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A-fib treatment offers options

Dr. Al Casale

Editor’s Note: This is the third in a series of columns to be published in The Express during February — National Heart Month — and authored by Dr. Alfred Casale, a cardiothoracic surgeon at Geisinger Medical Center.

Over the last two weeks, we’ve discussed both arrhythmia in general and its most common form, atrial fibrillation, or A-fib. In doing so, we’ve laid the groundwork to discuss the wide spectrum of options available to treat this irregular heartbeat.

Affecting between 2.7 and 6.1 million Americans, A-fib doesn’t always present severe symptoms, but it does always increase risk of stroke and heart failure. So, treatment is necessary, and that treatment is focused on achieving a healthy heart rhythm and rate and preventing stroke-causing blood clots and heart failure.

Treatment begins with identifying and managing any inciting issues, improving overall wellness and then starting appropriate medications. The majority of people living with A-fib can manage their condition this way, by altering their lifestyles and using medicines to regulate their arrhythmia and avoid its potential complications.

Traditionally, heart rate has been controlled by medications like beta blockers that slow the heart rate, and clotting has been addressed using blood thinners such as warfarin (Coumadin) or other, newer oral anticoagulants.

New A-fib treatment guidelines published by the American Heart Association in January 2019 indicate that these novel oral anticoagulants, also known as non-vitamin K anticoagulants and NAOCs, are the recommended medical intervention to prevent stroke over the traditionally championed warfarin, except in patients with artificial heart valves or moderate-to-severe narrowing of the mitral valve. The NAOC class includes dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa). How’s that for a mouthful!

NAOCs are the new standard, because there is evidence that they present less of a risk of severe bleeding and may be more effective in preventing clots than warfarin. Also, unlike warfarin, there is no need for constant testing to make sure there is enough of the drug in a patient’s bloodstream.

The guidelines also indicate that weight loss for overweight or obese patients lowers blood pressure, reduces risks associated with A-fib and can even reverse the condition.

For those who need intervention beyond exercise, healthy diet and medication, several procedures can improve quality of life.

Cardioversion restores a regular heartbeat. It can be done using medication, called pharmacologic cardioversion, or it can be accomplished electrically, by placing patches on the outside of the chest and sending a controlled electrical shock to the heart. Sometimes this is all that’s needed, especially if some cause of the A-fib has been identified and eliminated before the arrhythmia has become settled for more than a few months.

If A-fib recurs, has been in place for too long, or if medication is ineffective or causes severe side-effects, a procedure called A-fib ablation can be done in the cardiac catheterization laboratory with narrow catheters passed through the blood vessels accessed through the groin. Using these thin catheters, specially trained cardiologists known as electrophysiologists can use microwaves to heat or extreme cold to freeze heart tissue. These induced scars cause interruptions in the abnormal electrical pathways which lead to irregular heartbeat. Ablation has few risks and is precise and generally well tolerated.

Special imaging and mapping equipment have made these procedures quite successful in identifying and eliminating the culprit areas.

For some folks, clot formation cannot safely be prevented with blood thinners, and implantation of the Watchman device is an option for those patients. Again, using catheters and imaging to guide the device, the small umbrella-like Watchman is opened in the left atrial appendage, the smallish outpouching in the heart’s upper chamber where blood tends to stagnate and clot. The Watchman procedure is suitable for A-fib patients who do not have heart-valve disease.

Pacing is another valuable tool in the treatment of other abnormalities of the heart’s electrical rhythm.

Pacemakers and implantable cardioverter-defibrillators (ICDs) are surgically implanted devices that are safely wired to the heart to manage rhythms that are too fast or too slow.

Pacemakers send electrical signals to the heart and are typically used to treat slow heartbeat (bradycardia). ICDs monitor heart rhythm and can deliver a small electric shock to the heart if its lower chambers, the ventricles, begin to beat dangerously fast or erratically.

State-of-the-art electrophysiology labs in Geisinger hospitals feature cutting-edge diagnostic and surgical equipment to perform these and other procedures.

For some patients, open-heart surgery is the best option to treat A-fib. When medications and less invasive procedures cannot improve a patient’s quality of life or are not an option because of other medical conditions, A-fib surgery with an experienced cardiac surgeon can be a life-changing therapy.

OK, now you’re ready for your heart rhythm exam!

——

Dr. Alfred Casale, a cardiothoracic surgeon, is chief medical officer for surgical services for Geisinger and chair of the Geisinger Heart Institute. For information on alternative treatment for atrial fibrillation, visit https://geisinger.cc/2E2N8n8.

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