One of the most exciting new developments in atrial fibrillation (Afib) treatment, a genuinely groundbreaking advancement, is pulsed-field ablation. This improvement over traditional cardiac catheter ablation does not use heat or cold (thermal energy) but rather a burst of electrical activity to irreversibly damage malfunctioning heart cells. The pulse of electricity causes microscopic damage (electroporation) to the malfunctioning heart cell membrane, eventually destroying it. With proper targeting, pulsed-field ablation can eliminate the root cause of atrial fibrillation and potentially other arrhythmias while sparing sensitive surrounding structures like nerves, blood vessels, and the esophagus from damage.

On the other hand, medications, including anticoagulants and antiarrhythmics, are easy to prescribe and take. They have been used in patients with atrial fibrillation for many years, and improvements in their formulations make them more effective than ever and with fewer side effects.

There are two types of Afib medications: rhythm control and rate control.

The medications that patients are prescribed for atrial fibrillation fall into two categories. First are rate control medications that keep the heart beating in synch. Second are rhythm control drugs, also known as antiarrhythmic medications, that work by altering the electrical signals that control the heart’s rhythm, helping to restore a normal heartbeat. Some patients will also be prescribed anticoagulants, which reduce the likelihood of a blood clot in the left atrial appendage and thus significantly lessen the risk of stroke in a patient with Afib.

Does medical therapy or a procedure make more sense?

Before we answer this question, the most important thing to remember is that atrial fibrillation is a progressive condition that usually starts as paroxysmal or occasional. As a result, if you have experienced Afib or, really, any arrhythmia in the past, there is a likelihood that it will continue and potentially worsen in the future. Treating Afib and its earliest signs is the best way to avoid longer-term heart damage and help ensure that whatever treatment is chosen is as effective and safe as possible. After all, as Afib progresses, it becomes more challenging to treat, eventually becoming permanent and incurable in its worst manifestations.

Understanding the pros and cons of each option is essential for thoroughly evaluating the decision to have a procedure or take medication.

The pros of medication

• Easy to prescribe and take.
• If effective, medications allow patients to avoid procedural intervention.
• Depending on insurance coverage, medications may be cheaper.

The cons of medication

• About 50% of patients will not get results from medication.
• Some patients will experience significant side effects.
• Medications only work for as long as they are taken.
• Patients with clotting disorders or fall risk may not be suitable for anticoagulants.
• Medications do not treat the root cause of the problem.

The pros of procedural interventions

• For many, cardiac catheter ablation is a one-and-done procedure.
• Ablations today are safe, especially with the advent of pulsed-field ablation.
• Pulsed-field ablation is generally more effective than antiarrhythmic medication for Afib.
• Patients can avoid the sometimes-significant side effects associated with drug therapy.

The cons of procedural interventions

• Ablations are not guaranteed to work, with about 70-80% success.
• A follow-up ablation may be necessary if the arrhythmia persists or a new source of electrical dysfunction is found.
• Some patients may require staying on anticoagulant medication after their ablation.
• All procedural interventions come with inherent risks, no matter how small.
• Anticoagulants are more effective for stroke prevention than left atrial appendage closure (Watchman or Amulet) in patients who can tolerate blood thinners.

Atrial fibrillation is often best managed with a procedural option like pulsed-field ablation, but stroke risk is best managed with anticoagulant medication when appropriate.

The bottom line

It’s crucial to communicate openly with an electrophysiologist, not just a primary care physician or general cardiologist, to learn more about the particulars of your Afib. Not all patients are the same, and neither is every arrhythmia. Having a proper diagnostic workup and using the advanced tools available to your electrophysiologist is the best way to learn more about the arrhythmia and how best to treat it.

Ultimately, Medication may work well for some, while a procedural option is preferred for others because of its curative potential.

Our newest technology, pulsed-field ablation, has an improved risk profile over already safe thermal ablations like RF- and cryo-ablation. These advancements mean there has never been a better or safer time to opt for a procedural solution to your arrhythmia. Dr. Tordini is a leader in advanced arrhythmia treatment and has performed over 100 Farapulse catheter ablations, making her a nationwide leader in this new technology.

Next steps

The best next step for any patient who believes they have an arrhythmia (or have been diagnosed but never seen an electrophysiologist (EP)) is to see a qualified EP, discuss diagnostic options, and decide on the best treatment.

Meet Dr. Tordini

Andrea Tordini, MD is a Clinical Cardiac Electrophysiologist who specializes in the management of abnormal heart rhythms. Her special interests include atrial fibrillation ablation and management, evaluation and management of syncope and symptoms related to slow heart rhythms, pacemaker and cardiac defibrillator implantation, as well as the management of heart failure through cardiac resynchronization therapy.

Dr. Andrea Tordini provides her patients with personalized care to help relieve symptoms related to heart rhythm abnormalities and improve both the quality and longevity of life.  Call her office to schedule an appointment today at (813) 751-0775.

Disclaimer: This post is not a substitute for medical advice, diagnosis, or treatment from a licensed medical professional.