Your doctor is the best source of information on the drug treatment choices available to you.
Table 3. Drugs Commonly Used to Treat Atrial Fibrillation
Drug Type/Name Special Considerations Antiarrhythmics May infrequently produce very serious, irregular heartbeats (arrhythmias). Therefore, they should be used carefully in selected patients to treat life-threatening irregular heartbeats only. Tell your doctor if you have had a heart attack within the past two years. Can interact with other drugs. Check with your doctor if you are taking ?-blockers, other antiarrhythmics, phenytoin, digoxin, and muscle relaxants. Procainamide HCl (Pronestyl, Pronestyl SR, Procanbid) The prolonged administration of procainamide often leads to the development of a positive anti-nuclear antibody (ANA) test, with or without symptoms of a lupus erythematosus-like syndrome. If a positive ANA titer develops, the benefits versus risks of continued procainamide therapy should be assessed. Should be used only to treat life-threatening arrhythmias (irregular heartbeats). Procainamide may cause a decrease in the number of cells in your bone marrow. Procainamide may also cause symptoms of lupus. Quinidine gluconate This medication infrequently produces very serious, irregular heartbeats (arrhythmias). Therefore, it should be used carefully in selected patients to treat life-threatening irregular heartbeats only. Therefore, patients are usually started on quinidine while being monitored in a hospital setting with constant observation of their heart rhythm. Tell your doctor if you have had a heart attack within the past two years. May cause diarrhea, fever, rash, arrhythmia, abnormal ECG, nausea, vomiting, dizziness, headache. Flecainide acetate (Tambocor) This medication infrequently produces very serious, irregular heartbeats (arrhythmias). Therefore, it should be used carefully in selected patients to treat life-threatening irregular heartbeats only. Tell your doctor if you have had a heart attack within the past two years. Propafenone (Rythmol, Rythmol SR) May produce irregular heartbeats (arrhythmias). Therefore, it should be used carefully in selected patients to treat life-threatening irregular heartbeats. Tell your doctor if you have had a heart attack within the past two years. Sotalol (Betapace, Betapace AF) For the first three days you take sotalol, you will have to be in a facility where your heart can be monitored. Tell your doctor if you have or have ever had kidney disease. Betapace and Betapace AF are used for different types of irregular heartbeats and should not be used interchangeably. Make sure your doctor knows which product you have been taking. Disopyramide phosphate (Norpace) May infrequently produce very serious, irregular heartbeats (arrhythmias). Therefore, they should be used carefully in selected patients to treat life-threatening irregular heartbeats only. Tell your doctor if you have had a heart attack within the past two years. Metoprolol (Lopressor) When discontinuing chronically administered lopressor, particularly in patients with ischemic heart disease, the dosage should be gradually reduced over a period of 1-2 weeks and the patient should be carefully monitored. Ibutilide (Corvert) Ibutilide can cause potentially fatal arrhythmias, particularly sustained polymorphic ventricular tachycardia, usually in association with QT prolongation (torsades de pointes), but sometimes without documented QT prolongation. It is essential that Ibutilide be administered in a setting of continuous ECG monitoring and by personnel trained in identification and treatment of acute ventricular arrhythmias, particularly polymorphic ventricular tachycardia. Amiodarone (Cordarone) Amiodarone is intended for use only in patients with the indicated life-threatening arrhythmias because its use is accompanied by substantial toxicity including lung damage, liver damage, and worse heartbeat problems. Amiodarone increases the sensitivity of your skin to sunlight; too much exposure could cause a serious sunburn. Do not drink grapefruit juice during treatment with amiodarone; grapefruit juice affects how the drug is absorbed in the stomach. Vision problems that may lead to permanent blindness. You should have regular eye exams before and during treatment. Call your doctor if you have blurred vision, see halos, or your eyes become sensitive to light. Can cause a feeling of ?pins and needles? or numbness in the hands, legs, or feet, muscle weakness, uncontrolled movements, poor coordination, and trouble walking. ?-blockers Metoprolol (Lopressor); Atenolol (Tenormin); Esmolol (Brevibloc); Inderal (Propranolol) May cause tiredness, dizziness, depression, mental confusion, short-term memory loss, headache, insomnia, weakness, and fatigue in some people. Can interact with other drugs. Check with your doctor if you are taking aluminum salts, barbiturates, NSAIDs, digitalis, carbamazepine, penicillins, calcium salts, cholestyramine, theophylline, or rifampin. Use with caution if you have kidney or liver problems. Do not use if you are allergic to ?-blockers, have heart failure, blocked heart, Sick Sinus syndrome, or high blood pressure. Do not use if you are pregnant or nursing. Calcium channel blockers Diltiazem (Cardizem); Verapamil (Calan) May cause headache, dizziness, a sudden drop in blood pressure, and nausea. Can interact with other drugs. Check with your doctor if you are taking cimetidine, digitalis, nitrates, lithium, phenobarbital, cyclosporin, rifampin, carbamazepine, or ?-blockers. Use with caution if you have kidney or liver problems or congestive heart failure. Do not use if you are allergic to calcium channel blockers or are pregnant or nursing. Cardiotonics Digoxin (Lanoxin) May cause anorexia, diarrhea, nausea, and vomiting. May cause heart block, additional rhythm disturbances, or unacceptable increases or decreases in the heart rate. Can interfere with other drugs. Check with your doctor if you are taking digoxin, alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, quinidine, diltiazem, aminoglycosides, or erythromycin. Do not use if you are allergic to cardiotonics, have heart disease that results from a lack of dietary thiamine, a narrowed aortic artery, pericarditis, or Carotid Artery Sinus syndrome. Do not use if you are pregnant or nursing.
