Atrial Fibrillation

Long-Term Management

Every patient with atrial fibrillation cannot be converted back into sinus rhythm successfully and every patient who is converted back into sinus rhythm does not necessarily remain in sinus rhythm. In fact, within a year, one-third to one-half of all patients have at least one recurrence of atrial fibrillation. Patients at increased risk of recurrent atrial fibrillation include those whose atria are enlarged (dilated) and those with heart failure.

Many medications are now available that are used to try to keep patients in sinus rhythm and prevent the recurrence of atrial fibrillation. These medications include the following:

• Amiodarone (Cordarone®)
• Disopyramide (Norpace®)
• Dofetilide (Tikosyn®)
• Flecainide (Tambocor®)
• Procainamide (Procanbid®, Pronestyl®)
• Propafenone (Rhythmol®)
• Quinidine (Quinaglut®, Quinidex®)
• Sotalol (Betapace®)

All of these medications have side effects and many require periodic monitoring.

Patients who are successfully converted from atrial fibrillation back into sinus rhythm are considered to be at some risk for blood clot formation and stroke for 3 or 4 weeks. Blood-thinning medication is usually administered during this time.

Most patients who cannot undergo conversion or cannot be successfully converted into sinus rhythm are maintained on long-term blood thinning therapy. Typically, this consists of the once-a-day administration of warfarin (Coumadin®). The blood is periodically monitored to insure it is "thinned" to the appropriate degree. Many foods and medications, particularly antibiotics, can affect the degree to which the blood is thinned.

Patients who require long-term warfarin (Coumadin®) therapy should discuss with their doctor or health care provider which foods and medications they should avoid or take with caution. In a select group of patients, aspirin therapy alone provides adequate thinning of the blood. Some patients (particularly those with coronary artery disease) may be treated with warfarin (Coumadin®) and aspirin.

Patients who remain in atrial fibrillation may require long-term therapy with one or more medications that help prevent the heart rate from becoming too rapid. These medications may include beta blockers, calcium channel blockers, and digoxin.

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• Beta blockers are used to slow the heart rate. They include:
  • Atenolol (Tenormin®)
  • Bisoprolol (Zebeta®)
  • Carvedilol (Coreg®)
  • Metoprolol (Lopressor®)
  • Toprol XL®)
  • Nadolol (Corgard®)
  • Propranolol (Inderal®, Inderal LA®)
  • Timolol (Blockadren®)
  These medications are usually taken in pill form once or twice a day.

• Calcium channel blockers have multiple effects on the heart and arteries. Two of these agents can be used to slow the heart rate in patients with atrial fibrillation. These medications include diltiazem (Cardizem®) and verapamil (Calan®, Calan SR®, Covera HS®, Isoptin®, Isoptin SR®, Veralan®). Long-acting forms of these medications are available that are taken once or twice a day.
• Digoxin (Lanoxin®) is often used in the treatment of patients with heart failure, because it can stimulate the left ventricle to contract and pump blood more vigorously. Digoxin also slows electrical conduction through the AV node, and can decrease the rate at which electrical impulses are conducted from the atria down into the ventricles.

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