Treatment Options for Atrial Fibrillation Patient Information

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1 Patient Information Treatment Options for Atrial Fibrillation Page 1 of 8 Treatment Options for Atrial Fibrillation Patient Information Emory University Hospital Midtown Cardiac Electrophysiology Service Background: Atrial fibrillation (Afib) involves the abnormal and very rapid beating of the upper chambers (atria) of the heart that makes the rest of the heart beat fast, irregularly and inefficiently. Afib usually starts in the wall of the left upper chamber (left atrium) and then spreads across both atria and eventually down to the bottom chambers (ventricles) that pump blood to the rest of the body. Some Afib begins in the right atrium, travels to the left atrium, and then to the ventricles. Afib occurs mostly in patients who have known heart disease, either heart failure, abnormal heart valves, or coronary artery disease. Other patients with Afib may have no obvious heart disease, but a history of high blood pressure, obesity, lung disease, thyroid disease, or sleep apnea. The treatment of Afib includes identifying and treating any of the underlying risk factors. Your physician may order an echocardiogram to look at the heart valves and determine the size and function of the heart chambers, thyroid studies, pulmonary function tests, or a sleep study. Afib produces uncomfortable symptoms in many patients. It interferes with physical activity, causes fatigue, shortness of breath, lack of energy, or uncomfortable palpitations. In some patients, prolonged Afib may lead to blood clots forming in the heart that can break loose and cause a stroke or damage other vital organs. Blood thinners: The most important treatment for Afib involves using blood thinners like warfarin (Coumadin) to prevent blood clots and reduce the chance of stroke in those patients who have an increased risk of blood clot formation. Newer drugs like dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) can replace warfarin in many patients. Newly developed devices that seal the pouch of the left atrium where most clots form (left atrial appendage) can also reduce the chance of stroke. All the other remaining treatments for Afib focus on reducing symptoms and improving quality of life. Not all patients with Afib need to take blood thinners. Those who have low risk for stroke may be better off without the risk of bleeding complications. We use a scoring system (CHADSVasc2) to calculate each patient s risk for stroke. The score looks for a history of C (congestive heart failure), H (hypertension), A (age > 75 men; > 65 women), D (diabetes), S (previous stroke or TIA), and Vasc (vascular disease) to determine who needs to take blood thinners. We will discuss your risk score with you and whether you need to take blood thinners. Aspirin alone, or in combination with clopidogrel (Plavix) does not prevent stroke due to Afib as effectively as warfarin/coumadin, dabigatran, rivaroxaban, or apixaban. So, we do not use aspirin or clopidogrel as substitutes in patients needing blood thinners.