Avoid substances such as cigarettes, illicit drugs, or certain herbs that can trigger atrial fibrillation. Cigarettes, street drugs such as cocaine or amphetamines, and even caffeine can lead to atrial fibrillation. The same is true for excessive alcohol intake, and the use of certain herbs, such as Ephedra or ginseng.
When atrial fibrillation occurs on a long-term basis or symptoms are distressing, your doctor may recommend a procedure known as electrical cardioversion to restore normal heart rhythm Table 04. Electrical cardioversion is usually reserved for people with atrial fibrillation that do not respond to drugs. Electrical cardioversion restores the normal heart rhythm with electricity. The doctor will place conducting paddles on your chest and deliver volts of energy to shock the heart into a normal rhythm. It is an outpatient procedure, but requires a short-acting general anesthesia. You will be monitored during the procedure so that the doctor can make certain that your heart rate is within a safe range, and that your blood pressure remains normal. The level of oxygen in your blood is also checked. Recovery can take several hours. During this time, your doctor will conduct an EKG to monitor your heart rhythm and assess the results.
If your atrial fibrillation does not respond to drug therapy or electrical cardioversion, your doctor may destroy targeted areas of tissue in your heart using a procedure called radiofrequency catheter ablation. Radiofrequency catheter ablation is a relatively new procedure that is typically reserved for people with life-threatening fast heartbeats. People with atrial fibrillation who do not respond to standard therapies, those who cannot tolerate side effects of medications, and very young people who do not wish to take lifelong medications may also undergo ablation procedures
In radiofrequency catheter ablation, your doctor will make a small cut into a vein or artery and insert a very thin, flexible tube (catheter). Using an x-ray, he or she will guide the catheter through the blood vessel to the area of the heart where the chaotic, disorganized electrical signals are being released. A current is then transmitted to this site, which heat and kills the cells that are producing the extra electrical impulses.
Radiofrequency catheter ablation has relatively modest success rate at present (only 40%-60%). It usually requires local anesthesia (only a small area is numbed). Ablation coupled with insertion of a pacemaker has a high success rate; however, it does not cure AF. Rather it helps regulate the heart rate, and results in lifelong dependence on the pacemaker. If a pacemaker is inserted after the procedure, a hospital stay is required.
Table 4. Nondrug Therapies Used to Treat Atrial Fibrillation
Therapy What it does What you should know Electrical cardioversion Restores normal heart rhythm by delivering volts of energy to the heart. Outpatient procedure. Requires a short-acting general anesthesia (meaning that you?ll be asleep for a short period) Recovery takes a few hours, although your chest may remain tender for a few days. Radiofrequency catheter ablation Restores and maintains normal heart rhythm. Usually reserved for people who do not respond to standard treatments or who cannot tolerate side effects. Also used in young people who do not wish to take medications their entire lives. Done on an outpatient basis. Requires only local anesthesia (only a small area is numbed). High success rate for ablation coupled with pacemaker insertion, but moderate success rate with ablation alone. Pacemaker Often inserted during a cardiac ablation procedure to take over the heart?s rhythm and maintain a safe heart rate. Inpatient procedure often conducted after cardiac ablation. Most people can return to most normal activity within two to three weeks. Activities involving jerking motions must be avoided for at least eight weeks to avoid dislodging the pacemaker. (Such activities include swimming, bowling, tennis, carrying heavy loads, mowing the lawn, or shoveling snow.) Has a high success rate and low rate of complications. Leaves a small scar. Maze surgery Several incisions are made in the atrium and then sewn together again. This creates a single, maze-like path between the sinoatrial and atrioventricular nodes so that heart rhythm is restored. An ?open-heart? procedure requiring general anesthesia (you are asleep during the operation). Maze surgery is successful in restoring heart rhythm in 80% to 99% of people. Recovery time varies but can take several weeks after leaving the hospital.
