Atrial Fibrillation Treatment Decisions and Options

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Dr. Morris: Welcome to an MUSC Health Podcast. Hi, I'm Dr. Pam Morris, and I'm here today with Dr. Marcus Wharton who is Professor of Medicine and Director of Cardiac Electrophysiology at the Medical University of South Carolina. We're talking today about atrial fibrillation, and Marcus what I'd like to talk about now is once we've diagnosed a patient with atrial fibrillation, I'd like to talk about some of the treatment decisions and treatment options. Let's first begin with what types of patients need treatment for their atrial fibrillation.

Dr. Wharton: The goal of treatment for atrial fibrillation is symptom control. So if you're asymptomatic in terms of medicines to make you less symptomatic that doesn't make sense. So we use medications to control patients' symptoms when they have them. There's another issue of stroke risk, and we'll get back to that later on. But in terms of medications there are kind of two different approaches that we use in symptomatic patients of atrial fibrillation. Usually those symptoms are related to rapid heart rates, and so the first goal of therapy is to slow down that heart rate to decrease the symptoms, and potentially decrease the symptoms and potentially decrease the risk of worsening of their heart failure, or causing heart failure due to persistent rapid rates. And we have a number of different drugs we can use for controlling the heart rate. Typically we use Beta Blockers or calcium channel blockers. Those are the two most commonly used categories of drugs that we use. Occasionally, in patients with heart failure we'll use dijoxin, although the beta blockers and calcium channel blockers are much better at controlling heart rate in most individuals then are dijoxin. Once we've controlled the heart rate, then we're left with well, do we leave the person in atrial fibrillation, assuming that it's not stopping and starting on its own so they have persistent atrial fibrillation, or do we use antiarrhythmic drugs, a stronger category of medication to try to either put them back into a normal rhythm, or try to maintain normal rhythm after we've shocked them back into a normal rhythm.

Dr. Morris: Marcus is there an advantage of being in your normal rhythm, rather than in atrial fibrillation?

Dr. Wharton: Well for most people I think there is indeed an advantage from being in what we call normal sinus rhythm or normal rhythm compared to atrial fibrillation. Atrial fibrillation is not a normal rhythm, and for that reason it doesn't regulate the heart rate under the range of physiologic sorts of conditions that people expose themselves to, so you don't have good heart rate control during exercise, or maybe you don't even have good heart rate control during rest, or not during periods of exertion. And for that reason you have symptoms. And even if we can control the heart rate with the beta blockers or calcium channel blockers, frequently the irregularity of atrial fibrillation causes symptoms even when it's not rapid. And that's an important thing to remember. The symptoms are related to rapid rate and the irregularity of the rhythm. When we maintain normal rhythm, particularly in active, healthy people, people who are vigorous in different sports, or activities, or jobs, they are in general, and there are certainly exceptions to this, but they are in general better off when they are in normal rhythm. They feel better. You feel like the quality of life steadies in symptomatic patients with atrial fibrillation. They are generally much better in terms of their quality of life, and in terms of their exercise capacity when they're in a normal rhythm, compared to patients who are just controlled and left in atrial fibrillation. There is about twenty-five percent of patients, or a small number of patients with atrial fibrillation, who don't know they're in atrial fibrillation to begin with. In that situation it's a much more difficult issue about whether or not there's a benefit to

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