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, which may decrease the risk of a stroke
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 a 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 done 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 for a short moment. The goal is to reset your heart's normal rhythm.
You will be given a sedative before the procedure, so you shouldn't feel the electric shock. You may also receive medications to help restore a normal heartbeat (anti-arrhythmics) before 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, you may receive medications through an IV or by mouth to help 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 warfarin or another blood-thinning medication for several weeks to reduce the risk of blood clots and strokes. If your episode of atrial fibrillation lasted more than 48 hours, you may need to take this type of medication for at least a month after the procedure to prevent blood clots in the heart.
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:
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 how fast your heart beats and restore it to a normal rate.
- Digoxin. This medication may control the heart rate at rest, but not as well during activity. Most people need additional or alternative medications, such as calcium channel blockers or beta blockers.
- Beta blockers. These medications can help to slow the heart rate at rest and during activity. They may cause side effects such as low blood pressure (hypotension).
- Calcium channel blockers. These medicines also can control your heart rate, but 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. During this procedure, a doctor inserts long, thin tubes (catheters) into your groin and guides them through blood vessels to your heart. The catheter's tip produces radiofrequency energy, extreme cold (cryotherapy) or heat to destroy areas of heart tissue that are causing rapid and irregular heartbeats. Scar tissue forms, which helps signaling return to normal. Cardiac ablation may correct the arrhythmia without the need for medications or implantable devices.
Your doctor may recommend this procedure if you have atrial fibrillation and an otherwise normal heart and medication has not improved your symptoms. It may also be helpful for heart failure patients who have an implanted device and cannot take or tolerate anti-arrhythmic medications.
Maze procedure. There are several variations of the maze procedure. The doctor may use a scalpel, radiofrequency or extreme cold (cryotherapy) to create a pattern of scar tissue that interferes with stray electrical impulses that cause atrial fibrillation.
The maze procedures have a high success rate, but atrial fibrillation may come back. If this happens, you may need another cardiac ablation or other heart treatment.
Because the surgical maze procedure (using a scalpel) requires open-heart surgery, it's generally reserved for people who don't get better with other treatments or when it can be done during a 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 cause side effects, or if you're not a good candidate for these therapies, AV node ablation may be an option. The procedure involves using a catheter to deliver radiofrequency energy to the pathway (AV node) connecting the upper and lower heart chambers.
The procedure destroys a small area of heart tissue, preventing abnormal signaling. However, the upper chambers of the heart (atria) will still quiver. You'll need a pacemaker to be implanted to keep the lower chambers (ventricles) beating properly. You'll need to take blood thinners after this procedure to reduce the risk of a stroke due to 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. 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 to prevent strokes in people with atrial fibrillation. These medications include dabigatran, rivaroxaban, apixaban and edoxaban. They are shorter acting than warfarin and usually don't require regular blood tests or monitoring by your doctor. These medications aren't approved for people who have mechanical heart valves.
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.
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 eventually guide it 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. Candidates for this procedure may 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. Your doctor will evaluate you and determine if you're a candidate for the procedure.