How Atrial Fibrillation (AFib) Is Treated

Atrial fibrillation (AFib) is an irregular, frequently rapid heart rhythm originating in the atria (the heart's upper chambers). During a normal heartbeat, the atria pump blood into the ventricles (lower heart chambers). However, in AFib, the atria quiver (fibrillate), so blood is not pumped as efficiently or powerfully into the ventricles.

Symptoms like palpitations or chest discomfort may arise with atrial fibrillation, and blood clots can develop within the atria and cause a stroke.

Atrial fibrillation has no definite cure, although its symptoms can be reduced and blood clots may be prevented. This article will review the various treatments for atrial fibrillation, including lifestyle changes, medications, and surgical procedures.

Atrial Fibrillation

Atrial Fibrillation Treatments Target the Cause

Atrial fibrillation is common, affecting an estimated 3 to 6 million adults in the United States. AFib increases with age and typically develops in people with underlying heart problems like high blood pressure (hypertension), coronary artery disease, heart failure, or heart valve disease.

Other triggers or risk factors for AFib are:

Numerous strategies exist for managing atrial fibrillation, including lifestyle behaviors, medications, and procedures. These strategies aim to reduce AFib symptoms and help prevent blood clots. Addressing the underlying cause of your AFib is another critical component of a person's treatment plan.

For example, a healthcare provider may prescribe medication to lower blood pressure, manage diabetes, or help a person quit smoking. Likewise, medication combined with a nutrition and exercise program may be advised to help a person lose weight.

In some cases, treating a specific condition (e.g., hyperthyroidism) or eliminating a trigger (e.g., alcohol) can result in the reversal of AFib.

Atrial Fibrillation Medications

Three types of medications are used to manage AFib:

  • Drugs to restore or maintain the rhythm of the heartbeat
  • Drugs to control the speed (rate) of the heartbeat
  • Drugs to prevent blood clots from forming

Heart Rhythm Control Medications

Drugs used to rest or maintain a normal heart rhythm (sinus rhythm) and decrease AFib-related symptoms are called antiarrhythmics.

Antiarrhythmics commonly used to treat AFib include:

  • Pacerone, Cordarone (amiodarone)
  • Tikosyn (dofetilide)
  • Tambocor (flecainide)
  • Rythmol (propafenone)
  • Betaspace (sotalol)

The downside of antiarrhythmics is that rates of recurrent atrial fibrillation are still reasonably high. Moreover, these drugs are associated with potentially serious side effects and complications.

For example, the commonly used antiarrhythmic amiodarone is associated with lung and thyroid gland toxicity, nerve and eye problems, and unpleasant gastrointestinal side effects like nausea and constipation.

Lastly, while rare, antiarrhythmic drugs can trigger the onset of dangerous ventricular arrhythmias.

Specialized Care

A primary care provider can manage many cases of AFib. However, due to the high-risk nature of taking an antiarrhythmic, people are usually followed closely by an electrophysiologist, a cardiologist with special training in managing abnormal heart rhythms. 

Heart-Rate-Control Medications

Medications to control heart rate slow the heartbeat. Compared to antiarrhythmics, heart rate control medications are associated with a lower rate of hospitalization and significant adverse events. That said, it can be challenging to lower the heart rate enough to relieve AFib symptoms.

Medications used in the rate control strategy include:

  • Beta-blockers like Lopressor or Toprol XL (metoprolol) or Coreg (carvedilol)
  • Calcium channel blockers like Cardizem (diltiazem) or Cala SR, Verelan, and Verelan PM (verapamil)
  • Digitalis or Lanoxin (digoxin), although periodic blood tests need to be performed to a therapeutic and non-toxic drug level

Medicines to Prevent Blood Clots

Since the atria cannot strongly pump blood into the ventricles in AFib, blood pools and may form clots. If a blood clot travels to the brain, it can lead to a stroke.

Blood thinners (anticoagulants) are drugs that reduce the risk of stroke by helping prevent blood clots from developing. There is a risk of bleeding when taking an anticoagulant, so not everyone is a candidate.

Anticoagulants used in AFib include:

  • A direct oral anticoagulant like Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban), Savaysa, Lixiana (edoxaban)
  • Jantoven or Coumadin (warfarin), a pill that requires monitoring with regular blood tests to ensure therapeutic levels

Selecting an AFib Medication Strategy

Choosing a medication strategy requires considering factors like age, duration of AFib, symptoms, and history of stroke or other health problems. In the end, some people take both heart rate and rhythm control medicines, and many people with AFib take an anticoagulant to help prevent stroke.

Surgical and Nonsurgical Procedures

Cardioversion, catheter ablation, pacemaker implantation, or various surgical procedures can also be used to manage AFib.

Cardioversion

Cardioversion is restoring the heart's normal rhythm and may be performed electrically or chemically, as follows:

  • Electrical cardioversion involves applying an electrical current to the heart to restore the heart's rhythm. The electrical current is delivered by paddles on a device called a defibrillator.
  • Chemical or pharmacologic cardioversion involves administering an antiarrhythmic through an intravenous line (IV) in a person's arm to restore the heart's rhythm. This type of cardioversion takes longer to work than electrical cardioversion.

A significant downside of electrical or chemical cardioversion is its risk of stroke from blood clots lodged in the atria.

As such, cardioversion is typically delayed until a person has been treated with an anticoagulant for three to four weeks. The anticoagulant helps any preformed blood clots stabilize or resolve. Anticoagulation is also given after the cardioversion, for at least four weeks, and often much longer.