2 Patient Information Treatment Options for Atrial Fibrillation Page 2 of 8 Rhythm control: Physicians usually first try giving drugs to patients with Afib to keep the heart in rhythm, or when patients go into in Afib, to control how fast the heart beats during Afib in an effort to reduce symptoms. Often, we perform a cardioversion, a procedure that shocks the heart back to the normal rhythm. We might give you an anti-arrhythmic drug before cardioversion so that the drug will increase the chance that the heart stays in rhythm. We may repeat the cardioversion, when practical, to put you back in rhythm if the Afib recurs. Many patients do well staying on drugs that keep them in rhythm with occasional cardioversion. The drugs we most commonly use to keep the heart in rhythm are: Amiodarone (Cordarone), flecainide (Tambocor), sotalol (Betapace), propafenone (Rhythmol), dofetilide (Tikosyn), disopyramide (Norpace), and dronedarone (Multaq). These drugs can suppress many episodes of Afib. The success of drug therapy in preventing Afib varies from patient to patient, but averages around 50%. Some patients have rare occurrences of the fibrillation that we treat by repeating the cardioversion. The cardioversion is safe and causes no damage to the heart. We give you a strong sedative to be comfortable during the cardioversion. All anti-arrhythmic drugs used to treat Afib have potential side effects. They may trigger more dangerous rhythm problems, visual disturbances, fatigue, headaches, etc. Amiodarone, the most effective drug for suppressing Afib, can damage your lungs, liver, thyroid, and affect your vision. The US FDA has not approved amiodarone for the treatment of Afib. Physicians use it off-label since it suppresses Afib in patients with significant heart disease more safely and effectively than any other drug. Rate control: When the heart stays in Afib despite other treatment, the upper chambers of the heart will often inappropriately speed up the heart beat. Drugs called beta-blockers (metoprolol, nadolol, and atenolol) and calcium channel blockers (verapamil and diltiazem) prevent the Afib from driving the heart too fast by slowing down the number of impulses from the upper chambers that reach the lower chambers. Some patients can remain in Afib with a controlled heart rate and do well just on these drugs and on blood thinners. Once we reduce the risk of stroke with blood thinners, the only reason to treat Afib is to reduce symptoms from the irregular and inefficient heartbeat. But, if during Afib, the heart continually beats very fast for a long period of time, the fast beating can actually weaken the heart. Keeping the heart rate under control during Afib prevents, or reverses, the weakening caused by the fast beating. When drugs fail to keep the heart in rhythm, or when patients cannot tolerate the side effects from the drug, other procedures may help patients with symptoms from Afib. These procedures include ablation of the Afib, ablation of the AV node or His bundle with a pacemaker implant, and heart surgery for Afib. The vast majority of patients with Afib need only medical treatment that includes antiarrhythmic drugs, rate control drugs, and blood thinners. However, a minority of patients may need additional treatment options. AV node ablation: We perform His Bundle/AV node ablation to stop the Afib from making the heartbeat too rapidly or irregularly. First we try to control the rate with the drugs mentioned above. However, when those drugs fail to slow down the heart, we may recommend the AV node ablation. The procedure uses a catheter to destroy the fiber in the heart that transmits the impulses from the upper

3 Patient Information Treatment Options for Atrial Fibrillation Page 3 of 8 chamber to the lower chambers. It requires that we implant a permanent pacemaker (if you don t already have one) to prevent the heart from beating too slowly. Once we destroy that fiber, we cannot reverse it. Your heart stays in Afib, but you just cannot feel it. The pacemaker controls your heart rhythm. You still need to take blood thinners since the atria continue to fibrillate, but we can usually stop many of the other medicines. We usually perform this procedure when all other treatments fail to control Afib. Surgery: Surgery on the heart can sometimes correct the electrical abnormalities in the heart that cause Afib. The first one of these surgeries to be developed, the MAZE procedure, uses open-heart surgery to cut lines in the heart to cure the Afib. Surgeons have developed other ways to operate on the heart to prevent Afib. Some surgical procedures for Afib are done at the time of other heart surgery, like bypass or valve surgery, in patients who have symptoms from Afib. Other surgeries can be done specifically to treat Afib. Afib surgery uses general anesthesia and can be done through openings in the chest or between the ribs to get access to the surface of the atria directly. Some types of Afib surgery also require the need to ablate some of the target areas using catheters placed into the heart during a second hybrid procedure. Some patients have Afib surgery instead of catheter ablation, and others have surgery after attempts at ablation failed. Your physician will discuss with you whether to consider surgery for Afib as an option. Afib ablation: Procedures that use catheters to ablate the Afib provide an alternative to open heart surgery. The ablation procedure involves inserting catheters into the heart through punctures in a vein in your leg. We give you sedation, but we do not routinely use general anesthesia. We move the catheters into the heart and push them across the membrane (atrial septum) that divides the right and left upper chambers into your heart to enter the left upper chamber (trans-septal catheterization). Once inside the left upper chamber we give you large doses of blood thinners by vein to prevent clots from forming during the procedure. We use electrical recording/mapping tools and a computer that help guide us while we make a series of electrical burns into the wall of the heart chamber. These burns destroy the abnormal areas that trigger Afib. The target areas usually sit in tissue near where veins coming from the lung enter the left atrium (pulmonary vein isolation). We also isolate other areas of abnormal electrical activity that trigger the fibrillation (circumlinear left atrial ablation), and target other areas with abnormal electrical activity that triggers Afib. Afib ablation uses either radiofrequency current to burn the target areas or cryo lesions to freeze the target areas in the atrium. The Emory electrophysiologists have the capacity to use either technique, and we will discuss with you the advantages and disadvantages of each technique and the one your physician thinks is best for you. Blood thinners after ablation or surgery: Patients often ask if ablation of Afib eliminates the need to take blood thinners that prevent stroke. All patients must take warfarin/coumadin or one of the new blood thinners for at least one month after the ablation procedure. Those patients younger than 75 and with no evidence of heart disease can usually stop blood thinners after one month. We do not have any evidence that ablation or surgery allows us to stop blood thinners in elderly patients, or those with enlarged hearts, diabetes, previous stroke, or abnormal heart valves. Those patients should remain on blood thinners to avoid the risk of stroke. We will evaluate each patient s situation individually and discuss the risks and benefits of stopping blood thinners beyond 30 days after the ablation.

4 Patient Information Treatment Options for Atrial Fibrillation Page 4 of 8 Please remember that the reason to undergo Afib ablation (or surgery) is to eliminate the symptoms caused by Afib. If you have no symptoms from Afib, if you can t tell whether you are in or out of the normal rhythm, or if the Afib has not contributed to developing heart failure, you should not consider having Afib surgery or ablation. You should not undergo ablation or surgery thinking that it will eliminate the need to take blood thinners if you have Afib with an increased risk for stroke. If you want alternatives to taking blood thinners, you might be a candidate to receive a device that seals off the part of the atrium where the clots form. The Watchman device will soon receive FDA approval. Similar devices will soon undergo clinical trials as alternatives to blood thinners. You should discuss these options with your physician. The success rate of the ablation procedure varies from patient to patient; in our hospital, the chance of eliminating or greatly reducing Afib averages around 70% in patients who go in and out of fibrillation and less than 50% in patients with persistent or chronic Afib. Some centers report different success rates. Our success rate falls within the range reported by the centers with a large experience with this procedure. We hope that a single ablation session eliminates your Afib. However, one out of three patients needs to have a repeat procedure in order to stop the Afib. Therefore, you should realize that you may need more than one ablation procedure to eliminate your Afib. The ablation procedure carries a certain amount of risk. Major complications occur in 1 or 2 patients out of 100. The possible complications include severe bleeding, perforation of the heart with leaking and collection of blood into the sac surrounding and compressing the heart, stroke, bruising, infection, scarring of the veins that send blood from the lungs to the heart, and even death. Some of the complications may require emergency heart or vascular surgery. One severe complication, perforation of the left atrium into the esophagus (the swallowing tube), can be fatal even with immediate surgery. The chance of any complication varies from patient to patient, and we take many measures to reduce the risk to you. Your physician will discuss with you the potential complications in detail during the office visit prior to the ablation. Please ask questions if you do not understand any of these risks or need more information. Prior to the ablation procedure we might ask you to have a cardiac magnetic imaging (MRI) study of the heart. This test gives us information on the shape of the heart and the number and location of pulmonary veins to help us during the ablation. We may also repeat the MRI three months after the procedure to look for any damage to the pulmonary veins or other structures of the heart. Not all patients need to have the MRI scans. If you are taking an anti-arrhythmic drug, we may ask you to stop taking the drug five days prior to the procedure. Patients in persistent Afib taking amiodarone or other anti-aarrhythmic drugs should continue taking them right up until the time of the procedure. Please ask your physician whether you should stop your drugs and when. If you are on coumadin/warfarin, we may ask you to stop it five days prior to the procedure. Then, for the three days before the procedure, most patients will have to give themselves (or have someone give you) shots of a liquid blood thinner twice a day. We can train you or a family member, to give you these shots under the skin. You take the last shot the evening before the procedure. Some patients taking

