• When Atrial Fibrillation Medications Don’t Work


    Atrial fibrillation (Afib or AF) is the most common type of heart problem. In fact, the American Heart Association estimates that about 2.7 million people are living with Afib. If you or someone you care about has Afib, then you may be concerned about the day-to-day challenges that come with managing Afib. You may also be worried about the risks that accompany Afib, including increased likelihood for developing heart failure or having a stroke

    No doubt, Afib is a heart condition that requires careful management by you and your medical team. Fortunately, today there are a number of ways that Afib can be controlled so that it doesn’t disrupt your life and, for many people, there are medications and other treatment options that can help reduce Afib-related risks. A good place to start is understanding what Afib is and what causes it. Click here to learn about Afib.

    Once you understand how the heart is affected during an Afib episode, you’ll probably want to know what can be done to fix or at least manage your Afib. The answer to this question generally depends on how severe your Afib is, how it is affecting your daily life, and how much your Afib is increasing your risk for stroke or other serious complications. It’s very likely your medical team will urge you to make some heart-healthy lifestyle changes and, depending on your situation, they may also recommend medications, a medical procedure or surgery.

    Lifestyle Changes for Managing Atrial Fibrillation

    In addition to receiving medical care, you can do your part to help manage Afib by making the changes to your lifestyle that can help ensure good heart health.

    • Eating a healthy diet: A heart-healthy diet is rich in fruits, vegetables and whole grains. It is limited in salt and solid fats. Your healthcare team may suggest working with a dietician or nutritionist to develop an eating plan. You can use the resources on this website to help you get off to a good start.
    • Get to a healthy weight and stay there: People who are overweight or obese are greater risk for many heart-related problems. Your medical team can help determine what weight to strive for and help you develop a plan for reaching it.
    • Include physical activity in every day: Getting regular exercise is one of the keys to heart health. Most doctors recommend incorporating more movement into daily life, such as taking the steps rather than an elevator or escalator. Be sure to check with your doctor before embarking on any exercise plan.  Tips for getting physically active can be found in the SecondsCount Physical Activity, Exercise & Your Heart Center.
    • Quit smoking: Tobacco use is one of the leading causes of heart health problems. If you don’t smoke, don’t start. If you do smoke, now’s the time to quit. You can learn more about quitting smoking on this website. Your healthcare team is a great resource you can use to help you succeed. Talk with your doctors and nurses about quitting!
    • Keep blood pressure and cholesterol in check: High blood pressure and cholesterol (lipids) buildup are silent threats to the heart. Without you even knowing it, high blood pressure, high “bad” cholesterol or low “good” cholesterol may be taking their toll on your heart and blood vessels. Over time, these conditions can lead to heart attack, strokeperipheral artery disease and other forms of cardiovascular disease.
    • Enjoy alcohol and caffeine in moderation (or eliminate them entirely): Too much alcohol or caffeine can spell trouble for the heart, particularly when used in excess.

    Medications for Atrial Fibrillation

    Treatment for atrial fibrillation has two goals:  stroke prevention and control of Afib symptoms.

    To help prevent stroke, doctors prescribe blood-thinning (anticoagulant) medications. These medications help keep blood flow from slowing down in the area of the heart called the left atrial appendage (or LAA), as can happen during atrial fibrillation. If the blood flow gets sluggish and clots form, a clot (also called thrombus) can travel from the heart and become lodged in the brain. The clot can block blood flow and may cause a stroke. People who have atrial fibrillation and high blood pressure (hypertension), diabetes, older age, or a history of stroke or heart failure are recommended to take blood-thinning medications. Their risk of bleeding while taking blood-thinners is lower than their risk of stroke without blood-thinners.

    The blood-thinning medications used to help prevent the formation of blood clots include the following

    The symptoms of atrial fibrillation are produced by the irregular heart rhythm and because it often causes the heart rate to get very fast. This is why doctors often prescribe medications aimed at rate control or rhythm control. In some cases, the medication is used for control of both.

    • Beta blockers are a class of medications that are 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. Diltiazem is an example of a calcium channel blocker. These drugs affect a channel in the cells of the heart 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.
    • Digoxin is an older drug that is still used to assist in the overall heart rate control for people with Afib.
    • Amiodarone is a medication prescribed to restore the heart to normal sinus rhythm. Or it may be used to keep the heart in normal rhythm after a procedure called electrical cardioversion, where the heart is shocked into normal rhythm. Sotalol may be used for rhythm management.
    • Propafenone and flecainide are referred to as class IC medications. Class I medications effect 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.
    • Quinidine may be used for rhythm control.
    • Dronedarone is a rhythm control medication.

    If you are a good candidate for medication, your doctor will work with you to decide on the appropriate medication and treatment plan for you.

