The atrial fibrillation treatment that is most appropriate for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the treatment goals for atrial fibrillation are to:
- Reset the rhythm or control the rate
- Prevent blood clots
- Decrease the risk of strokes
The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need more invasive treatment, such as medical procedures using catheters or surgery.
In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. Treating the condition causing atrial fibrillation may help relieve your heart rhythm problems. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.
Resetting your heart's rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it.
Cardioversion can be conducted in two ways:
Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily.
When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed during sedation, so you shouldn't feel the electric shock. Your doctor may give you medications to help restore normal sinus rhythm (anti-arrhythmics) prior to the procedure.
Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm.
This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic medication or a similar one to try to prevent more spells of atrial fibrillation.
Before cardioversion, you may be given a blood-thinning medication such as warfarin (Coumadin, Jantoven) for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 48 hours, you'll need to take warfarin for at least four weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm.
You may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion.
Maintaining a normal heart rhythm
After electrical cardioversion, your doctor may prescribe anti-arrhythmic medications to help prevent future episodes of atrial fibrillation. Medications may include:
- Dofetilide (Tikosyn)
- Propafenone (Rythmol)
- Amiodarone (Cordarone, Pacerone)
- Sotalol (Betapace, Sorine)
Although these drugs may help maintain a normal heart rhythm, they can cause side effects, including:
Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, there is a chance of another episode of atrial fibrillation.
Heart rate control
You may be prescribed medications to control your heart rate and restore it to a normal rate. Heart rate control can be achieved through several medications.
The medication digoxin (Lanoxin) may control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers.
Beta blockers may cause side effects such as low blood pressure (hypotension). Calcium channel blockers can also cause side effects, and may need to be avoided if you have heart failure or low blood pressure.
Catheter and surgical procedures
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:
Catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.
In catheter ablation, a doctor inserts long, thin tubes (catheters) into your groin and guides them through blood vessels to your heart. Electrodes at the catheter tips can use radiofrequency energy, extreme cold (cryotherapy) or heat to destroy these hot spots, scarring the tissue so that the erratic signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices.
Surgical maze procedure. The maze procedure is conducted during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue.
Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy also can be used to create the scars, and there are several variations of the surgical maze technique.
These procedures have a high success rate, but atrial fibrillation may recur. Some people may need catheter ablation or other treatment if atrial fibrillation recurs.
Because the surgical maze procedure requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair.
Atrioventricular (AV) node ablation. If medications or other forms of catheter ablation don't work, or if you have side effects or are not a good candidate for other procedures, AV node ablation may be another option. The procedure involves applying radiofrequency energy to the pathway connecting the upper chambers (atria) and lower chambers (ventricles) of your heart (AV node) through a catheter to destroy this small area of tissue.
The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though. A pacemaker is then implanted to keep the ventricles beating properly. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke because your heart rhythm is still atrial fibrillation.
Preventing blood clots
Many people with atrial fibrillation or those who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to a stroke. The risk is even higher if other heart disease is present along with atrial fibrillation.
Your doctor may prescribe blood-thinning medications (anticoagulants) such as:
- Warfarin (Coumadin, Jantoven). Warfarin may be prescribed to prevent blood clots. If you're prescribed warfarin, carefully follow your doctor's instructions. Warfarin is a powerful medication that may cause dangerous bleeding. You'll need to have regular blood tests to monitor warfarin's effects.
Newer anticoagulants. Several newer blood-thinning medications (anticoagulants) are available. These medications are shorter acting than warfarin and don't require monitoring. Also, these medications are not approved for people who have mechanical heart valves. It's very important to take these medications exactly as prescribed.
Dabigatran (Pradaxa) is an anticoagulant medication that's as effective as warfarin at preventing blood clots that can lead to strokes, and doesn't require blood tests to make sure you're getting the proper dose.
You shouldn't take dabigatran if you have a mechanical heart valve due to an increased risk of stroke or heart attack. Talk to your doctor about taking dabigatran as an alternative to warfarin if you're concerned about your risk of stroke.
Rivaroxaban (Xarelto) is another anticoagulant medication that's as effective as warfarin for preventing strokes. Rivaroxaban is a once-daily medication. Like any other anticoagulant, follow your doctor's dosing instructions carefully and don't stop taking rivaroxaban without talking to your doctor first.
Apixaban (Eliquis) is another anticoagulant medication that's as effective as warfarin for preventing strokes.
Left atrial appendage closure
Your doctor may also consider a procedure called left atrial appendage closure.
In this procedure, doctors insert a catheter through a vein in the leg and guide it to the upper right heart chamber (right atrium). Doctors then make a small hole in the wall between the upper heart chambers and guide the catheter to the upper left heart chamber (left atrium). A device called a left atrial appendage closure device is then inserted through the catheter to close a small sac (appendage) in the left atrium.
This may reduce the risk of blood clots in certain people with atrial fibrillation, as many blood clots that occur in atrial fibrillation form in the left atrial appendage. People who may be candidates for this procedure include those who don't have heart valve problems, who have an increased risk of blood clots and bleeding, and who are aren't able to take anticoagulants or they aren't effective. Your doctor will evaluate you and determine if you're a candidate for the procedure.
Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal.