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."

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.

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.

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.

Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA). Dosage is determined by your healthcare professional based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.

What are the common side effects of AFib meds?

Different classes of medications have different side effects. However, this is not a complete list, and you should consult a healthcare professional for possible side effects and drug interactions based on your specific situation.

Antiarrhythmic medications produce many and sometimes severe side effects, including arrhythmia, speeding up the heart, liver damage, lung damage, and heart failure. Side effects can persist for weeks, even after discontinuing the drug. They are not prescribed to patients who have heart failure, heart disease, or are very advanced in years.

What are the best home remedies for atrial fibrillation?

Successful atrial fibrillation treatment requires a substantial personal investment in home remedies and lifestyle changes involving diet, exercise, and stress.

1. Lose excess weight

Weight loss will substantially reduce the load on the heart. Also, losing excess weight and keeping it off will help make changes to the atria that reduce or possibly eliminate AFib.

2. Eat a heart-healthy diet

A heart-healthy diet involves eating plenty of vegetables, fruits, fiber-rich foods, nutrient-rich foods, and low-fat meat and dairy. Avoid sugar, salt, and saturated fats. Some foods will trigger an episode, but the type of food will vary from person to person. Because each episode risks the formation of a blood clot, avoid the foods that may trigger episodes.

3. Exercise more

Exercise is vital for a healthy heart, and it can help change the structure of the atria to help reduce or reverse AFib. Moderate daily exercise for at least 30 minutes a day, five days a week is sufficient. Don't overdo it, though. Physical exertion is one of the most common triggers of AFib, so avoid intense or high-endurance exercise. Any exercise that carries a risk of injuries, such as skiing, mountain biking, climbing, hockey, or similar sports, should probably be avoided by people on blood thinners.

4. Reduce stress

Stress not only affects heart health, but it is also the most common trigger of AFib episodes. Avoiding stress is not always possible, but relaxation activities, exercise, good sleep hygiene, and avoiding stimulants can reduce stress.

5. Avoid alcohol, smoking, and caffeine

Alcohol, caffeine, and stimulants can trigger AFib. It is best to avoid them. Smoking can double the risk of getting AFib. Nicotine, a stimulant, is also a powerful trigger of atrial fibrillation.

Frequently asked questions about atrial fibrillation

What can trigger atrial fibrillation?

The most common triggers of atrial fibrillation are stress, physical exertion, fatigue, alcohol, caffeine, nicotine, stimulants, and infections. Some foods or situations may trigger an event, but they will vary from person to person.

How do you stop AFib at home?

The only proven ways to slow down the heartbeat are vagal nerve maneuvers or biofeedback exercises such as yoga, meditation, or deep breathing. The vagus nerve controls the organs in the body, including the heart. Shocking the vagus nerve temporarily disrupts it, slows the heart, and can help return the heart to a normal rate. Examples include putting the face in cold water, holding the knees against the chest, coughing, or covering the nose and mouth and trying to push the air out of the lungs.

How can I stop AFib naturally?

If diagnosed early, AFib could be managed naturally through dramatic and committed lifestyle changes. These include eating a heart-healthy diet, regular exercise, reducing stress, quitting smoking, and swearing off the use of alcohol, caffeine, and stimulants.

Blood clots and strokes are always a risk and can happen during any atrial fibrillation episode, even the first one. Blood clots cannot be stopped naturally. They will require medications.

What is the drug of choice for AFib?

Nearly all patients will take a blood thinner to reduce the risk of stroke, but the drug prescribed will depend on the patient's risk factors and tolerance of side effects. The two major classes of AFib drugs, rate control drugs, and rhythm control drugs, are equally effective at preventing episodes. Some drugs work better than others, but the medication prescribed will depend on pre-existing medical conditions, risk factors, and the patient's age and tolerance for side effects.

What foods should be avoided with atrial fibrillation?

Atrial fibrillation will require a commitment to a heart-healthy diet. Avoid foods with unsaturated fats, salt, or sugar.

What is the best treatment for atrial fibrillation?

Lifestyle changes and blood thinners may be enough for patients with an early diagnosis. Other patients with more severe symptoms may require medications to control the rate or rhythm of the heartbeat. Surgery is highly successful and associated with a significant increase in quality of life. Still, surgery is only necessary if the patient has a high risk of stroke or the condition is not responding to medications or electric cardioversion.

What is the first-line treatment for atrial fibrillation?

In a healthcare provider's office, the first-line treatment will be blood thinners and a rate control or rhythm control medicine. In an emergency room, if the patient is having an active episode, there is a high risk for a stroke. The first-line treatment will be electrical cardioversion to restore the heart's normal rate and rhythm. Anticoagulants will be immediately given. If the patient is not having an active episode in the emergency room, the first-line treatment will be anticoagulation drugs.

Which beta blocker is best for atrial fibrillation?

Beta blockers are often the first-line medication to establish a normal heart rate. The most commonly used beta blockers for AFib are atenolol, metoprolol, bisoprolol, and nadolol. The "best" beta blocker will depend on the potency of the drug, how long the drug is active in the body, as well as its side effects and affordability.

Can you control AFib without medication?

Depending on how soon the condition is diagnosed, you may be able to control AFib episodes through dramatic and highly-committed lifestyle changes without heart medications. The risk of blood clots cannot be managed without medication, though.

Related resources for atrial fibrillation

• 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation
• Atrial fibrillation (AFib)
• Atrial fibrillation as a leading factor for stroke: The Framingham Study
• How to choose between rate control and rhythm control for atrial fibrillation: Video interview with Dr. Eric Pystowsky
• The current approach of atrial fibrillation management