Health & Medicine • V – history of vascular disease • A – age > 65 – 74 years old • Sc – Sex (female) A patient is given 1 point for each risk factor except for those marked with a subscript 2 (get 2 points). If you have > 1 point, you should be considered for one of the blood thinning medications (known as anticoagulants) mentioned below. Patients with a score of 0 may be considered for no anticoagulation. Medications for atrial fibrillation Medications are either geared to prevent strokes, control heart rate, or control the rhythm of the heart. Lists included here are not meant to be comprehensive. We encourage you to contact our office for the latest advancements in the medical management of AF. How do I prevent a stroke? Stroke prevention is achieved by taking a medication that prevents the formation of clots – collectively known as anticoagulants. For over 50 years, the only effective medication available was warfarin (Coumadin®). However, there are 3 new agents available that offer similar protection without the fuss that surrounds warfarin such as frequent blood monitoring or being concerned about diet or other medication interactions • dabigatran (Pradaxa®) • rivaroxaban (Xarelto®) • apixaban (Eliquis®) In low risk patients, aspirin has been used; however, its use is falling out of favor since better agents are now available. Important precautions when taking blood thinning medication • Call your healthcare provider right away if you have any usual bleeding or bruising • If you forget to take your daily anticoagulant dose don’t take an extra dose to “catch up”! Follow your healthcare provider’s directions of what to do if you miss a dose. • Always tell your physician, dentist, and pharmacist that you have been prescribed an anticoagulant medication • Remember that other medications, and sometime supplements, can impact the effectiveness of these medications – either rendering the anticoagulant ineffective or overly effective What if I am high risk for stroke but not a candidate for anticoagulation? Unfortunately, not every patient is able to take blood thinning medication safely. A
patient may have experienced a prior bleed while taking a blood thinner or is at risk for following. Until recently, these patients had no alternative but to accept the risk of stroke. However, we now have minimally-invasive procedures aimed to close a structure known as the left atrial appendage (LAA) which is the culprit for blood clots 90% of the time. Thin flexible tubes are inserted into blood vessels in the leg and possibly into the sack surrounding the heart. These thin tubes serve as a method to deliver either a stitch (Lariat®)that closes the LAA from the outside of the heart or a seal (Watchman™) that sits inside the heart to seal off the entrance to the LAA. Patients typically spend one evening in the hospital and go home the next day. Recovery is short with patients up and walking within hours of the procedure. Heart rate controlling medications Beta blockers, calcium channel blockers, and/or digoxin are often used to help prevent the heart from racing while in AF. Adequate heart rate control will frequently result in symptom improvement. Examples of these types medications include: • Carvedilol • Metoprolol • Atenolol • Diltiazem • Verapamil • Digoxin Heart rhythm controlling medications Sometimes medications are required to maintain a normal rhythm and prevent the recurrence of AF. Collectively, these medications are known as anti-arrhythmic drugs. These medications require close monitoring by your healthcare provider if prescribed: • Flecainide (Tambecor®) • Propafenone (Rythmol®) • Sotalal (Betapace®) • Dofetilide (Tikosyn®) • Amiodarone (Pacerone® or Cordarone®) • Dronedarone (Multaq®) The decision to use electrical cardioversion A cardioversion is an outpatient procedure which allows for the immediate restoration of normal rhythm. The procedure is painless and involves going to sleep for 2-3 minutes while a quick current of electricity is sent through the heart resulting in a normal heart beat. It is the “reset button” for the heart. Sometimes, a patient will need to undergo a transesophageal echo-
Can AF be cured? The jury is still out on this question. At this time, there is no definitive cure for AF. However, catheter ablation is the closest tool we have to preventing the long-term recurrence of AF. AV-node ablation with pacemaker implantation This strategy is reserved for highly-symptomatic patients whose heart rate cannot be controlled by medications and who are
cardiogram (TEE) prior to the procedure to confirm that no blood clots are sitting in the heart. A TEE is also an outpatient procedure where the patient swallows a thin ultrasound probe similar to an endoscopy. Pictures of the heart are taken and then the probe is removed. Atrial fibrillation catheter ablation By far, the most effective method in preventing recurrence of AF is by catheter ablation. Ablation is typically reserved for symptomatic patients with recurrent AF who are intolerant of one of the rhythm controlling medications mentioned above or do not wish to subject themselves to the potential side-effects from these medications. A catheter ablation is a minimally invasive procedure performed by a heart rhythm specialist known as an electrophysiologist. The procedure is akin to having a cardiac catheterization or angiogram in that a patient lies on a table. Very thin spaghetti – like catheters are inserted into the body via the blood vessels in the leg. An electrically sensitive catheter is used to identify areas of the heart that are electrically malfunctioning. These catheters either heat or cool the heart tissue to destroy these malfunctioning areas. In the appropriate patient, the success rate of preventing AF recurrence is typically 70%. About 1 out or every 3 to 4 patients will need to have the procedure done twice. In these patients, the success rate can be as high as 80-85%. Recovery is short with patients walking within hours of the procedure. Patients will typically spend 1 evening in the hospital and go home the next day.
not candidates for an AF catheter ablation. In these situations, the only way to prevent the heart from continuously racing is to disconnect the normal wiring of the heart (the AV node) and have a pacemaker take over the job of assuring that the heart beats at a normal rate. Patients often note an immediate improvement in symptoms after having this procedure. At First Coast Heart & Vascular Center, we pride ourselves in offering comprehensive management for patients with atrial fibrillation. Our skilled cardiologists and electrophysiologists are able to offer contemporary medical management options. For symptomatic patients not responding and/or tolerating medical therapy, Dr. Neil Sanghvi and Dr. Dinesh Pubbi are able to perform an AF catheter ablation using state-of-the-art equipment found at several local hospitals. And, for patients unable to take anticoagulation, our physicians can evaluate you to determine whether you are a candidate for a left atrial appendage closure device.
First Coast Heart & Vascular Center, PLLC
14810 Old St Augustine Road, Suite 201 Jacksonville, FL 32258 3901 University Boulevard, Suite 221 Jacksonville, FL 32216 (904) 423-0010 www.firstcoastheart.com San Jose
Published on Jun 13, 2014