Why treat atrial fibrillation? Certainly the most important reasons are to minimize strokes or cardiac decompensation (congestive heart failure or angina).


This is the second in a two-part series about atrial fibrillation.

Why treat atrial fibrillation? Certainly the most important reasons are to minimize strokes or cardiac decompensation (congestive heart failure or angina).
The cost of atrial fibrillation treatment is not cheap and exceeds $6.4 billion per year in the United States alone, not including time lost from work.  
Moreover, up to two-thirds of patients have symptoms disruptive to their lives.   
Treatment begins with trying to identify cause in a given individual.  
Causes are quite varied: hypertension, especially if untreated; congestive heart failure; coronary disease; prior rheumatic fever; and valvular heart disease lead the list.     
Less-common causes include hyperthyroidism, use of over-the-counter decongestants, stimulants, excess caffeine, some herbal medicines, alcohol abuse, low levels of sodium, potassium, magnesium or calcium, blood clots to the lung, pneumonia or lung cancer.   
Cardiac ultrasound is ordered to screen for any valvular disease, like that related to remote rheumatic fever.
Rheumatic fever patients are at two to seven times higher risk of eventual CVA than the general atrial fibrillation population, even if treated with blood thinners. If not treated, this risk is up to 14 times higher.   
It is important to emphasize atrial fibrillation may be asymptomatic in many individuals, only to be discovered when a medical professional checks someone’s pulse or EKG.   
In treating atrial fibrillation, one not only wishes to prevent heart failure or stroke, but if these already have occurred, to prevent their worsening.  
In some cases, the electrical and structural changes of the atrial tissue underlying atrial fibrillation maintenance and progression may be reversible.   
Just as these changes continue to perpetrate themselves the longer atrial fibrillation persists, the reverse is true when atrial fibrillation rate is controlled, or when rhythm returns to normal with changes at least partially reverting back towards normal.   
Once in atrial fibrillation, various hormones are released into the bloodstream, which ultimately cause further scar formation and further loss of atrial muscle tissue.
Two classes of anti-hypertensive drugs — ACE inhibitors (Lisinopril or Prinivil) and ARB’s (Diovan, Cozaar, Avapro, Atacand, Micardis) — control hypertension and can counterbalance these hormones, thereby helping slow or prevent future scar formation.  
In some cases, these actually may regress already-formed scar, helping other simultaneously used drugs to restore normal rhythm.   
Atrial fibrillation therapy involves some form of anti-coagulation, supplemented by either antiarrhythmic drug therapy or by non-pharmacologic catheter ablation (done in a hospital’s electrophysiology cath lab).   
Therapy for any given patient is individualized. Some are not candidates for Coumadin blood thinner but rather are most safely treated with an aspirin.  
These include the elderly, those prone to falling, patients with alcoholism, etc.
Only your referring physician can make this decision.  
Two major approaches of pharmacologic therapy exist:  control of the rapid heart rate (with the patient allowed to remain in atrial fibrillation) vs. restoration of normal rhythm with suppression of atrial fibrillation.   
Rate control is used in permanent atrial fibrillation patients who have little hope of having normal rhythm restored.  
Examples are patients with either rheumatic heart disease, very enlarged atria or those in whom using antiarrhythmic drugs to restore normal sinus rhythm has unacceptably high risks of causing new potentially more dangerous rhythm disturbances (“proarrhythmia”).   
With one or two exceptions, any of these drugs can cause proarrhythmia.  
Coronary disease patients, especially those with prior heart attack or with weakened heart muscle, are most vulnerable.    
In the rhythm control group, potentially used agents include Amioradone, Multaq, Flecanide, Sotalol or Propafenone.   
In those patients for whom the rate control approach has been opted for, beta-blockers (e.g. Metoprolol or Atenolol), calcium channel blockers (Verapamil or Cardizem) and, to a lesser degree, Digoxin, are used to slow the rate.   
Sinus rhythm cannot always be restored by drugs alone and these patients need to undergo electrical cardioversion while asleep with intravenous sedation.
In this procedure, a shock is delivered to the heart via chest wall patches to restore normal rhythm, either in the hospital’s cardiac catheterization lab or in the ICU.
Finally, for patients whose atrial fibrillation has failed to respond to several different anti-arrhythmic drugs, a second option exists — catheter-based ablation.  
Ablation is done in the  catheterization lab and involves threading tiny electrical wires up the blood vessels of the groin to the heart.  
Through these, precisely-positioned applications of electrical energy are delivered to the abnormal left atrial tissue to permanently restore rhythm.  
Although results are encouraging, this technique has continued to evolve during the last 15 years.  
Forty percent of patients will experience a recurrence or partial failure of the first procedure and need a second or third ablation.  
Nonetheless, recent studies suggest the overall atrial fibrillation recurrence rate over time may be lower with catheter-based ablation than with anti-arrhythmic drugs.  
All the above said for atrial fibrillation also is true for atrial flutter, a slower, closely related rhythm that needs as aggressive treatment as atrial fibrillation.
A flutter ablation has a much higher initial success rate (95 percent to 98 percent).   
Close evaluation by the patient’s physician or nurse practitioner with referral in some cases to a cardiologist or cardiac electrophysiologist is key in this disease.

Dr. Henry Fronc Jr. specializes in cardiology, heart disease and cardiovascular disease at Cardiovascular Care in Newton.