People are often overwhelmed with all the information out there about AFib and how to treat it. To help with the decision making, a decision matrix can be found below that lists out the pros and cons for each AFib treatment option available.
Consult with doctors and family, collaborate with other AFIB patients, list pros and cons, decide on an action plan, and then execute your plan.
Watch Dr. Randall Wolf provide an overview of treating atrial fibrillation with the video above.
Option 1 – DO NOTHING
- No medications
- No surgical risk
- Ongoing research may discover new treatments
- Without treatment, 1 in 3 people living with AFIB will have a stroke in their lifetime
- AFIB progression (paroxysmal to persistent) at 1 yr 10%-20%, after 12 yrs 50%-77%
- Persistent AFIB leads to substrate modification, thickening, stiffening, scaring walls
- Heart muscle remodeling eventually makes AFIB more difficult to treat
- Declining left ventricular ejection fraction rate (30% in my case)
- Events cause light-headedness, fatigue, shortness of breath, confusion
- Unable to maintain aggressive physical conditioning for healthy lifestyle
- Increase potential for future dementia, fibrosis, oxidation, shortened lifespan
- May eventually need pacemaker, defibrillator, or heart transplant Over time; physical, psychological, emotional stress greatly diminish quality of life.
OPTION 2 – CARDIOVERSION/MEDICATIONS
- No surgical risk
- Cardioversion (chem/electrical) may restore NSR for some (NSR = Normal Sinus Rhythm)
- Anticoagulant helps reduce stroke risk by ~60%
- Meds slow HR, lower blood pressure, increase blood flow
- May slow progression of AFIB-related heart damage
- Cardioversion (chemical or electrical) often needed to restore NSR
- Cardioversion success rate often not long-lasting (<1 yr ~50-90%, >1 yrs ~50%)
- Without rhythm/rate control, heart damage listed under option 1 continues
- Meds manage symptoms, do not block source of chaotic electrical impulses
- Antiarrhythmic/anticoagulant medication out of pocket drug costs
- Requires strict medication regimen, typically loses effectiveness over time
- Potential negative interactions with other medications (now or future)
- Drugs (i.e. amiodarone, digoxin) can cause organ damage (liver, thyroid, lung, eyes)
- Side effects: low blood pressure, light sensitivity, confusion, impaired reactions
- Suppressed HR/BP causes fatigue, tiredness, restricts physical conditioning
- Capillaries weaken with age, increases future risk of anticoagulant-related bleeding
- Future surgeries require anticoagulant pause, increasing chance for clots/stroke
- Anticoagulant restricts hazardous occupations and X-sports participation
- AFIB psychological/emotional stress most likely still a factor.
OPTION 3 – PVI CATHETER ABLATION
If successful, NSR stops further AFIB-related heart damage Success Rates:
Optimal Candidate: 60-80%
Moderate Candidate: 45-65%
Poor Candidate: 35-50%
Optimal Candidate: 60-80%
Moderate Candidate: 45-65%
Poor Candidate: 35-50%
Significantly reduces AFIB psychological/emotional stress. May be able to stop antiarrhythmic drugs. Tackle AFIB now; reduce future compounding health issues associated with multiple age-related illnesses.
LAA may later be ablated to stop related impulse source. Some medical ctrs offer separate mechanical LAA occlusion or ligation procedures to reduce the chance of clots and stroke. If PVI ablation operation later followed by LAA occlusion or ligation operation, may be able to stop the anticoagulant drug.
- Varied success rates dependent on medical ctr/doctor/case volume/experience
- A lot of patients attending AFIB Conf because one or more catheter ablations failed
- Electrophysiologists don’t have direct view of beating heart while ablating
- Reports of weak transmural lesions, burn/freeze injury to major nerves/esophagus
- Radiation exposure if center uses fluoroscopy X-ray machine to view catheters
- Ablation instruments/devices create “spot weld” pattern which can leave gaps
- Burn/freeze patterns often require repeat touchup ablations to close gaps
- Multiple dotted catheter burn spots (around PV) scars more heart tissue than straight lesion created using mini-maze radio frequency (RF) ablation clamp
- Procedure includes punching hole through heart’s septum from right to left atrium
- Catheter ablation operation still has small complication/infection/morbidity risks PV isolation alone does not eliminate LAA possible source of electrical impulses
- Remain on anticoagulants due to LAA potential for blood clots/stroke
- Implanted LAA mechanical occlusion device may leak/LAA impulse source remains
- Requires two separate operations if able to later add LAA occlusion or ligation
OPTION 4 – SURGICAL ABLATION (WOLF MINI-MAZE)
- If successful, NSR stops further AFIB-related heart damage
- Dr Wolf availability/experience (15+ years, over 2000 cases)
- Wolf success rate: paroxysmal (92%), persistent (85%), long-standing persistent (75%)
- One operation (PVI+LAA excision), no fluoroscopy (radiation)
- Precise transmural lesions using bipolar RF ablation clamp
- Micro video camera used for direct view of heart ablations
- Ganglia Plexi stimulated/tested/ablated as appropriate
- LAA excision removes potential AFIB impulse/clot source
- Very likely able to stop anticoagulant/antiarrhythmic drugs
- LAA removal significantly decreases hypertensive systolic BP
- Ends AFIB psychological/emotional stress
- Able to return to active lifestyle/X-sports
- Tackle AFIB now; reduce future compounding health issues associated with multiple age-related illnesses
- Pre-operation anxiety
- Time, costs, logistical arrangements associated with travel to Texas for procedure
- Minimally-invasive ablation operation still has small complication/morbidity risks Typical surgery post-op discomfort/minor scaring
Your medication options for treating AFib:
There are three primary goals in the treatment of AFib:
- Slow the heart rate
- Prevent clots and strokes
- If possible, restore the heart to its regular rhythm
Blood-thinning medications, including aspirin and warfarin, may help reduce stroke risk. In fact, long-term use of warfarin has been proven to prevent up to 80% of strokes in people suffering from AFib. Aspirin is an option when the risk of stroke is not high. To reduce heart rate, many people can be treated with medications such as digoxin, alone or in combination with beta-blockers and calcium channel blockers, as well as other medications. Your treatment will depend on your age, physical condition and history of heart disease.
Beta-blocker medications slow the heart rate and decrease how forcefully the heart contracts, reducing the amount of oxygen the heart needs to work. Beta-blockers are often used to treat heart conditions, including high blood pressure, heart failure, fast or irregular heart rates, and mitral valve prolapse, and to help decrease or prevent chest pain. Beta-blockers are also used for migraine headaches, social anxiety disorder, glaucoma, and a common type of movement disorder called essential tremor.
Examples of Beta-Blockers Include
- Acebutolol hydrochloride (Sectral)
- Atenolol (Tenormin)
- Betaxolol (Kerlone)
- Bisoprolol (Zebeta)
- Carteolol (Ocupress)
- Carvedilol (Coreg)
- Esmolol (Brevibloc)
- Labetalol (such as Normodyne or Trandate)
- Metoprolol (such as Lopressor or Toprol XL)
- Nadolol (Corgard)
- Penbutolol sulfate (Levatol)
- Pindolol (Visken)
- Propranolol (Inderal)
- Sotalol (Betapace AF)
- Timolol (Blocadren)
Calcium Channel Blockers
Calcium channel blocker medications prevent calcium from entering muscle cells and blood vessels. As a result, blood vessels relax, slowing the heart rate and increasing blood flow to the heart muscle while reducing blood pressure.
Calcium channel blockers are used to treat heart conditions, including high blood pressure, chest pain caused by coronary artery disease, heart failure, and fast or irregular heart rhythms. They are also used to treat severe headaches.