If your condition cannot be controlled with medication or by controlled electric shock, you may need to undergo surgery to have a pacemaker installed. A pacemaker is a small device that maintains a safe heart rate by delivering timed electrical impulses to your heart. Pacemakers cannot cure AF; however, they can maintain a regular heartbeat after ablation and while taking anti-arrhythmic or rate-slowing drugs. Pacemakers vary by type and rate of delivery of impulses, and are selected based on the lifestyle and age of the patient, and the type and severity of the heart problem. After cardiac ablation, your surgeon threads the pacemaker leads through the catheter to the heart chambers that need correcting. Then the surgeon makes a small pocket under the skin of the upper chest wall to hold the pacemaker, and closes the pocket with stitches.
If you have tried other therapies and still have troublesome symptoms, your doctor may recommend that you undergo a relatively new type of surgery known as the maze procedure. During maze surgery, the surgeon makes cuts into the atrium to interfere with the electrical impulses. The incisions are then sewn together again. This technique prevents extra impulses from crossing the incisions to disrupt the normal rhythm. This prevents fibrillation, and restores normal heart rhythm. The maze procedure is an open-heart operation, meaning that the chest will be opened. During such procedures, the heart is stopped temporarily, and its beating is done by a heart-lung machine.
Stress reduction techniques such as yoga, meditation, or biofeedback may be helpful in reducing symptoms and slowing the heart rate. Emotional stress and anxiety can increase release of stress hormones into the bloodstream and interfere with normal heart rhythm and pumping strength. Relaxation techniques that focus on deep breathing and concentration, such as yoga and meditation, can slow the heart rate, reduce other symptoms, and improve your ability to cope with stressful events before symptoms start. Biofeedback is a technique that is used to “open communication” between you and your body. Although the nervous system normally controls the seemingly automatic responses produced by your body, biofeedback teaches you to manage this process through relaxation and concentration.
On rare occasions, atrial fibrillation occurs during pregnancy. Although heart palpitations, dizziness, and even fainting are common in pregnancy, they are not usually caused by atrial fibrillation. However, if you are pregnant and experience any of these symptoms, your doctor will want to conduct a complete physical examination to rule out heart-related and non-heart-related causes. Such factors as thyroid disease, caffeine intake, and cigarette smoking can all contribute to arrhythmia. If you have atrial fibrillation, it may cause a sudden decrease in blood pressure and slow the fetus’s heart rate. In this situation, your healthcare provider may decide to treat you with small doses of drugs, or conduct a cesarean section. If the symptoms do not subside and you are at risk for serious heart complications, your doctor may recommend electrical cardioversion. If necessary, other treatments may be considered after delivery.
The β-blockers metoprolol (Lopressor) and labetalol (Normodyne, Trandate) are generally considered to be safe even in the first trimester, although they can potentially lead to growth retardation. In the third trimester, most of the drugs can be used if absolutely necessary; however, data are limited regarding their effects.
Most people with atrial fibrillation can lead normal lives. The heart returns to a normal rhythm in roughly 50% of people whose atrial fibrillation comes on suddenly. However, atrial fibrillation is more serious if it is caused by underlying, longstanding heart disease. Atrial fibrillation can also lead to heart failure and strokes. Early diagnosis and treatment are essential.
The number and type of follow-up visits to your doctor that are necessary after atrial fibrillation is diagnosed depend on the severity of the disease and the type of treatment you’re receiving. If you are taking medication to control your atrial fibrillation, your doctor will want to see you regularly to make sure that your symptoms are effectively controlled, and to ensure that you are able to tolerate any side effects. How often you need to be seen depends on different factors, such as your age, any type of existing heart disease or other risk factors, the medication you’re taking, and whether you are taking anticlotting medication at the same time.
Keep in mind that if you have any symptoms, such as severe chest pain, sudden shortness of breath, return of heart palpitations, fainting, or dizziness, you should contact your doctor immediately. If you are taking warfarin (Coumadin) to prevent blood clots, it is important to tell your doctor if you have any unusual bleeding or bruising, or if you have any other problems.
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