Managing AFib: understanding the treatment options

Your heart is a muscle, but it’s also a complex piece of electronics. Electrical impulses shoot through your heart, causing it to fill up with blood and squeeze it out into the rest of the body. Normally that electricity creates a nice, steady rhythm. But when these electrical signals that coordinate heartbeats are not working properly, it can result in an abnormal heartbeat, called an arrhythmia.

When you have an arrhythmia, your heart beats too quickly, too slowly or in an erratic pattern. Arrhythmias can hinder blood flow to the body, damaging organs and contributing to a range of potentially life-threatening health conditions, including cardiac arrest and stroke. Atrial fibrillation, or AFib, is the most common type, affecting between 2.7 and 6.1 million people in the U.S. each year.

AFib occurs when the electrical signals that regulate heart rhythm don’t move through the heart correctly, causing its top chambers—the atria—to flutter or quiver. As a result, all the blood doesn’t leave the upper chambers, causing it to pool. When blood pools it can form a clot, and a clot can leave the heart and block blood flow to the brain, causing a potentially deadly stroke. The good news is that AFib can be managed. Learn about the range of existing treatment options for the condition.

Most people are able to identify at least some of their AFib triggers, such as heavy drinking, drug use, smoking and exercise, which could help them reduce the frequency of their attacks. Keep in mind however, AFib may be hard to predict as triggers can vary from one person to the next.

If you have AFib, your healthcare provider may recommend that you make some healthy lifestyle changes to help control your condition and lower your risk for high blood pressure and heart disease. These changes may include:

• Maintaining a healthy weight
• Getting regular exercise
• Adopting a heart-healthy diet
• Taking steps to ease stress
• Not smoking

People with early atrial fibrillation may also turn to medication as an early treatment. Treating Afib with medication is a three-pronged approach: There are drugs to slow the heart rate, drugs to regulate the electrical rhythm, and drugs to stop the blood from clotting and potentially causing a stroke. “A lot of people can go years with just medication,” says David Affleck, MD, a cardiothoracic surgeon at Ogden Regional Medical Center in Ogden, Utah. “The downside to this is you’re not changing the triggers that cause the Afib. You will probably need medication for the rest of your life.”

Cardioversion is a procedure used to restore a normal heart rhythm. For the procedure, patients are given mild anesthesia before receiving electric shocks on the outside of their chest with paddles or patches. Cardioversion is similar to defibrillation but much lower levels of electricity are used. This shock can help “reset” the heart, restoring a normal heartbeat, or rhythm.

In some cases, a device, called a pacemaker, which sends steady electrical signals to the heart to help it maintain a normal rhythm, may be used to help manage AFib. It’s important to understand however that a pacemaker will not cure AFib. Pacemakers only deal with slow heart rhythms—not fast ones. But it is possible for someone’s heart rate to be slow and still be irregular, or in atrial fibrillation. In these cases, a pacemaker might make people feel better, but they still have the condition. Some medications for AFib could also slow the heart rate. This is another reason why someone with the condition might benefit from a pacemaker.

When AFib can’t be controlled by lifestyle changes, medication or cardioversion, there are a number of procedures available as next steps, such as catheter ablation—a minimally invasive procedure that uses energy, such as radiofrequency, laser or cryotherapy, to kill the cells that create the irregular heartbeat.

During a catheter ablation procedure, a cardiac electrophysiologist inserts a long, thin tube (catheter) into a blood vessel in the groin and guides it up to the area inside the heart that’s causing the irregular heartbeats. The top end of the catheter produces extreme cold or heat to destroy the heart tissue that’s triggering the fast and irregular heartbeats. In some cases however, AFib may return following catheter ablation. The procedure usually has a short recovery period but may need to be performed more than once.

Surgical ablation, also known as a maze procedure, may be recommended for people who need heart surgery for another reason, those with AFib that isn’t controlled by medication and less invasive procedures or those with a history of stroke or other blood clots.

In a surgical ablation, instead of using a catheter, a cardiothoracic surgeon either opens up the chest or makes small incisions by the armpits. Surgical ablation is a more invasive procedure, but it’s highly effective for certain patients. “It has the highest cure rate, the lowest recurrence rate and the lowest long-term stroke rate,” says Affleck. “But it’s a big operation: you’re opening the sternum and deflating the lungs, and there’s a long recovery.”

Hybrid isn’t so much a technique as it is an approach, Affleck explains. A hybrid ablation is one in which the cardiac electrophysiologist and the surgeon work together. One problem with catheter ablation is it’s hard to burn the back wall of the heart from the inside without damaging the aorta and esophagus, which sit behind the heart, while a surgical ablation is a difficult operation with a long recovery time. A hybrid approach can solve both problems. “Catheter ablation is one technique, surgical ablation is one technique, hybrid ablation is both working together,” Affleck says. “I do what’s difficult for a catheter to do, and the electrophysiologist does the burns that I find difficult.”

Even minimally invasive ablation surgery requires the surgeon to deflate each lung in turn in order to get to both sides of the heart. That’s too intense for some patients, especially those who are obese or whose lungs already don’t work well. In these cases, a convergent ablation may be performed. Similar to a hybrid ablation where the surgeon and the electrophysiologist work together, during a convergent ablation the surgeon goes in through the abdomen, eliminating the need to deflate the lungs.