Atrial Fibrillation Treatment and Medications

The human heart beats 100,000 times a day without missing a beat. But just like any other muscle, sometimes it spasms. It may feel like a passing emptiness in your chest like your heart skipped a beat, or it may feel like it has revved up for a few seconds. Everyone experiences these transient episodes, but they could be a sign of atrial fibrillation. If it is, several treatment options can help manage and even reverse it.

What is atrial fibrillation (AFib)?

Atrial fibrillation (AFib) is an irregular heartbeat that originates in the upper two chambers of the heart, called the atria. Usually, the heart beats at a steady rate with a coordinated rhythm between these upper chambers and the lower chambers, called the ventricles. AFib is like a muscle spasm in the upper two chambers. This speeds up the heart and throws off the heart's rhythm, a condition called "heart arrhythmia."

AFib may feel like an occasional inconvenience, but it is a serious medical condition. An abnormal heartbeat does not pump blood through the heart correctly. Blood can pool in the upper chambers and form a blood clot. When the clot exits the heart, it can block a blood vessel and damage the body's organs or cause a stroke.

People with AFib are five times more likely to have a stroke than the rest of the population. It also significantly increases the risk of heart disease and heart failure. The condition contributes to upward of 166,000 deaths per year in the United States, and that number is rising as the population ages. It's a common condition that 2.7 to 6.1 million Americans live.

RELATED: Heart disease statistics

Physical changes to the heart (due to age, heart disease, structural heart defects, hypertension, or something else) can cause AFib. AFib episodes are "triggered" by random electrical signals that sometimes cascade off the large veins that channel blood into the atria. Most commonly, these random electrical signals originate in the pulmonary veins, which connect the lungs to the left atrium.

These random electrical signals are normal and usually ignored by the heart. Physical changes to the heart, however, may cause the atrial muscles to spasm in response to these signals. These spasms make more physical changes to the heart tissue. Eventually, tissue develops in small areas on the heart that are prone to "short circuits," again, causing more spasms whenever they're triggered.

AFib is a progressive condition if left untreated. Episodes of abnormal heart rhythm continually make changes to the atrial tissue, creating more areas on the heart that can short circuit. Over time the condition may become untreatable.

There are four types of AFib:

• Paroxysmal: Episodes occur more than once for less than a week.

• Persistent: Episodes continue to occur for longer than a week.

• Long-standing: Episodes occur for longer than a year.

• Permanent: The condition is considered untreatable.

How is atrial fibrillation diagnosed?

The first step is to recognize the symptoms of atrial fibrillation:

• Heart palpitations

• General fatigue or tiredness

• Dizziness

• Shortness of breath

• Excessive sweating

• Chest pain or discomfort

Some people show no symptoms. They do not realize there's a problem until a health practitioner notices an irregular heartbeat or pulse. However, most people with no symptoms do experience "hidden" symptoms like occasional shortness of breath, unexplained sweating, or fatigue. Some people with the condition just don't feel good, which is often overlooked.

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Any symptom of AFib, including hidden symptoms, should be taken seriously if the person has any of these risk factors:

• Advancing age

• Heart disease

• High blood pressure

• Obesity

• Diabetes

• Overactive thyroid

• Alcohol use

• Enlargement of the heart

• Structural heart defects

AFib is often diagnosed during a doctor's visit. Some patients, however, are first diagnosed in an emergency during an active episode. Smartwatches with a built-in heart monitor, are also helping with early AFib diagnosis.

Diagnosis involves identifying the condition, a possible cause, and determining the risk for stroke. The healthcare provider will perform the following tests:

• Physical exam and medical history

• Electrocardiogram (EKG) that shows the heart's electrical activity

• Ultrasound echocardiogram (ECG) that allows the healthcare professional to watch the heart beating.

The EKG and ECG are usually enough to support a diagnosis of AFib. The physician, however, may perform more procedures:

• A transesophageal echocardiogram (TEE) may be performed if there might be a blood clot in the heart that poses an immediate risk for stroke. A long, thin tube is inserted down the throat so the doctor can image the heart without the ribs obscuring any blood clot.

• Blood tests can determine a cause for the condition, such as electrolyte imbalance, infection, or overactive thyroid.

