The treatment for atrial fibrillation (AF) may change from person to person, as there are several options to choose from. Your doctor or healthcare professional will explain to you the benefits and potential risks or side effects of each treatment to help you decide which treatment(s) would suit you best.

Treating AF will help you:

• lower your risk of having a stroke
• control your symptoms of AF by controlling your heart rate and rhythm

Lowering risk of Stroke

Based on an assessment of your AF, doctors may recommend an anticoagulant or “blood thinning” medicine to help lower your risk of stroke through preventing the formation of blood clots. There are two general classes of blood thinners that can be taken in tablet form: Warfarin and Novel Oral Anticoagulants.

The decision to start all blood thinning agents is considered very carefully for each individual balancing your bleeding risk against your risk of stroke. Your health practitioner will estimate the risks of both and discuss what may be right for you.

While anticoagulants lower your risk of stroke, they don't remove all risk, so it is important that you are aware of the signs of a stroke and if you notice any, you call 111 immediately.

Warfarin

What can it do for me? - Warfarin is probably the most well recognised blood thinning agent which has been used for many years to lower the risk of blood clots in people with AF. 

It is very effective at reducing the risk.  People with AF on Warfarin are around two thirds less likely to have a stroke than people not taking any blood thinning medication.

What’s the down side? –  Warfarin must be taken once a day, every day. Its effect can be influenced by other medication and even your diet so there is need for ongoing monitoring.  Your doctor won’t know the dose you will need until you start taking the medication so it sometimes takes days or even weeks to get the dose right. Regular blood tests are required to monitor the time it takes your blood to clot. By reducing your risk of clotting Warfarin does unfortunately put you at risk of bleeding elsewhere. 

It is estimated that the risk of having a major bleed, requiring admission to hospital, occurs in up to 3% of people on Warfarin per year. On rare occasions these are fatal. Serious bleeds are treated with Vitamin K and other agents.

Dabigatran

What can it do for me? – Dabigatran is a newer agent used to prevent clotting.  The dose does not need to be adjusted and there is no monitoring required, so no blood tests needed. It also is not effected by food types and has less interactions with other medications.

It has two possible dosages and must be taken twice a day every day.  In comparison with Warfarin the 150mg dose is approximately one third more effective at reducing strokes with similar chance of bleeding complications. The 110mg dose is similar at reducing strokes but has a lower risk of bleeding complications. The lower dose tends to be used in older patients or when kidney function is not normal.

What’s the down side? – Dabigatran can cause some stomach side effects like indigestion and heartburn.  Similar to Warfarin, by reducing your risk of clotting, Dabigatran increases your risk of bleeding.  The effect of the drug wears off quite quickly on stopping, and a specific reversal agent exists for serious bleeds.

Aspirin

Aspirin is not recommended to reduce stroke risk in atrial fibrillation.

Controlling AF Symptoms

Managing your AF often involves taking medication prescribed by your doctor or health professional. Your medication can also help lower your risk of developing complications linked to AF. Sometimes your doctor might have to make some changes to your medication to find the most suitable treatment for you and to get the best control of your symptoms. Some of these medications will need to be taken in the long term or, even, over a lifetime.

It is important that you understand:

• What your medication does
• How to take your medication safely
• How long you will have to take it for
• Side effects to look out for and what to do if you develop side effects

Make time to discuss with your doctor, nurse or pharmacist both the benefits and risks of your medication and why you need to take them.

Side effects

Your doctor may prescribe medicines to help improve your AF rate and your symptoms. Like most people, you will probably not experience any side effects at all. If you do, they can sometimes disappear after a while. If you think you are experiencing side effects to any medication, make sure to contact your GP or healthcare provider. They may be able to change the dose or prescribe a different medication. Do not stop medications unless advised by your healthcare professional.

If you’re worried about side effects, speak to your doctor or pharmacist.

Controlling heart rate

Your AF symptoms can be treated through rate control, which uses prescribed medication to control your heart rate. This will make your heart beat more slowly, even if the heartbeats remain irregular. Your heart can function well with atrial fibrillation as long as the rate is controlled.

Medications that control heart rate include:

Beta Blockers 

• What can it do for me? – Beta Blockers prevent the adrenaline speeding up your heart which in turn lowers your blood pressure and heart rate. If you have heart failure, it can stop it from getting worse.
• What do I need to look out for? – You may feel tired and/or have cold feet and hands. Other effects might include nightmares, dizziness, skin rash, light-headedness or pins and needles.  You may feel worse to start with but this usually goes away within a few weeks. If you have erection problems after starting this medication, talk to your doctor.
• What checks do I need? – Your blood pressure (BP) and heart rate should be monitored by your GP/nurse at each visit, and more frequently if your dose changes.
• What else do I need to know? – You will generally need to start on a low dose and then gradually increase. This will be set by your doctor. Any change of dose should be made slowly as recommended by your doctor.

