Medication Vs. Procedures for The Treatment of Afib and Its Potential Consequences

Heart rhythm problems like Atrial Fibrillation or Afib rarely reach the top of our list of health concerns. For many, the symptoms associated with Afib, like heart palpitations, increased heart rhythm, breathlessness, and fatigue, may be minor and fleeting enough that we think it is normal, or at least not terribly concerning. This is especially true in younger patients who believe their age prevents them from having heart issues like arrhythmia. However, cardiac arrhythmias are a genuine concern that can have follow-on consequences if not diagnosed and treated at their earliest stages. By understanding the risk factors associated with untreated or undertreated Afib, we can better understand the choice of treatment options. It allows us to compare rate control drugs, antiarrhythmics, and anticoagulants with procedures like cardiac catheter ablation or Watchman left atrial appendage closure.

The Risks We Need to Address

Afib creates a five times higher risk of stroke. This risk is caused by a small outpouching of the heart, known as the left atrial appendage or LAA. The LAA serves no known purpose but can become problematic in patients with arrhythmias like Afib. When the heart is pumping normally, the rhythmic motion allows for efficient in-and-outflows, but during AFib, blood can begin to pool within the LAA. Stagnant blood then begins to clot. Eventually, a small piece of that clot can break off and enter the circulatory system. When the clot finally reaches the brain, it can block off tiny blood vessels and thus cause a stroke.

Atrial fibrillation patients are also at a five times higher risk of a heart attack. While Afib itself does not directly cause a heart attack, the underlying cardiovascular concerns that cause Afib are significant risks for cardiovascular disease. For example, many Afib patients also have atherosclerosis – the narrowing of the coronary arteries due to plaque buildup on the arterial walls. This not only increases blood pressure but can also cause or worsen Afib. Left untreated, this atherogenic progression can lead to occlusion of the blood vessel and, ultimately, a heart attack.

Untreated or undertreated Afib can also result in long-term congestive heart failure. The heart is a muscle and needs to be exercised like any other. However, overdoing it for long periods causes the muscle to enlarge but ultimately lose power. Much like going to the gym and pushing yourself every day will eventually lead to muscle failure, the same occurs due to the constant rapid heartbeats associated with later-stage Afib – persistent and long-standing persistent.

The Case for Medical Intervention for Afib

Medication is often the frontline defense against the progression of Afib. After all, medication is easy to prescribe and take, and its risks may seem far lower than any procedural intervention. Patients may need to take a combination of three medication types.

First is an anti-arrhythmic, which helps normalize the heart’s errant electrical impulses to improve or stop the random, disorganized heart rhythm. These medications may not slow the heart rate.

Rate control medications can be used to slow down the heartbeat. However, they do not necessarily normalize its rhythm. Strict rate control, under 80 bpm, or lenient rate control, under 110 bpm, are acceptable options and will be determined by your EP.

There are many and varied medications to address the above, and they are classified as sodium channel blockers, beta-blockers, potassium channel blockers, amiodarone, dronedarone, and more.

Anticoagulants reduce the stickiness of blood platelets and minimize the risk of clot formation in the left atrial appendage and elsewhere in the body. These medications are colloquially known as blood thinners, though they do not truly thin the blood. These medications can be very effective in patients with a significant risk of stroke and are, in fact, universally preferred over Left Atrial Appendage closure if well tolerated and indicated.

Of Note: Many patients end up in the emergency room due to a particularly severe episode of Afib – a common occurrence due to some patients mistaking the palpitations for a heart attack. In the ER, cardioversion (electric shock) or intravenous drugs will likely be the first line of defense to correct the arrhythmia, at least temporarily. Patients often receive an Afib diagnosis at this point. They will be referred to an electrophysiologist for longer-term management, including the oral medications mentioned above or a longer-term procedural solution like ablation, as discussed below.

The Case for Procedural Intervention for Afib

When it comes to atrial fibrillation, controlling the discomfort and minimizing the risk of future problems is critical. As such, a procedural intervention can be a more permanent and often more effective solution than medical therapy. Think of it as a one-and-done operation for patients that qualify. In appropriately screened patients, typically those with paroxysmal or occasional Afib, the success rate is about 70%. This means most patients can get off or reduce their medication, thus avoiding some of the worst side effects.

Cardiac catheter ablation is also safe and has minimal downtime. In fact, many patients skip medication entirely and go for the more permanent solution immediately. This is not to say that cardiac catheter ablation does not come with some risks. As with any interventional procedure, patients will have a comprehensive consultation with Dr. Tordini before the procedure to understand these considerations. However, ablation patients are typically very pleased with the results of their procedure, and ablations do not preclude other future interventions for arrhythmia or cardiovascular disease.

Comparing a procedural solution, such as Watchman Left Atrial Appendage Closure device implantation, to medication is less favorable toward the procedure. This is because anticoagulant medications are so effective. In fact, LAA closure procedures like Watchman are only indicated if the patient is contraindicated for anticoagulants (for example, if they are a fall risk or have a bleeding issue). We evaluate patients based on their CHA2DS2-VASc score, which assesses stroke risk and guides us in the following steps.

The Bottom Line

With incredible technological advances and refinements in the medical therapies we use for arrhythmias like Afib, patients have more options than ever before. While this is undoubtedly an extraordinary development, it also necessitates consulting with an experienced and knowledgeable electrophysiologist like Dr. Tordini. We encourage patients with palpitations to speak to their primary care physician and cardiologist and make an appointment with Dr. Tordini at one of her three offices in and around Tampa. Doing so increases the chances of getting early intervention and opens the fullest breadth of available treatment options.

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

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Cardiology

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Cardiology

Andrea Tordini, MD

Clinical Cardiac Electrophysiology

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