Dear Dr. Roach: I am an 88 year old female in relatively good health. A year and a half ago I had atrial fibrillation and had two cardioversions. (The first lasted a year; the second only lasted three months.) The diagnosis is paroxysmal atrial fibrillation.
My cardiologist recommended a third cardioversion, which would require taking 400mg of Multaq twice a day before the procedure, and continuing to take this medication for the rest of my life (assuming the procedure is successful; otherwise, a more potent drug would be mandatory). Or — my choice — I can do nothing, as long as I can bear these episodes of fatigue, shortness of breath and palpitations. Right now I should be in “remission” as I have no symptoms. (However, when I take an ECG test, it still shows that I have atrial fibrillation.) My blood pressure, cholesterol, triglycerides, etc., are all at good levels. My question: In your opinion, if I choose to “tolerate” intermittent episodes of atrial fibrillation, won’t this eventually lead to the development of congestive heart failure?
Answer: The main concern here, besides reducing symptoms (which you don’t normally have), is the development of a stroke, so anyone with atrial fibrillation is considered for anticoagulation. There are other concerns, including the development of heart failure. People with atrial fibrillation who have frequent and rapid heart rates are at risk of developing heart failure. “Paroxysmal” atrial fibrillation comes and goes: there is about the same risk of stroke with paroxysmal atrial fibrillation as with continuous atrial fibrillation.
Besides drugs to reduce the risk of stroke, there are two main strategies called “rate control” and “rhythm control”. Cardioversion (using electricity to break the cycle of atrial fibrillation and return the heart to a normal rhythm), followed by treatment with antiarrhythmic drugs like dronaderone (Multaq), is the control strategy for the rhythm. Rhythm control is usually preferred in people at higher risk for heart disease, especially if they haven’t had atrial fibrillation in more than a year. People with symptoms or a history of heart failure usually do well with a rate control strategy. Otherwise, a rate control strategy is reasonable. As long as the rate is controlled properly (which may require you to wear a device to monitor your heart rate for several days or weeks), you are at a low risk of developing heart failure.
It is very important to know how often these episodes of palpitations occur and how fast your heart rate is. Medications can be used to slow the heart rate (rate control strategy), but sometimes people continue to have symptomatic episodes despite medications to slow the heart rate, in which case the rate control strategy is recommended.
There are still other options. One is a procedure to destroy or isolate the part of the heart responsible for atrial fibrillation, such as a “catheter ablation” procedure. Some people will need a pacemaker after these types of procedures. The Watchman device reduces the risk of stroke, but does not affect rhythm or rate.
Dr Roach regrets that he cannot respond to individual letters, but will incorporate them into the column whenever possible. Readers can email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.