If you’re one of the 2.7 million Americans who live with atrial fibrillation — a tricky-to-treat condition that causes your heart to beat irregularly — you may be unsure how to treat it.
Symptoms of atrial fibrillation, also called afib, can be debilitating. They may include palpitations, shortness of breath, fatigue, and weakness.
But trying to reduce these symptoms through drugs that control the abnormal heart beat, called anti-arrhythmic drugs, can come with serious side effects.
Another treatment option is catheter ablation. During ablation, the abnormal heart tissue is destroyed by burning or freezing it. Ablation has a greater chance of reducing and even eliminating your symptoms and making you feel better. But the procedure is invasive, expensive, and not right for everybody.
How do you choose between the two? Having a clear sense of the risks and benefits for both can help.
Neither anti-arrhythmic drugs nor catheter ablation decrease the risk of stroke — these treatments are designed to control symptoms caused by the abnormal heart rhythm.
Walid Saliba, MD, a cardiologist who treats atrial fibrillation at the Cleveland Clinic in Ohio, says, “The aim of any treatment for atrial fibrillation is to reduce the burden of the arrhythmia — the frequency, impact, and symptoms — and improve quality of life.”
Treatments are more effective and better understood than ever, say experts. Guidelines issued in March 2014 by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society recommend ablation as a first-line therapy for atrial fibrillation.
And research continues. A large trial called Cabana is underway, sponsored by the National Institutes of Health, to provide even more answers regarding the use anti-arrhythmic medication versus ablation.
Medications can stabilize the heart muscle tissue and help return the heart to its normal rhythm, notes the American Heart Association. Some people take the meds every day, while others take them just when they feel palpitations. These drugs work well for some people, but not all. How do the pros and cons compare for now? Here’s a look.
Pros of Anti-Arrhythmic Drugs for Atrial Fibrillation
- Many options Your doctor will recommend certain drugs based on your age, your health, and the severity of your symptoms. “If there’s underlying heart disease, you may be restricted in what medication you can take,” says Dr. Saliba.
- Cost effective Medication is typically less expensive than procedures like ablation, in the short term. But if your atrial fibrillation results in repeated hospital visits and changes in your meds to better manage your symptoms, the cumulative costs may even out over time.
- Noninvasive It’s easier to take a pill than to undergo surgery. Patients who are squeamish about surgical procedures and more comfortable taking a less aggressive approach to controlling their symptoms typically start with medication.
- Moderate success rate Success rates average around 50 percent overall. “Research shows that with medication there’s a good 40 to 60 percent maintenance of normal rhythm at one year,” says Saliba. “And that’s acceptable to some patients.”
Cons of Anti-Arrhythmic Medication
- Dangerous side effects and interactions Nausea, dizziness, diarrhea, breathing problems, and swelling are some of the side effects associated with anti-arrhythmic drugs. Other side effects are more serious. The drug amiodarone (Cordarone, Pacerone, Nexterone), for instance, can cause scarring of the lungs, a condition called pulmonary fibrosis. It can also interact with blood thinners, which you may be taking to reduce your risk of stroke. Tikosyn (dofetilide) can cause dizziness and can interact with antibiotics. All anti-arrhythmic drugs can cause life-threatening heart rhythm disturbances, such as ventricular tachycardia or ventricular fibrillation. This is why some heart patients are hospitalized for observation for three to four days when they first start taking them.
- Less effective over time The benefits of these drugs diminish with time, says Gopi Dandamudi, MD, cardiologist and assistant professor of clinical medicine at Indiana University School of Medicine's Krannert Institute of Cardiology in Indianapolis. “Less than 20 percent of patients truly maintain sinus [normal] rhythm on anti-arrhythmic medication,” he adds.
- Blood thinners If you are in afib at the time that the anti-arrhythmic medications are started, then you will need to be on blood thinners for at least a few weeks (and weren't previously on blood thinners). This will help to decrease the risk of having a stroke, but blood-thinning medication also comes with an added risk of causing problems with bleeding.
Catheter ablation has evolved over the last decade into a routine procedure, and compelling evidence supports its effectiveness. During the procedure, which is conducted by an electrophysiologist under local anesthesia, the tip of a catheter is guided to the area of heart tissue that is producing abnormal electrical signals. The catheter emits a pulse of painless radio-frequency energy that destroys the abnormal tissue, correcting the irregular heartbeat.
Research into the long-term effects of catheter ablation is promising. “If you look at the studies over the last 10 years,” says Saliba, “there’s no doubt that ablation results in more freedom from atrial fibrillation at one-year and three-year follow-ups compared to anti-arrhythmic medication.”
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Pros of Ablation
- Higher success rate On average, ablation has a 70 to 80 percent success rate. Those who are young, whose afib is intermittent, and who have no underlying heart disease, can have success rates as high as 95 percent. Those with persistent afib who are older and have underlying heart disease have a lower success rate — around 40 to 60 percent. The skill of the operator is also a factor, with highly experienced practitioners at high volume medical centers having higher success rates.
- Low risk of complications Fewer than 5 percent of patients develop any problems. Rarely, the use of the catheters can damage your blood vessel, or cause bleeding, or infection. The risk of more serious complications, like stroke and heart failure, is less than 1 percent. Dr. Dandamudi says, “Most of the risks of catheter ablation are avoidable and not life-threatening.”
- Quick recovery The procedure takes about two to four hours, and patients can be discharged the same day or after an overnight stay. It causes little or no discomfort and is done under mild sedation with local anesthesia. “The vast majority of patients sail through the procedures and go home the next day,” says Dandamudi.
Cons of Catheter Ablation
- Repeat procedures For 20 to 30 percent of patients, the first ablation doesn’t work and they have to go back for another. That’s because some abnormal tissue might have been missed, or burned tissue healed and recovered function. “You can increase the success rates by another 10 percent with a repeat ablation,” says Dandamudi.
- Ablation doesn’t work for everybody. Ablation works best on patients who have the kind of atrial fibrillation that comes and goes (called paroxysmal) and are otherwise healthy. People who aren’t well suited for it are those with long-standing afib who have underlying heart disease. Another factor is how long the afib has been going on. “Someone who has had it for just one year has a much better chance of having a positive outcome than someone who has had it continuously for five or ten,” says Saliba.
- Sometimes medication is still needed. It can take one to three months for scars to fully form on the sites that were ablated and to know if the procedure worked. During that time, a patient may still experience palpitations and may even be prescribed antiarrhythmic medication. “Sometimes you need both ablation and medication for things to work and result in significant oppression of atrial fibrillation,” says Saliba.
- New arrhythmias Ablations can sometimes even cause new arrhythmias. When an area of scar is created in a chamber of the heart, that scar can be the site of a new abnormal rhythm, though this is rare.
- Blood thinners You will need to be on blood thinners for a few weeks after the ablation to decrease the risk of stroke, even if you weren’t on blood thinners before.