“It must be something in the water,” is what we say at the office and hospital when we talk about Atrial Fibrillation.
The reason is that Atrial Fibrillation is the most common heart rhythm disorder that we see and we see it often. Here is an example. On a regular day in the office last week, 4 out of 15 patients had a diagnosis of Atrial Fibrillation. And, later that day, I implanted a permanent pacemaker in a patient with chronic atrial fibrillation who had developed a very slow heart rate.
Atrial fibrillation is what we call an “irregularly irregular” rhythm. There is no clear cadence to it. Multiple causes exist. Let me name a few of them—post-operative (after surgery) stress especially after heart surgery, hypertension, thyroid disease, alcohol, sleep apnea. Atrial fibrillation is more common in older patients.
Atrial fibrillation is classified as “paroxysmal” if it comes and goes. If it stays, it becomes “permanent.” If it stays as your rhythm indefinitely, it is “chronic.”
Fortunately, we have two very good treatment strategies for Atrial Fibrillation.
One is called rhythm control. We try to restore normal rhythm with medicines and there are many medications that can be used. Some can be given as an “outpatient” and some require a brief hospital stay. Sometimes, a cardioversion is required. This is a procedure to shock the heart back to normal rhythm.
The other major strategy is called “rate control.” Here we accept that the rhythm will be atrial fibrillation. The goal is to control the heart rate so that there are no symptoms or significant limitations.
Several major heart studies have shown that both rhythm control and rate control can be effective treatment strategies. People do well with both approaches.There are two more points I want to review.
Anti-coagulation (blood thinning)
The first is anti-coagulation (blood thinning). With atrial fibrillation, there is an increased risk of blood clots. The chief concern about blood clots is stroke. Since we know that being on a blood thinner is a double-edged sword (prevents clots but can cause bleeding), we have to be careful about when to prescribe an anti-coagulant.
To help us, we have a number of “risk scores” based upon several factors including:
- congestive heart failure
- hypertension
- age
- diabetes
- prior stroke
- vascular disease
- gender
The old standard for blood thinning is warfarin (Coumadin). Several years ago, new blood thinner were introduced and are at least equally effective (Eliquis, Xarelto, Pradaxa).
Treatment Options for Atrial Fibrillation
The second point to review is procedural options for treatment of atrial fibrillation.
- Pacemakers. Pacemakers are considered if medicines used to control the rapid heart rates of atrial fibrillation result in very slow pulse rates. The pacemaker is used as a “safety net” to avoid very slow rates and allow the treatment of fast heart rates. Pacemakers can also be used when atrial fibrillation is so difficult control that we have to ablate or interrupt the heart’s electrical system. At that point, the patient is “dependent” upon the pacemaker for heart rhythm.
- Pulmonary Vein Isolation (PVI). There is another kind of ablation procedure. It is called Pulmonary Vein Isolation (PVI) and is used to try to cure atrial fibrillation. We know where most atrial fibrillation starts. It is near the pulmonary veins that return blood to the heart from the lungs. This ablation is to interrupt the electrical activity in that area to prevent atrial fibrillation. It has about a 70% success rate.
I hope this discussion has highlighted key points about Atrial Fibrillation and helped you “walk through” some of the steps we take when treating Atrial Fibrillation.
Kenneth Adams, MD, FACC
Senior Cardiologist and Medical Director at Pentucket Medical Associates
Dr. Adams cares for patients at our Pentucket Medical Haverhill office. Please call (978) 521-3200 to request an appointment today.