Atrial fibrillation: Shifting strategies for early treatment?

The heart rhythm disorder known as atrial fibrillation (afib) occurs when the heart’s electrical system goes awry. Instead of the heart’s natural pacemaker creating a steady beat, the heart’s upper chambers (atria) pulsate rapidly — up to hundreds of times per minute. Most of the electrical impulses telling the lower chambers (ventricles) to contract don’t get through but many do, triggering a racing, irregular heartbeat that can leave people dizzy, breathless, or fatigued.

Therapies to tackle this common arrhythmia have improved over the years. Now, new findings suggest it may be time to rethink the treatment for people newly diagnosed with afib (see “Afib: Rhythm vs. rate control”).

Afib: Rhythm vs. rate controlGiven recent progress in afib therapy, experts decided it was time to compare the two main treatment strategies for the condition. Their findings appeared in the Aug. 29, 2020, issue of The New England Journal of Medicine.Who: 2,789 people from 135 medical centers in 11 European countries. Their average age was 70, and all had been diagnosed with afib in the past year.What: Half the participants received rhythm control therapy, which included anti-arrhythmic drugs such as flecainide (Tambocor) and amiodarone (Pacerone, others) or an ablation procedure (see main text). The other half received standard care, which typically includes medications such as beta blockers to slow the heart rate.When: Participants were followed a median of just over five years.Key findings: The three serious outcomes — hospitalization, stroke, or death from cardiovascular disease — occurred in 316 of those receiving usual care but in just 249 of those who received early rhythm control therapy.

Varied symptoms

Bouts of afib may occur in brief episodes lasting hours to days, or continue for months or even years. The effect on people’s lives also varies quite a bit. “Some people are debilitated by symptoms after being in afib for just five minutes,” says Dr. William Sauer, chief of the Cardiac Arrhythmia Service at Harvard-affiliated Brigham and Women’s Hospital. Others don’t even realize they have the condition until it’s discovered by chance during a routine check-up.

Two main strategies can help tame afib. One, known as rate control, involves taking medications that keep the heart rate in a normal range. The other, known as rhythm control, involves restoring the heart to its normal rhythm with a medication or a minimally invasive procedure. For decades, doctors have tended to start with rate control, mainly because the drugs used for rhythm control have more worrisome side effects. But the new study found that people who started with rhythm control rather than rate control soon after their diagnosis had fewer strokes and were less likely to die from heart disease.

Getting into the rhythm

The findings were a bit surprising, says Dr. Sauer. “But they probably reflect the fact that doctors are getting better at using rhythm control strategies,” he says. Historically, doctors haven’t prescribed anti-arrhythmic drugs unless a person had frequent, bothersome symptoms. The drugs are safe, but people taking them need to be closely monitored because of possible toxic effects on the liver, lungs, and thyroid, says Dr. Sauer. Rarely, rhythm-controlling drugs trigger a potentially dangerous heart rhythm in the ventricles.

If the drugs aren’t working or cause troubling side effects, doctors can turn to catheter ablation. For this procedure, a doctor gently guides a thin, flexible tube (catheter) into a large vein and threads it up to the heart. Special instruments deliver heat or extreme cold to destroy (ablate) tiny spots of tissue in the atrium to squelch the abnormal electrical signals before they set off an episode of afib.

In the study, nearly one in five people received catheter ablation. Ablation techniques have evolved over the past two decades and improve every year, Dr. Sauer points out.

Advice for people with afib

However, it’s important to recognize that the most serious threat from afib is the heightened risk of stroke. That’s why most people with afib should also take anti-clotting drugs regardless of the other treatments they receive, including ablation. Most primary care providers aren’t comfortable prescribing rhythm control medications, says Dr. Sauer. “If you’re diagnosed with afib, it’s worth consulting a cardiologist to make sure you’re getting optimal treatment to minimize your symptoms, any drug side effects, and your risk of stroke.”

Bible verses for today’s meditation and inspiration: Matthew E. McLaren

 “Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things.” – Philippians 4:8

 “Therefore I tell you, whatever you ask for in prayer, believe that you have received it, and it will be yours.” – Mark 11:24

 “Anxiety weighs down the heart, but a kind word cheers it up.” – Proverbs 12:25

 “Who of you by worrying can add a single hour to your life?” – Luke 12:25

 “For I know the plans I have for you, declares the Lord, plans for welfare and not for evil, to give you a future and a hope.” – Jeremiah 29:11

“If you, then, though you are evil, know how to give good gifts to your children, how much more will your Father in heaven give good gifts to those who ask him!” – Matthew 7:11

 “A cheerful heart is good medicine, but a crushed spirit dries up the bones.” – Proverbs 17:22

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