Atrial fibrillation treatment options

Atrial fibrillation treatment is meant to achieve one or more of these goals:

• Prevent blood clots

• Restore a normal heart rate

• Restore a normal heart rhythm

AFib treatment options will depend on the patient's age, risk for stroke, heart rate, symptoms, medical conditions, and tolerance for side effects.

Medications

The paramount goal of AFib treatment is to prevent stroke or other blood vessel blockage. Nearly all doctors will prescribe a blood thinner to reduce the risk of blood clotting. They may prescribe rate control medications to return the heart to a normal pace, but these often do not restore an organized heartbeat as rhythm control medications do. Both types are equally effective at preventing AFib episodes, so the choice between the two will be made based on other considerations, such as the patient's age or tolerance for side effects.

Electrical cardioversion

Electrical cardioversion applies a low-voltage electrical shock directly to the chest. It is often used in an emergency to "reset" the heart to a normal heart rhythm (sinus rhythm). It may also be used at any time during treatment. Before applying electrical cardioversion, the physician will perform a transesophageal echocardiogram (TEE) to identify blood clots in the heart. A normal rate will pump the blood clot out of the heart, so the patient will have to be treated with blood thinners first.

Surgery

As with medications, surgical procedures can help reduce the risk of stroke, restore a normal heart rate, or restore an organized heartbeat. There are four surgical operations to treat AFib:

• Catheter ablation: Surgical ablation is the destruction of the tissue that is responsible for the disease. In catheter-based ablation, a tube is introduced into the heart and selectively destroys the atrial tissue passing on erratic electric signals.

• Maze procedure: The maze procedure (or Cox-Maze III procedure) is a highly successful surgical treatment. Using cold or radiofrequency energy, the surgeon destroys spots of atrial tissue in a circle around the large veins and other areas. The scar tissue that forms blocks abnormal signals from entering the heart from those veins and restores a natural rhythm. Another part of the procedure closes off a part of the heart that causes blood clots and reduces the risk of stroke. Because this is open-heart surgery, most people will try other treatment options first.

• Left atrial appendage closure: The left atrial appendage is a pouch on the left atrium that serves no purpose in pumping blood, but during an AFib episode, blood can pool inside the pouch and start clotting. It is the primary source of blood clots in the heart. A left atrial appendage closure places a closure device over this pouch to close it off. This procedure dramatically reduces the risk of blood clots.

• Pacemakers: if medications and ablation surgery have not been successful, an implantable pacemaker can restore the heart's normal rhythm and rate.

Atrial fibrillation medications

AFib medications can prevent blood clots, return the heart to a normal rate, or restore the heart's normal rhythm.

Blood thinners

Blood thinners reduce the body's ability to form blood clots. For patients with a low risk of stroke, antiplatelet medications such as low-dose aspirin are sufficient. These medications prevent platelets, the cells in the blood that form blood clots, from grouping together. Patients at an increased risk for blood clots will take anticoagulation drugs, such as warfarin, dabigatran, rivaroxaban, and apixaban, all of which block the chemical processes platelets use to form blood clots.

RELATED: Do you have to take blood thinners for AFib?

Rate control medications

AFib causes the heart to race, which can damage the lower chambers of the heart (the ventricles). Rate control medications slow the heart down, preventing the heart from speeding up. Rate-control medications work by interfering with the chemical processes responsible for muscle contractions.

Beta blockers are considered the best medication for rate control. Calcium-channel blockers, such as verapamil or diltiazem, may also be used. Cardiac glycosides, such as digoxin, are the first-line treatment for patients with heart failure, low blood pressure, who are highly sedentary, who are older.

RELATED: What is a beta blocker?

Rhythm control medications

Rhythm control medications, or antiarrhythmic drugs, are prescribed to restore or maintain normal heart rhythm. The prescribed medication will be based on the structure of the irregular heartbeat and the patient's tolerance for side effects. The most common rhythm control medications prescribed are propafenone, flecainide, amiodarone, dofetilide, dronedarone, and sotalol.

What is the best medication for atrial fibrillation?

Most patients diagnosed with atrial fibrillation will be prescribed a blood thinner to prevent stroke. They will often be put on a rate control or rhythm control medication as well.

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