• Treating Atrial Fibrillation with Pharmacologic Cardioversion


    If you have atrial fibrillation (Afib or AF), your care team will talk with you about various options for managing your symptoms. Your doctors and nurses will probably recommend heart-healthy lifestyle changes that could help reduce your Afib symptoms. They may also recommend medications that could “reset” your heartbeat so that it beats as it should.

    When your heart is beating normally, this is called normal sinus rhythm. Taking medications to help your heart stay in normal sinus rhythm is called pharmacologic cardioversion. It is often the first strategy for treating Afib.

    If pharmacologic cardioversion does not work for you, your care team may consider other treatments, such as electrical cardioversion, catheter ablation or pacemaker implantation. Here we review how pharmacologic cardioversion works.

    How Pharmacologic Cardioversion Helps with Atrial Fibrillation

    If you have Afib, your heart’s natural pacemaker (called the sinoatrial node, or SA node) is not generating electrical impulses as it should. Instead, disorganized electrical signals from other portions of your heart cause your heart to beat erratically. This irregular heartbeat also causes the upper chambers of your heart (the atria) to quiver (fibrillate), so your heart cannot pump blood as it should. When your heart “goes into Afib,” it may beat too quickly and then slow down so much that you feel weak and dizzy, or you may even lose consciousness. The medications that doctors prescribe for pharmacologic cardioversion were developed to control either heart rate or heart rhythm. In some cases, the medication may be used to control both.

    Before You Begin with Pharmacologic Cardioversion

    Before starting you on any medications, your doctor will want to confirm that you are a good candidate for them. He or she may request blood tests to learn more about your heart condition and your overall health. You can learn more about blood tests here.

    To recommend medications and dosages for managing your Afib symptoms, your doctor will consider your age, activity level, overall health, other medications you are taking, how severe or frequent your Afib symptoms are and how prior treatments worked for you. Your doctor will also take into account the type of AFib you have. Paroxysmal atrial fibrillation is characterized by Afib symptoms that last seven or fewer days. Persistent atrial fibrillation is defined by Afib episodes that last more than seven days.

    Your care team will also talk with you about any other medications you are taking as well as any side effects or other problems you may have had with medications you took in the past. Be sure to tell your care team about all of your medications, including prescriptions, over-the-counter medicines, supplements and vitamins, as well as any allergic reactions or side effects that you have experienced when taking medications. All of this information is important because it will help your care team make the best recommendations for your specific situation.

    What Are the Benefits & Risks of Pharmacologic Cardioversion?

    The main benefit of pharmacologic cardioversion is that it can restore your heartbeat to a normal sinus rhythm and keep your heart beating as it should. The medications may make it possible for you to go through your days without the tiredness, lightheadedness, shortness of breath and other disconcerting symptoms of atrial fibrillation.

    Another benefit is pharmacologic cardioversion does not require any medical procedure. And, because a number of medications are available today, it is likely that your care team will find the combination that works for you.

    Side Effects & Allergic Reactions

    It is important to keep in mind that no treatment is without risks. All medications, including those for pharmacologic cardioversion, have side effects. Some side effects may be minor and may go away in time; however, some side effects are signals that you and your care team need to consider other treatment options. Cardioversion medications are known to cause side effects such as:

    • Stomach upset
    • Diarrhea
    • Pain
    • Tiredness
    • Loss of appetite

    If you have any of these side effects, you should let your care team know because some side effects can be dangerous and because your care team may be able to make adjustments to your medication regimen – changing the medications you are taking or the dosages – for you.

    Side effects that are not typical and require immediate medical attention include:

    • New or worsening dizziness or lightheadedness
    • Sweating
    • Heart palpitations
    • Weakness

    If you have these symptoms, call 9-1-1 immediately because you may be experiencing a serious heart problem.

    Allergic Reactions

    Some people also have allergic reactions to certain medications. If you experience swelling of your lips or face, trouble breathing, or break out in a rash or hives, seek medical attention immediately.

    Medications Used for Pharmacologic Cardioversion

    The types of medications used for pharmacologic cardioversion are the following:

    • Amiodarone is prescribed to restore the heart to normal sinus rhythm, or it may be used to keep the heart in normal rhythm after electrical cardioversion (a minimally invasive procedure where the heart is shocked into normal rhythm).
    • Sotalol may be used for heart rhythm management and used for restoring normal sinus rhythm.
    • Propafenone and flecainide are referred to as class IC medications. Class IC medications affect sodium transport across cell membranes in the heart. These medications are reserved for rhythm control in people whose only heart problem is Afib. That is, people with known blockages in their heart arteries and people who have weakened and dysfunctional heart muscle are generally not prescribed these medications.
    • Beta blockers are a class of medications commonly used for heart rate control. These medications block some of the effects of adrenaline, which tends to make the heart beat faster. Metoprolol is an example of a commonly used beta blocker.
    • Calcium channel blockers are another frequently used medication for heart rate control. These medications affect a channel in heart cells that controls the flow of calcium in and out of these cells. Blocking the transport of calcium through these channels slows the rate of the heart. Diltiazem is an example of a calcium channel blocker.
    • Digoxin is used to assist in the overall heart rate control for people with Afib.
    • Quinidine may be used for rhythm control.
    • Dronedarone is a rhythm control medication.

