Treatment

Treatments for atrial fibrillation include medications to control heart rate and reduce the risk of stroke, and procedures such as cardioversion to restore normal heart rhythm.

It may be possible for you to be treated by your GP or you may be referred to a heart specialist (a cardiologist). Some cardiologists, known as electrophysiologists, specialise in the management of abnormalities of heart rhythm.

You'll have a treatment plan and work closely with your healthcare team to decide the most suitable and appropriate treatment for you. Factors that will be taken into consideration include:

• your age
• you overall health
• the type of atrial fibrillation you have
• your symptoms
• whether you have an underlying cause that needs to be treated

The first step is to try to find the cause of the atrial fibrillation. If a cause can be identified, you mayonlyneed treatment for this. For example, if you have an overactive thyroid gland (hyperthyroidism) , medication to treat it may also cure atrial fibrillation.

If no underlying cause can be found, the treatment options are:

• medicines to reduce the risk ofa stroke
• medicines to control atrial fibrillation
• cardioversion(electric shock treatment)
• catheter ablation
• having a pacemaker fitted

You'll be promptly referred to your specialist treatment team if one type of treatment fails to control your symptoms of atrial fibrillation and more specialised management is needed.

Medicines to control atrial fibrillation

Medicines called anti-arrhythmics can control atrial fibrillation by:

• restoring a normal heart rhythm
• controlling the rate at which the heart beats

The choice of anti-arrhythmic medicine depends on the type of atrial fibrillation, any other medical conditions you have, side effects of the medicine chosen and how well the atrial fibrillation responds.

Some people with atrial fibrillation may need more than one anti-arrhythmic medicine to control it.

Restoring a normal heart rhythm

A variety of medicines are available to restore normal heart rhythm, including:

• flecainide
• beta-blockers, particularly sotalol
• amiodarone
• dronedarone(only for certain people)

An alternative medication may be recommended if a particular medicine doesn't work or the side effects are troublesome.

Newer medicines are in development, but aren't widely available yet.

Controlling the rate of the heartbeat

The aim is to reduce the resting heart rate to under 90 beats per minute, although in some people the target is under 110 beats per minute.

A beta-blocker , such asbisoprolol or atenolol, or a calcium channel blocker, such asverapamil ordiltiazem, will be prescribed.

A medicine calleddigoxin may be added to help control the heart rate further. In some cases, amiodarone may be tried.

Normally, only one medication will be tried before catheter ablation (see below)is considered.

Side effects

As with any medicine, anti-arrhythmics can cause side effects. The most common side effects of anti-arrhythmics are:

• beta-blockers tiredness, coldness of hands and feet, low blood pressure, nightmares and impotence
• flecainide nausea, vomiting and heart rhythm disorders
• amiodarone sensitivity to sunlight (high-protection sunscreen must be worn or skin covered up), lung problems, changes to liver function or thyroid function (regular blood testscan check for this) and deposits in the eye (these disappear when treatment is stopped)
• verapamil constipation , low blood pressure, ankle swelling and heart failure

Read the patient information leaflet that comes with the medicine for more details.

Medicines to reduce the risk of a stroke

The way the heartbeats in atrial fibrillation means there's a risk of blood clots forming in the heart chambers. If these enter the bloodstream, they can cause a stroke (see complications of atrial fibrillation for more information).

Your doctor will assess your risk and try to minimise your chance of having a stroke. They'll consider your age and whether you have a history of any of the following:

• stroke or blood clots
• heart valve problems
• heart failure
• high blood pressure (hypertension)
• diabetes
• heart disease

You may be given medication according to your risk of having a stroke. Depending on your level of risk, you may be prescribed warfarin or a newer type of anticoagulant , such as dabigatran, rivaroxaban, apixaban or edoxaban(see below).

If you're prescribed an anticoagulant, your risk of bleeding will be assessed both before you start the medication and while you're taking it.