5 Patient Information Treatment Options for Atrial Fibrillation Page 5 of 8 warfarin should continue it right through the procedure without the need for the shots. Please ask your physician which strategy applies to you. Patients taking Pradaxa, Xarelto, or Eliquis should not take the drug for one full day before the procedure. Some patients with persistent Afib may have to undergo a trans-esophageal echocardiogram (TEE), just before the ablation procedure. The TEE will tell us whether you have accumulated any clots in the atrium that might increase the risk of stroke during the ablation. If we find clots, we will likely postpone the procedure after giving you more blood thinners. Patients with persistent Afib need to be on adequate doses of blood thinners for at least one month prior to the ablation procedure. You should not eat anything after midnight on the night prior to the procedure. You may take your morning medicines with small sips of water the morning of the procedure. If you use a CPAP machine for sleep apnea, please bring it with you. We will use it during the procedure to help you breathe easier and make you more comfortable. You should arrive at the hospital at least two hours before the scheduled procedure. One of our physicians will see you and obtain a consent for the procedure. A nurse will shave the area near your groin and prepare you for the procedure. You will receive sedatives and pain medicine through an IV, and they will make you feel groggy and sleepy, but you will breathe on your own. We usually do not use general anesthesia during Afib ablation. Expect the ablation procedure to take four hours and we will monitor you for at least four hours after the procedure. Please tell us if you feel pain or discomfort during the procedure. Tell us if you are too awake, if you are too aware of what is going on, or if you are not comfortable. A specially trained nurse will administer more of the medication to make you comfortable. After the ablation: You will need to lie still with your right leg straight for four hours after the procedure. We will monitor you in the Cardiac Observation Area after the ablation procedure and perform an ultrasound test (echocardiogram) to check your heart. We will start you on blood thinners, either injectable heparin followed by warfarin/coumadin, or one of the new blood thinners that doesn t require the use of the heparin shots. We anticipate that you will go home the day of the procedure. However, please bring clothes and be prepared to spend one night in the hosptial if needed. If you live far from Atlanta, we suggest that you stay in a local hotel for the first night before traveling home. If you have a long drive home, you should stop every two or three hours, get out of the car, and stretch your legs for a few minutes. This will help reduce the risk of blood clots forming in the veins where we inserted the catheters. You should anticipate some discomfort in your chest for a few days after the procedure. The ablation causes inflammation in your chest. Although it may be uncomfortable, it is not dangerous. We will prescribe anti-inflammatory drugs for you to take. We may also give you drugs to prevent acid build-up from irritating your esophagus. Let us know if you develop sever pain problems swallowing or drinking, if your leg swells, becomes red or painful, of if you have fever. Those patients with chronic or persistent Afib prior to the ablation may need to continue taking amiodarone or another anti-arrhythmic drug for three months. We usually will discontinue the

6 Patient Information Treatment Options for Atrial Fibrillation Page 6 of 8 antiarrhythmic drugs after the ablation in patients with intermittent Afib prior to the ablation. Please do not throw away your antiarrhythmic drugs. You may experience palpitations. The full effect of the ablation procedure may not take hold until three months after the ablation. So, we may ask you to take those antiarrhythmic drugs again for a short period of time. Also, do not be discouraged if the Afib returns in the first three months. If it recurs after three months, we will discuss treatment options including using antiarrrhythmic drugs or a repeat ablation to eliminate any tissue that may still trigger the fibrillation. You should return to see our nurse practitioners one month after the ablation to get an ECG. If you live far away, we will ask you to see your local physician instead. At three months after the procedure, you will return to our clinic to get an ECG, and we might give you a monitor to wear for four weeks to detect any remaining Afib. Even if you do not think you have had any fibrillation, we may ask you to wear a monitor that automatically detects Afib at three months, six months, or one year after the ablation. We will see you in the office again at 6 months and 1year after the ablation. If you are having any trouble, or if you have questions, call the office (404) The number for after-hours emergencies is (404) Please ask for the electrophysiology physician on-call. In case of severe bleeding, weakness, trouble forming words, or loss of consciousness, go to the nearest emergency room and have them contact us. If you have symptoms that suggest to you that the arrhythmia has returned, please call us. We may ask you to return for an ECG, and if the Afib has returned within the first three months we will schedule you for a cardioversion. Reducing the time your heart spends in Afib in the period after the ablation increases the chance that the procedure takes hold and has a long-lasting effect. We hope to improve your symptoms and quality of life by eliminating or reducing your Afib. In many patients a single procedure succeeds and they do not need to see us after the follow-up visits. Others may continue to have symptoms and need further follow-up or treatment. We will remain available to you as you see the need. Emory Atrial Fibrillation Support Group: Emory Heart and Vascular Center offers a support group for all patients with Afib and their family members. The meetings occur on Saturday mornings every three months, and consist of a lecture on a rotating Afib topic from an Emory Electrophysiologist, a light lunch, and a chance to talk with other Afib patients. All meetings include an opportunity to ask a wide range of Afib related questions. For more information or to register for the meetings, visit emoryhealthcare.org/afsupportgroup or contact Mathew Levy at Frequently asked questions: Is Afib genetically transmitted/does it run in families? We have observed Afib clusters in a number of individuals within the same family. There is some evidence that certain genes may be associated with some electrical abnormalities of the heart cells that produce Afib. However, there is not direct genetic test that identifies a genetic cause of Afib in most patients.