    In addition to the medications your care team prescribes to manage your heart rate and rhythm, it is likely that you will also need to take blood-thinner medications (anticoagulants). These medications are used to help prevent blood clots from forming and causing a stroke. After your cardioversion procedure, your cardiologist or electrophysiologist will make sure that you are taking a blood-thinner for at least a month in most cases. Although the cardioversion will put your heart back in normal rhythm, for the first few weeks there is still a risk of blood clots forming in the heart. So even if you had a transesophageal echocardiogram prior to the cardioversion that showed no clot, precautions must be taken to prevent one from forming after the procedure.

    To learn more about the different types of anticoagulant medications and how they work, click here.

    Challenges with Taking Heart Medications & Tools to Help

    If you have any form of heart disease, including atrial fibrillation, then medications will be an important aspect of both your treatment plan and a strategy for helping to prevent a cardiovascular event, such as a stroke. For all of the medications your doctor prescribes, including the heart rate and rhythm control medications that are used for pharmacologic conversion, it is important that you -

    • Take your medications as directed by your doctor.
    • Do not reduce the amount of medication you take.
    • Do not stop taking the medication until directed to do so by the same doctor who prescribed it.

    With some medications, including the anticoagulant warfarin (Coumadin), it is also necessary to go to regular doctor’s visits where your care team will perform blood tests to ensure the warfarin is working as it should and not causing side effects. If this monitoring requirement will present challenges for you, be sure to tell your care team. They may be able to prescribe a medication other than warfarin or recommend a procedure, such as left atrial appendage closure, which may make it possible for you to avoid taking an anticoagulant.

    Taking Medications as Directed

    To be as effective as possible, medications must be taken as prescribed. In fact, sometimes not taking a medication as directed can have dangerous consequences.

    This means that you should take exactly the amount prescribed as many times as directed. It also helps to take your medications at the same time each day. If you develop a routine for taking your medications, you may find it easier to remember and keep track.

    You can find tips for taking medications as prescribed here on SecondsCount. Here are some articles to get you started:

    Tell Your Care Team About Any Side Effects

    Many medications have side effects. If your medications cause side effects that interfere with your day-to-day life or make it difficult for you to stick with your prescription, tell your care team. They may be able to make a change that is safe for you and will eliminate or reduce the side effects. It helps to take notes about the side effects that you experience. That way, you can answer any questions your care team may have, and the information you share may help them adjust your medication regimen to get it just right for you.

    If Cost Is a Worry, Ask for Help

    The high cost of medications is one of the most common reasons patients give for not taking their medicines. But when you consider what is at stake—your health and possibly your life—you must find a way to afford them. That’s why it helps to talk candidly with your care team. They can help you determine what your health insurance plan will (or will not) cover. To learn more about health insurance plans, visit the SecondsCount Guide to Health Insurance.

    We have also compiled 10 strategies for tackling concerns about the costs of medications. These are a good place to turn if you are concerned about costs, but they are no substitute for talking with your care team – including your pharmacist – about your concerns. Fortunately, there are several prescription assistance programs that you may be eligible for. Your care team can tell you about them.

    Know Your Pharmacist

    We often overlook one of the most important members of our healthcare team — our pharmacist. Your pharmacist can do much more than fill prescriptions. He or she can also answer questions about:

    • Health insurance
    • Generic drug options
    • Drug side effects and interactions
    • Drug safety
    • Discounts on medications and prescription assistance programs
    • Container (child-proof caps) and drug-dispensing issues
    • Large print drug information and instructions
    • Medication storage and disposal
    • The best times to take medication
    • Tools to help you remember multiple medications

    For help choosing a pharmacist, click here.

    Your Heart-Healthy Lifestyle

    No matter how well a medication works, the most important factor in its continued success is you. You cannot keep up your heart health without putting forth an effort. A heart-healthy lifestyle will provide your heart with optimal conditions for good health, and will allow your medications to have their maximum beneficial effect. Talk to your doctor about the following:

    Be sure to talk openly and honestly with your doctor and your medical team. Ask all of your questions, even questions you might think are trivial or embarrassing. Your care team is there to help you throughout your long-term journey toward heart health.

    Learn More

    For more information about atrial fibrillation, including various treatment strategies for managing symptoms and reducing the risk for stroke, visit the SecondsCount Atrial Fibrillation information center.