Aspirin isn't recommended to prevent strokes caused by atrial fibrillation.

Warfarin

People with atrial fibrillation who have a high or moderate risk of having a stroke are usually prescribed warfarin , unless there's a reason they can't take it.

Warfarin is an anticoagulant, which means it stops the blood clotting. There's an increased risk of bleeding in people who take warfarin, but this small risk is usually outweighed by the benefits of preventing a stroke .

It's important to take warfarin as directed by your doctor. If you're prescribed warfarin, you need to have regular blood tests and, after these, your dose may be changed.

Many medicines can interact with warfarin and cause serious problems, so check that any new medicines you're prescribed are safe to take with warfarin.

While taking warfarin, you should be careful about drinking too much alcohol regularly and avoid binge drinking .

Drinking cranberry juice and grapefruit juice can also interact with warfarin and isn't recommended.

Alternative anticoagulants

Rivaroxaban, dabigatran, apixaban and edoxaban arenewer anticoagulants and an alternative to warfarin.

The National Institute for Health and Care Excellence (NICE) has approved these medicines for use in treating atrial fibrillation. NICE also statesthat you should be offered a choice of anticoagulation and the opportunity to discuss the merits of each medicine.

Unlike warfarin, rivaroxaban, dabigatran, apixaban and edoxaban don't interact with other medicines and don't require regular blood tests. In large trials, the medicines have been shown to be as effective or more effective than warfarin at preventing strokes and deaths. They also have a similar or lower rate of major bleeding.

You can read more about rivaroxaban, dabigatran and apixabanin the NICE guidance about Atrial fibrillation: management .

Edoxaban is recommended as an option for preventing stroke, heart diseaseand coronary artery disease in people with atrial fibrillation who have one or more risk factors, such as:

• heart failure , high blood pressure or diabetes
• a previous history of stroke or transient ischaemic attack (TIA)
• aged 75 years or older

You can read the NICE guidanceabout Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation .

Cardioversion

Cardioversion may be recommended for some people with atrial fibrillation. It involves giving the heart a controlled electric shock to try to restore a normal rhythm.

Cardioversion is usually carried out in hospital so that the heart can be carefully monitored.

If you've had atrial fibrillation for more than two days, cardioversion can increase therisk of a clot forming.In this case, you'll be given an anticoagulant for three to four weeks before cardioversion, and for at least four weeks afterwards to minimise the chance of having a stroke. In an emergency, pictures of the heart can be taken to check for blood clots, and cardioversion can be carried out without going on medication first.

Anticoagulationmay be stopped if cardioversion is successful. However, you may need to continue taking anticoagulation after cardioversion if the risk of atrial fibrillation returning is high and you have an increased risk of having a stroke (see above).

Catheter ablation

Catheter ablation is a procedure that very carefully destroys the diseased area of your heart and interrupts abnormal electrical circuits. It's an option if medication hasn't been effective or tolerated.

Catheters (thin, softwires)are guided through one of your veins into your heart, where they recordelectrical activity. When the source of the abnormality is found, an energy source, such as high-frequency radiowaves that generate heat, is transmitted through one of the catheters to destroy the tissue.

The procedure usually takes two to three hours, so it may be carried out under general anaesthetic (which means you're asleep during the procedure).

You should make a quick recovery after having catheter ablation and be able to carry out most of your normal activities the next day. However, you shouldn't lift anything heavy for two weeks, and driving should be avoided for the first two days.

Pacemaker

A pacemaker is a small, battery-operated device that's implanted in your chest, just below your collarbone. It's usually used to stop your heart beating too slowly, but in atrial fibrillation it may be used to helpyour heart beat regularly.

Having a pacemaker fitted is usually a minor surgical procedure carried out under a local anaesthetic (the area being operated on is numbed and you are awake during the procedure).

This treatment may be used when medicines aren't effective or are unsuitable. This tends to be in people aged 80 or over.

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