In last month’s column, definition and etiology of Atrial Fibrillation (A-Fib), the most common arrhythmia was discussed. Because A-Fib is fast and irregular at its onset, the symptoms may include palpitation, shortness of breath, dizziness, fatigue, and chest pain.
Some patients may not feel the symptoms and the arrhythmia may be incidentally discovered. Typically younger patients are more symptomatic. Once, the rate of A-Fib is controlled, symptoms fade away.
The consequence of A-Fib, rather than the arrhythmia itself is the most concerning, namely stroke. Because the atrium loses its contractility, the blood tends to stagger and doesn’t flow. Therefore, clot may form and may travel to brain and cause stroke.
Heart Failure is another common and concerning consequence that usually is due to rapid A-Fib. In fact, Heart Failure is a risk factor for high incidence of A-Fib which then becomes a vicious cycle; hence the medical saying: A-fib begets Congestive Heart Failure (CHF) and CHF begets A-Fib.
Patients with newly discovered A-Fib should undergo certain tests namely Echocardiogram to evaluate for any structural heart disease and adequacy of heat pump function. Blood test is done to rule out thyroid disease and a thorough history is taken to address any underlying and possibly reversible culprits.
The treatment of A-Fib falls into two categories. First is to control the rate and slow the rapid heart rate. This is accomplished typically with medications such as Metoprolol, Diltiazem, or Digoxin, etc.
Sometimes combinations of medical therapy are required to control the rate. Once the rate is controlled, some de novo A-Fib may revert back to normal rhythm. If the rhythm remains in A-Fib, an attempt may be taken to revert the rhythm to normal by a process called cardioversion which is either chemically with medication or electrically by applying a shock of electricity to reset the electricity and break the A-Fib rhythm.
This is done under anesthesia in hospital. Prior to this procedure, Trans-esophageal Echocardiogram (TEE) is required to rule out existing blood clot which then cardioversion becomes contra-indicated.
In some people the rhythm remains in A-fib despite many attempts and for symptom relief, A-Fib ablation which is modifying electrical property of Atrial tissue may be considered. This is usually reserved for younger patients and in hands of experienced centers and operators.
Another scenario may come into play called Sick Sinus Syndrome or Tachy-Brady syndrome which happens in older individual with fast and slow rhythm simultaneously. A pacemaker is required for the slow heart rate and medication as discussed above for the fast heart rate.
The other important factor in treatment is to decrease the risk of stroke. Risk factors of stroke in A-Fib are based on presence of Age over 75, Diabetes, Heart Failure, Hypertension, and history of previous stroke. If any one of the above or combination exists, then blood thinner medication, Warfarin (Coumadin) is prescribed to decrease the risk. The level should monitored meticulously. Overtreatment increases risk of bleeding. A new exciting medication is under investigation and may be very soon be available as efficacious as Warfarin without the need of constant monitoring. If no risk factors are present then Aspirin or Plavix should be used.
A-Fib is common and may be paroxysmal. Patients with symptoms and risk factors as discussed should seek medical attention to discover to investigate if A-Fib is present and to prevent stroke and detrimental consequences of this common arrhythmia.
Dr. Omid Kohani is a clinical cardiologist with advanced training in diagnostic cardiovascular imaging in Fresh Meadows. He has active affiliation with Long Island Jewish Hospital, North Shore University Hospital of Manhasset, and Beth Israel Medical Center in Manhattan. He is located at 75-68 187th Street, Fresh Meadows, 718-454-2500.
