Long-Term Atrial Fibrillation Management
Some patients with atrial fibrillation (AFib, AF) cannot be converted back into sinus rhythm successfully, and every patient who is converted back into sinus rhythm does not necessarily remain in sinus rhythm. In fact, within a year, one-third to one-half of all patients have at least one recurrence of atrial fibrillation. Patients at increased risk of recurrent atrial fibrillation include those whose atria are enlarged (dilated) and those with heart failure.
Many medications are now available that are used to try to keep patients in sinus rhythm and prevent the recurrence of atrial fibrillation. These medications include the following:
- Amiodarone (Cordarone)
- Disopyramide (Norpace)
- Dofetilide (Tikosyn)
- Flecainide (Tambocor)
- Procainamide (Procanbid, Pronestyl)
- Propafenone (Rhythmol)
- Quinidine (Quinaglut, Quinidex)
- Sotalol (Betapace)
All of these medications have side effects and many require periodic monitoring.
Reducing Stroke Risk
Patients who are successfully converted from aAFib back into sinus rhythm are considered to be at risk for blood clot formation and stroke for 3 or 4 weeks. Blood-thinning medication is usually administered during this time. Blood thinners may cause bleeding, which may be serious.
Patients who cannot undergo conversion and those who cannot be successfully converted into sinus rhythm are maintained on long-term blood thinning therapy. Typically, this consists of the once-a-day administration of warfarin (Coumadin, Jantoven, generics) or a newer anticoagulant called rivaroxaban. In patients on warfarin, the blood is periodically monitored to insure it is "thinned" to the appropriate degree. Rivaroxaban, which also is taken once daily, doesn't require the frequent monitoring and dose-adjustment as warfarin.
According to guidelines issued by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society in 2014, other patientsfor example, most women with aFib and people over the age of 65also may be advised to take blood thinners. In fact, these guidelines suggest that blood thinning medications should be recommended for about 91 percent of all patients with atrial fibrillation and almost 99 percent of people with the condition who are over the age of 65 .
Many foods and medicinesparticularly antibioticscan affect the degree to which the blood is thinned. Patients who require long-term warfarin therapy should discuss with their doctor or health care provider which foods and medications they should avoid or take with caution.
In a select group of patients, aspirin therapy alone provides adequate thinning of the blood. Some patients (particularly those with coronary artery disease) may be treated with warfarin and aspirin.
According to research presented by the American Heart Association in April 2012, some patients with aFib who are on anti-clotting medications and stop taking the drugs are at higher risk for stroke or blood clot within a month. Patients should talk to their doctor if they are instructed to stop taking their medication, for example, because of side effects or an upcoming surgical procedure.
Patients who remain in atrial fibrillation may require long-term therapy with one or more medications that help prevent the heart rate from becoming too rapid. These medications may include beta blockers, calcium channel blockers, and digoxin.
- Beta blockers are used to slow the heart rate. They include:
- Atenolol (Tenormin)
- Bisoprolol (Zebeta)
- Carvedilol (Coreg)
- Metoprolol (Lopressor)
- Toprol XL)
- Nadolol (Corgard)
- Propranolol (Inderal, Inderal LA)
- Timolol (Blockadren)
- Calcium channel blockers have multiple effects on the heart and arteries. Two of these agents can be used to slow the heart rate in patients with atrial fibrillation. These medications include diltiazem (Cardizem) and verapamil (Calan, Calan SR, Covera HS, Isoptin, Isoptin SR, Veralan). Long-acting forms of these medications are available that are taken once or twice a day.
- Digoxin (Lanoxin) is often used in the treatment of patients with heart failure, because it can stimulate the left ventricle to contract and pump blood more vigorously. Digoxin also slows electrical conduction through the AV node, and can decrease the rate at which electrical impulses are conducted from the atria down into the ventricles.
AFib Not Caused by Heart Valve Problems
In December 2012, the FDA approved apixaban (Eliquis) to reduce the risk of blood clots and stroke in people with atrial fibrillation that isn't caused by heart valve problems. This medication is not used in people who have undergone heart valve replacement or those with aFib caused by a valve problem. The most serious risk associated with apixaban is bleeding. Premature discontinuation of the drug may increase stroke risk.
Edoxaban (Savaysa) was approved by the FDA in January 2015. This anti-clotting medication can be used to reduce the risk for stroke and blood clots in people with Afib not caused by a heart valve problem, and also to treat deep vein thrombosis and pulmonary embolism in patients previously treated with an anti-clotting injection or infusion.
Savaysa carries a Boxed Warning indicating that the drug is less effective in patients with impaired kidney function. Labeling information also indicates that premature discontinuation of the medication increases stroke risk and notes that spinal hematomas may develop in patients taking Savaysa who undergo spinal anesthesia or lumbar puncture (spinal tap). Common side effects include bleeding (which may be life threatening) and anemia (low red blood cell count).
Updated by Remedy Health Media