Do not stop taking a beta-blocker suddenly without first consulting your doctor. It is important not to stop beta-blockers suddenly or run out of medication. When you take a beta-blocker regularly, the body gets used to it. So, if you suddenly stop taking it, it can sometimes cause problems such as palpitations, a rise in blood pressure, or persistent angina pains. If you do need to stop taking a beta-blocker, your doctor may advise a gradual reduction in dose.

Calcium Channel Blockers 

• What can it do for me? – Calcium Channel Blockers like Diltiazem, Felodipine, Amlodipine and Verapamil have a number of effects on the heart. They help slow down the heart rate by reducing the number of electrical impulses that pass through the atrioventricular (AV) node into the lower heart chambers (ventricles). They are used to slow down the heart rate in patients with AF and to reduce the strength with which the muscle cell contracts.
• What do I need to look out for? – Constipation, headaches, swollen ankles and tiredness are the most common side effects.
• What checks do I need? – Your blood pressure and heart rate should be monitored.
• What else do I need to know? – You should avoid grapefruit or grapefruit juice while taking diltiazem. There is a chemical in grapefruit and grapefruit juice that prevents the absorption of Diltiazem. Levels of these drugs can become too high and cause severe side effects.

Digoxin

Digoxin is commonly used to control the rate of AF. It slows the heart rate and increases the pumping force (contraction) of the heart. It can help to reduce symptoms of AF such as breathlessness and palpitations.

• What do I need to look out for? – Digoxin may occasionally cause a loss of appetite, fainting, nausea and vomiting. On rare occasions, it may cause painful, enlarged breasts in both men and women.
• What checks do I need?  – You may need to have regular blood tests to ensure you have correct levels of digoxin in your blood.

Controlling heart rhythm

• For some people  AF may be treated through rhythm control, which tries to restore your heart rhythm back to its normal state. The type of treatment suitable for you will depend on your type of AF, how long you have had it, whether you are symptomatic, and any other health conditions you may have. Rhythm treatment may benefit those who have symptomatic AF.

Cardioversion

Cardioversion is a procedure used to try to reset your heart back to its normal rhythm. There are two types of Cardioversion:

• Electrical Cardioversion

This procedure, also called Direct Current (DC) cardioversion, uses a defibrillator to give out a controlled electrical shock to the heart to try to restore a normal rhythm. The electrical impulse is sent to your heart through your chest wall using pads or electrodes placed on your chest.

The electrical impulse disrupts the abnormal rhythm for a split second, allowing your heart to resume a normal rhythm. The procedure takes a few minutes and you will be put to sleep to avoid any discomfort.

Electrical Cardioversion can be a successful form of treatment for people with symptomatic AF, however it is not always the most suitable one. There is also the risk of your AF returning. If that happens, this treatment may be repeated.

• Pharmacological Cardioversion

This treatment, also known as chemical cardioversion, uses medicines (called anti-arrhythmics) to try to bring back a normal rhythm to your heart. Your healthcare professional may give you these anti-arrhythmics in an oral form (tablet) or intravenously (IV – through a vein) while your heart rhythm is closely monitored.

Common Anti-arrhythmics include :

Amiodarone -  Amiodarone can be very effective in controlling abnormal rhythms such as AF.

• What I need to look out for – side effects are not common but Amiodarone can cause issues with your thyroid, lungs or liver. It can also make you sensitive to sunlight.
• What checks do I need? – You will require regular blood tests to check thyroid and liver function.
• What else do I need to know? – If you are exposed to sunlight you should use a high factor sunblock and wear sun-protective clothing.

Flecainide – Flecainide may be used for heart arrhythmias and is only prescribed by a specialist.

• What I need to look out for – Generally people don’t experience any side effects but Flecainide can sometimes cause nausea, blurred vision or dizziness when used for the first time.

Electrophysiology Studies and Catheter Ablation

Electrophysiological (EP) study is a procedure that allows your doctor to take a closer look at your heart's electrical activity. This may help the doctor better understand where the abnormal rhythm is coming from.

Your doctor will only recommend that you have an EP study if he or she thinks the benefits outweigh the risks.

During the EP study into the cause of your AF, your doctor may want to treat the problem at the same time using Catheter Ablation, a treatment that may help control or correct an abnormal heart rhythm, during the procedure.This involves sending energy through a specialised catheter to destroy (ablate) the areas inside the heart, which are causing the abnormal rhythm. This energy may be either radiofrequency (hot) or cryoablation (cold).

This type of treatment does come with risk and is generally a possible option for people with significant symptomatic AF. If your doctor thinks you may benefit from an EP study and ablation they will discuss the benefits and risks with you. 

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