ibutilide is successful in converting selected patients with atrial fibrillation into sinus rhythm in approximately 60-70% of cases. Ibutilide is associated with a small risk for causing other abnormal heart rhythms, and patients treated with ibutilide must be monitored for several hours after administration of the medication.

Many other medications are also used to try to chemically convert atrial fibrillation back into normal sinus rhythm. These include the following:

• Amiodarone (CordaroneA®)
• Disopyramide (Norpace®)
• Flecainide (Tambocor®)
• Procainamide (Procanbid®, Pronestyl®)
• Propafenone (Rhythmol®)
• Quinidine (Quinaglute®, Quinidex®)
• Sotalol (Betapace®)

Unstable patients
In unstable patients, those experiencing severe shortness of breath, chest pains, or lightheadedness due to low blood pressure, it may be necessary to "shock" the heart back into sinus rhythm.

Cardioversion is used to attempt to convert the patient with atrial fibrillation back into sinus rhythm by electrically shocking the heart. During this procedure, the patient is usually sedated or put to sleep through intravenous infusion of one of several new short-acting medications. Special pads or paddles are then applied to the chest and increasing energy levels of electrical charge are produced in an attempt to shock the heart back into sinus rhythm. Although the shocks can cause significant discomfort, most patients are asleep during the procedure and remember little, if anything, about the experience afterward.

Complications
Some patients who are converted from atrial fibrillation to sinus rhythm, either by medicines or by shocking the heart, have a small risk that a clot has already formed in the left atrium. Once the heart is converted back into sinus rhythm, this clot may travel to the left ventricle and then be pumped to the brain, causing a stroke.

It is generally believed that patients at risk for this complication are those that have been in atrial fibrillation, without being treated with blood-thinning agents, for more than two or three days or for some unknown duration. In these patients, two approaches are utilized. The first is to place the patient on the blood thinner warfarin (Coumadin®) for 3 to 4 weeks before attempting to convert the atrial fibrillation back to sinus rhythm. Treatment during this time prevents the formation of additional blood clots and allows the body to more or less dissolve any blood clot that may have formed in the left atrium. Many factors influence the decision to treat a patient with 3 to 4 weeks of blood-thinning therapy before attempting to convert the heart, or to perform a TEE and then attempt to convert the heart.

The second approach to treating an unstable patient is a procedure called transesophageal echo (TEE) During a TEE, a special microphone device is passed down the mouth into the esophagus, which is located directly behind the heart. Special sound waves are sent through this microphone-like device to image the heart and its chambers. The excellent quality of the pictures of the heart's chambers obtained by this process can be used to assess whether or not a clot has formed in the left atrium. If no clot is seen, an attempt is made to convert the heart back into sinus rhythm. Patients undergoing TEE are usually given an intravenously administered sedative to relax them during the procedure and have their throats sprayed with a numbing medication, making it easier to tolerate the procedure.

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