    If Medications Fail to Control Atrial Fibrillation

    Following a heart-healthy lifestyle and taking medications as prescribed works for many people who have Afib. Unfortunately, this strategy doesn’t work for everyone. And, for some people, lifestyle changes and medications work for a while but may stop being effective over time. Other people struggle with taking Afib medications. If you need help making healthy lifestyle changes or if you are having trouble taking your prescribed medications, don’t be embarrassed. You are not alone. Many people who take heart medications need help. The good news is that your medical team may be able to help you.

    • They may be able to refer you to a cardiac rehabilitation program, which helps people with heart problems to make (and stick with) healthy habits. You can learn more about cardiac rehab here.
    • It’s also possible that your medications could be adjusted so that you find it easier to take them. This website includes several articles on how to keep track of your medications and how to work with your pharmacist and other healthcare providers to make taking medications easier. Click here to check them out.

    If it turns out that your Afib can’t be well-managed with heart-healthy lifestyle changes and medications, don’t give up. Your healthcare team should be able to work with you to develop a treatment plan that addresses how to manage your heart’s rhythm and how to reduce the risk of blood clots for stroke and other complications.

    Procedures & Surgeries for Managing Atrial Fibrillation

    Today, there are a number of treatment options for restoring the heart to normal rhythm. These include the following:

    • Electrical cardioversion: While the patient is under sedation, the doctor administers a brief shock to the heart, which resets the heart to its normal rhythm. More information about electrical cardioversion can be found here.
    • Catheter ablation: If the cause of your Afib is one or more “hot spots” that trigger the heart to quiver (fibrillate), you may consider catheter ablation. In this procedure, a specialist called an electrophysiologist guides long, slender tubes (catheters) through the blood vessels to the heart. Once the catheter has reached a “hot spot,” the electrophysiologist zaps the spot with either heat or cold. This destroys the cells that are causing the irregular heart activity. Click here to learn more about catheter ablation.
    • Pacemaker implantation: In some cases, particularly with sick sinus syndrome (also known as sinus node disease or sinus node dysfunction), the medical team may recommend implanting a pacemaker to assist in keeping the heart beating in a normal rhythm. A pacemaker is a small electronic device that is implanted into the chest surgically. It produces electrical impulses that stimulate the heart to beat at a normal rate. There are limitations to how precisely medications can control heart rate. Sometimes medications can’t slow the heart down enough and other times they may slow it too much. This is where a pacemaker may help by “backing up” the medications. A pacemaker can help stimulate the heart to beat more quickly if it’s beating too slowly or it may prevent a heart rate that is way fast. In this respect, it helps to support the heart’s own natural electrical impulses. Click here for more information about pacemakers.
    • Atrioventricular (or AV) node ablation: In AV node ablation, radiofrequency energy is applied to the pathway in the heart between the upper heart chambers (the atria) and the lower heart chambers (the ventricles). The energy is directed at the area called the atrioventricular node to destroy the tiny amount of tissue that is conducting the irregular Afib impulses to the ventricles. Usually, a small pacemaker is also implanted help the heart maintain normal rhythm.
    • Surgical maze procedure:  If you are scheduled for open-heart surgery to treat another condition, such as a faulty heart valve or blocked arteries, your heart surgeon may also perform a surgical maze procedure to treat your Afib. The surgeon will make tiny incisions in the upper chambers of the heart. These incisions will heal but they leave behind scar tissue. Why would you want scar tissue in your heart? Because scar tissue does not carry electrical impulses. In fact, it disrupts the signals that would otherwise stimulate the heart to go into Afib.

    Procedures for Reducing the Risk of Stroke

    Some people have atrial fibrillation that cannot be eliminated or even adequately controlled. In these situations, the healthcare team may focus on options that reduce the risk for stroke. Left atrial appendage (LAA) closure (also known as LAAC or LAA closure) is a procedure that seals off an area of the heart called the left atrial appendage, or LAA. The LAA is a small sac positioned on the upper left side of the heart, just off of the upper left heart chamber. The LAA is the section of the heart where blood is most likely to collect during Afib episodes. When the blood gathers in the LAA, blood clots can form. If even one blood clot escapes the LAA and travels to the brain, an ischemic stroke can occur. A stroke is an emergency that requires immediate medical attention to restore proper blood flow to the heart. Depending on how severe the stroke is or how long the blood flow to the brain is disrupted, a stroke can cause disability or even death.

    The goal of LAA closure is to seal off the LAA completely so that blood cannot enter or leave the LAA sac. There are different LAAC techniques, including sewing sac closed with a tool (LARIAT) or implanting a tiny device (WATCHMAN or AMPLATZER Cardiac Plug) in the opening of the LAA. Both of these procedures are considered to be minimally invasive – meaning the patient does not have to undergo open surgery.

    You can learn more about LAAC procedures in the SecondsCount Left Atrial Appendage Closure Center.