7 Patient Information Treatment Options for Atrial Fibrillation Page 7 of 8 Does Afib shorten one s life span or increase the risk of death? Some studies of populations with Afib suggest that overall, people with Afib tend to not live as long as those without Afib. One reason is that patients with Afib also have significant heart disease, such as congestive heart failure, valve disease, and coronary artery disease. However, no one has clearly shown that patients with isolated Afib and no other heart disease have decreased life span compared to similar patients without Afib. Does Afib get worse over time? Do the episodes increase in frequency and severity? Many patients with Afib will progress to develop more frequent episodes, episodes that last longer and are harder to stop, and ultimately go into persistent Afib. The longer the heart stays in Afib the more resistant the Afib becomes to treatment. The aging process alone makes it more likely for Afib to develop or for it to get worse with time. What activities tend to trigger episodes of Afib? Most Afib episodes tend to come and go regardless of what patients do. However, there are certain activities that are more likely to trigger Afib in those patient who already have it. Excessive fatigue, dehydration, lack of sleep or a change in your sleep patterns can all trigger Afib. Alcohol use, with binge-drinking, is a very strong trigger of Afib: People usually go into Afib the next day, the so called Holiday Heart Syndrome. Do certain illnesses or other conditions trigger Afib? Any acute illness can bring out Afib. Colds, upper respiratory infection, asthma and other lung conditions can do it. Some medicines like brochodilators (inhalers) can trigger Afib as well Any physical stress on the body like surgery, can also trigger Afib. Can a patient with Afib travel safely? Generally, patients with Afib can travel safely. However, long flights, traveling to areas of high altitude, changing diets and sleep habits may trigger Afib during the trip. We recommend that patients with Afib pay close attention to hydration (drink plenty of water), sleep, avoid excessive alcohol, and not overdo physical activity at altitude. If you are on a blood thinner, make sure the dose is adequate. It is a good idea to have the name of physicians or facilities in the area will you will travel. We suggest you discuss your travel plans with your physician ahead of time. Can I exercise with Afib? A patient with Afib should be able to exercise regularly. However, in some patients, excessive exercise triggers Afib. Some people trigger their Afib when the pulse exceeds a certain target. If so, try to exercise below that trigger pulse rate. Patients with persistent Afib can also exercise as long as they are on medications to control their resting heart rate. If you exercise while in Afib, please realize that you may tire more easily and you will not be able to reach the same level of activitiy that you are used to. Your pulse will quickly jump up to a high rate before it settles down some. The first few minutes of exercise may be difficult and then you can continue more easily. How many cardioversions can one person have? A cardioversion is very safe. The shock does not damage the heart, but may irritate the skin. A person may have a number of cardioversions with little risk But, at some point, repeat cardioversions

8 Patient Information Treatment Options for Atrial Fibrillation Page 8 of 8 may become impractical or inconvenient. Some patients can take a large single dose of Flecainide or Propafenone to convert the Afib without an electrical cardioversion: The Pill-in-the-Pocket approach. Discuss this with your physician How soon after an ablation procedure can I return to normal activity? Different people respond differently to the procedure. Some feel very little discomfort and return to full activity in one or two days. Others feel chest pain, fatigue, and don t get back to normal for up to one week. You should avoid strenous activity and swimming for the first two days to allow the punctures in the leg to heal. After that, you can proceed with normal activity as you see fit. If you have any questions about Afib or the ablation procedure, please do not hesitate to ask: Emory University Hospital Midtown Cardiac Electrophysiology Service (404) Version: May 21, 2014

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