Examples Of These Medications Include:
- Amlodipine besylate (Norvasc)
- Diltiazem hydrochloride (Cardizem, Dilacor-XR, Tiazac)
- Felodipine (Plendil)
- Isradipine (DynaCirc)
- Nicardipine hydrochloride (Cardene)
- Nifedipine (Procardia XL)
- Verapamil (Calan SR, Isoptin SR)
- Nisoldipine (Sular)
Cardiac glycosides are medications that can help the heart beat slower and stronger, which helps the heart pump more blood with each beat. Cardiac glycosides are used to treat heart failure and may also be used to treat irregular rapid heartbeats in the upper heart chamber (AFib).
Examples Of Cardiac Glycosides Include:
- Digoxin (such as Lanoxicaps, Lanoxin)
- Digitoxin (Crystodigin)
High levels of a cardiac glycoside in the bloodstream can slow the heart rate below normal (bradycardia). This is most likely to occur in people who are receiving medication to help reduce water retention (water pills or diuretics), especially those with decreased kidney function.
Antiarrhythmic medications may be used to return an irregular heartbeat (arrhythmia) to its normal rhythm, prevent the occurrence of an arrhythmia, or control the heartbeat during an arrhythmia. These drugs work mostly by stabilizing the heart muscle tissue or slowing the heart rate.
EXAMPLES OF ANTIARRHYTHMIC MEDICATIONS ARE:
- Ibutilide (Corvert)
- Amiodarone (such as Cordarone or Pacerone)
- Flecainide (Tambocor)
- Sotalol (Betapace AF)
- Procainamide (Procanbid)
- Propafenone (Rythmol)
- Quinidine (such as Quinidex)
- Disopyramide (Norpace)
- Dofetilide (Tikosyn
Restoring the rhythm
To help the heart maintain a normal rhythm, a procedure called cardioversion may be effective. Cardioversion delivers brief electrical shocks that stun the heart and temporarily stop all-electric activity. This may allow the normal rhythm to reemerge. However, medication may be required to maintain the normal rhythm and it is not always effective. Cardioversion is used in situations and also may be done electively. Catheter ablation is a method to relieve the rapid, irregular heartbeat that accompanies AFib. This procedure involves disconnecting the atria from the ventricles electrically. Without the signals from the atria, the ventricles would beat extremely slowly, requiring a permanent pacemaker in anyone who chooses this procedure.
For some hard-to-treat AFib, a surgical procedure that is occasionally performed is the “maze” procedure in which a surgeon divides the atria into small, isolated sections. The chaotic electrical activity of the heart is halted because the electrical impulses cannot cross the scars that separate the sections of the atria. It should only be used for people with severe AF that can’t be controlled with medication, or for people undergoing heart surgery for other reasons.
Catheter Ablation- Pulmonary Vein Ablation (Isolation)
Current PV ablation techniques are achieving partial success rates in curing paroxysmal AF. Medications that did not work before may now control the AF. But for some, there may not be any noticeable improvement at all.
During PV ablation a soft, thin, flexible tube with an electrode at the tip is inserted through a large vein or artery in your groin and moved into your heart. This catheter is directed to the precise location(s) in your heart that is producing your AF. These points are burned off or isolated from your heart.
If you are in AF during the catheter ablation procedure, it’s relatively easy for the doctors to determine where the A-Fib signals are coming from and to ablate (destroy) them.
However, if you have intermittent AF (Paroxysmal AF), it’s harder to pinpoint exactly the source(s) of the A-Fib signals. The challenge for doctors is how to locate and eliminate AF signals when the patient is not in AF. Since research has shown that almost all A-Fib signals come from the openings (ostia) of the four pulmonary veins in the left atrium, one technique is to make circular radiofrequency (RF) Ablation lines around each pulmonary vein opening (called “Circumferential” or “Empirical Ablation”). This isolates the pulmonary veins from the rest of the heart and prevents any pulses from these veins from getting into the heart. However, it’s difficult to make circular RF lesions and they aren’t always successful. This technique can achieve good success rates for people with paroxysmal AF. For people with chronic AF, success rates may not be as good.