Rarely, electrical cardioversion may be performed emergently in people with atrial fibrillation who are hemodynamically unstable, meaning their heart cannot supply their body's vital organs with adequate blood flow.

Catheter Ablation

Catheter ablation is a minimally invasive procedure that can correct atrial fibrillation by destroying the area of the heart that is sending abnormal electrical signals.

During the procedure, catheters (thin, flexible wires) are inserted into a blood vessel, usually in the groin area, and advanced into the heart. Heat (radiofrequency energy) or cold (cryoablation) are then used to ablate (destroy) tissue to create scarring to stop the abnormal signaling pathway.

While catheter ablation has the potential to cure AFib, complications may occur, such as bleeding, blood clots to the lung (pulmonary embolism), stroke, injury to the heart, and, although rarely, death.

Pacemaker Implantation

Pacemakers are implanted devices that send electrical impulses to the heart muscle to prevent the heart from beating too slowly. Pacemakers are typically used in people with AFib who also experience a slow heart rate (bradycardia) during treatment with antiarrhythmic medications or after catheter ablation.

A pacemaker may also be implanted in people with atrial fibrillation who experience sick sinus syndrome, in which the heart fluctuates between episodes of AFib and a slow heart rate.

Maze Procedure

The maze procedure is a surgery that creates lines of scars, like networks of paths in a maze, within targeted areas of the atria by applying radiofrequency or cold energy (cryoablation). The "maze" of scar tissue interrupts abnormal electrical signals to restore the heart's normal rhythm.

Traditionally, the maze procedure is performed in a person undergoing open heart surgery for another indication like coronary artery disease or heart valve disease.

The maze procedure can now be performed using minimally invasive techniques, where instead of a large incision (6–8 inches) in the chest, tiny cuts in between the ribs are used to access the heart with surgical tools.

How Successful Is the Maze Procedure?

The maze procedure has evolved over the years. The most recent version—the Cox-maze IV procedure—has a success rate (freedom from AFib) of 92% one year after surgery and 77% 10 years after surgery.

Left Atrial Appendage Closure (LAAC)

The left atrial appendage is a small pouch in the left atrium (upper left heart chamber), a common location of blood clots in people with atrial fibrillation.

Closing or sealing off the left atrial appendage surgically or with a Food and Drug Administration (FDA)–approved device (so blood cannot pool within it and clot) is typically performed in people with AFib who are at a high risk of stroke but cannot take blood thinners.

Overall, LAAC devices offer a promising alternative to long-term anticoagulation with a decreased bleeding risk. Still, LAAC is a surgical procedure associated with various complications, such as blood clotting around the device and fluid buildup around the heart sac (pericardial effusion).

Complementary Treatments for AFib

Complementary therapies have shown promise in helping improve symptoms of atrial fibrillation, namely yoga, acupuncture, and biofeedback. While these therapies can ease the burden of living with AFib and improve quality of life, they are not intended to replace standard AFib treatments.

Dietary supplements like omega-3 fatty acids, vitamins with antioxidant properties like vitamin C and vitamin E, and herbal supplements, such as berberine or cinchona bark, or the Chinese medicine Shensongyangxin, have also been considered for helping manage AFib.

Unfortunately, the scientific evidence supporting their benefit in managing atrial fibrillation is scant. Moreover, supplements, especially herbal products, may interact with AFib and other heart medications.

Avoid Harm

To avoid adverse reactions, do not take any supplement, vitamin, or herbal medicine without discussing it with a healthcare provider first.

AFib Lifestyle Changes

Healthy lifestyle behaviors play a crucial role in living with atrial fibrillation, as they can help reduce AFib episodes and unpleasant symptoms.

Lifestyle behaviors found to be beneficial in AFib care include:

  • Performing regular moderate-to-vigorous physical activity with a goal of 210 minutes per week
  • Maintaining a healthy weight
  • Stopping smoking
  • Abstaining from alcohol
  • Sticking to healthy eating pattern
  • Avoiding caffeine if it triggers your symptoms

Can AFib Be Cured?

With some exceptions (e.g., reversible AFib triggers like alcohol), atrial fibrillation is typically a recurrent and lifelong condition. The good news is that despite the lack of a definite cure, AFib can be managed well, so many people experience long, happy, and active lives.

If you or a loved one has atrial fibrillation, it's normal to feel worried or overwhelmed, especially when first diagnosed.

Consider these valuable coping strategies as you navigate a diagnosis of atrial fibrillation:

  • Communicate concerns with your healthcare provider, and don't hesitate to ask questions.
  • Seek out comfort and connection from loved ones or a support group.
  • Be open to changes in lifestyle and social activities to improve symptoms.
  • Practice self-compassion and relaxation techniques like journaling or meditation.

Summary

Atrial fibrillation (AFib) is an irregular, usually rapid heart rhythm originating in the atria (the heart's upper chambers). It causes the atria to quiver, or fibrillate, preventing blood from being strongly pumped into the ventricles (the heart's lower chambers).

Treatment of AFib involves multiple components, including cardioversion to restore the heart's normal rhythm and long-term medications to slow the heart's speed, maintain the heart's normal rhythm (antiarrhythmic), and prevent blood clots (anticoagulants).

Catheter ablation (to scar the heart to disrupt abnormal signaling pathways), the use of a pacemaker (a device to prevent the heart from beating too slowly), and the maze procedure (where a pattern of scar tissue is created within the atria) are additional ways to manage AFib.

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Colleen Doherty, MD

By Colleen Doherty, MD
 Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis.