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Atrial Fibrillation is a life-long condition with no ‘quick fixes.’  Managing and treating your AFib will be an ongoing partnership between you and your medical team, including your GP and cardiologist.

Working out the right treatment for your Atrial Fibrillation can be a gradual process as there is no ‘one size fits all’ solution. Your management plan will involve some ‘trial and error’ while you and your doctors find a treatment that works best for you.

Your treatment plan or strategy may change over time. A medication strategy that once worked well for you may become less effective over time which may prompt your doctor to change your strategy.  Some people may experience side effects from certain medications and need to change course.   Some medication options may simply be ineffective for your Atrial Fibrillation.

It is best to approach your AFib treatment plan with patience and an expectation of a gradual process versus a quick solve.

There are four main components or ‘pillars’ to managing AFib. These are:

  1. Stroke Prevention
  2. Rhythm Control
  3. Rate Control
  4. Lifestyle Modification

Stroke prevention is the first pillar of Atrial Fibrillation management – once the stroke risks are determined and addressed, the other components of AFib management are more optional and tailored to the patient’s symptoms.

Anticoagulant medication plays an important role in minimising stroke risk. Other medications play an important role in keeping heart rhythms and heart rates at stable.  There are several medications on the Australian market, aimed at reducing a patient’s risk of stroke and heart failure. This article will review some of the most commonly recommended medications by the Institute’s team of Cardiac Electrophysiologists (EPs).

As with all medications, certain people may react differently and have varying side effects – it is important to always consult your doctor about appropriate use of medication for your AFib, and keep them informed of your experience.

In this article, you will learn about using medication strategies to help manage AFib, including:

four pillars to the management of afb.

Which Medication is the Best for the Treatment of AFib?

Electrophysiologists (EPs) at the Institute think about three primary categories of AFib medication, based on these three different objectives:

  1. Reducing the risk of clots and stroke
  2. Controlling the heart rate
  3. Managing the heart rhythm
 

There is a large variety of medications to treat AFib. When EPs talk about controlling atrial fibrillation, the medication prescribed will depend on the objective or the priority for you, and the type of AFib you have, as well as personal characteristics such as your age and if you have any other medical conditions or medications.

Common AFib Medications are Grouped into Three Categories

There are three main groups of AFib Medications: Anticoagulants (‘blood thinners‘), heart rate control medications, antiarrhythmic medications (heart rhythm control), and they all perform different functions.

Anticoagulant Medications (‘Blood thinners’)

    1. These medications are called blood thinners but they do not really thin the blood. They block blood clotting factors so the lengthen the time your blood would normally take to form a blood clot. 
    2. These medications help blood flow smoothly through veins and arteries. They reduce your blood’s ability to form clots (solid clumps of red blood cells and platelets that stick together).
    3. These medications mainly come in tablet form although some anticoagulant medication is given as an injection under the skin or as an intravenous infusion.
    4. Medications in this group include Warfarin, Rivaroxaban “Xarelto”, Apixaban “Eliquis” and Dabigatran “Pradaxa”.

 

Antiplatelet Medications

  1. The most familiar drug in this group is Aspirin
  2. Note: Aspirin and other Antiplatelet medications are not used in Atrial Fibrillation management because they do not prevent AF related blood clots and strokes.
  3. – medications in pill form that target tiny particles in the blood called platelets.

 

Heart Rate Control Medication

There are 3 classes of these medications used in AF management.

  1. Beta-blockers, also known as beta-adrenergic blocking agents. These drugs inhibit the effect of adrenaline on the heart and blood vessels.  They lower the heart rate and reduce the blood pressure.
  2. Calcium Channel Blockers (Verapamil, Diltiazem). These drugs slow the heart rate and lower the blood pressure as well but not as effectively as beta blockers.
  3. This drug will slow the heart rate without lowering the blood pressure.  It is an older drug and is less effective than Beta-blockers and Calcium-channel blockers.  It is used as an additional drug or as alternative if the other heart rate slowing medication is not well tolerated.

 

Antiarrhythmic Medication (Heart Rhythm Control Medication)

There are 3 main medications used in Australia for managing heart rhythm

  1. Sotalol
  2. Flecainide
  3. Amiodarone

Preventing Blood Clots and Managing Stroke Risk

Medication is an important part of a patient’s overall AFib treatment plan because it plays a crucial role in reducing the risk of stroke. According to the National Heart Foundation of Australia, people with AFib have a five times greater risk of stroke than those without. However, with the right treatment strategy, stroke amongst AFib patients is largely preventable.

AFib contributes to stroke risk because it can cause blood clots to form in the heart. Those blood clots can then travel from the heart through the arteries and into the brain. Once in the brain, the clots can block the brain’s blood vessels and stop the blood from flowing – causing a stroke and, potentially, heart failure.

The risk of clots and stroke vary with age and with the frequency and duration of the fibrillation. EPs use various algorithms to assess stroke risk, including the CHA2DS2-VASc Score. The CHA2DS2-VASc Score helps to determine a patient’s risk level – the more co-morbidities a patient has, the higher their risk is for having a stroke. For example, if you’re 40 and have no other heart disease, no high blood pressure, diabetes, heart failure, nor coronary disease, your risk of a stroke is very low. But if you’re 75 years of age with high blood pressure, then you have a higher risk and will likely be prescribed a blood thinner to reduce the risk of clots and strokes.

a black background with a red line and a red heart.

Based on this scoring system, your doctor will decide whether to start you on a blood thinner. There are several commonly prescribed blood thinners or ‘anticoagulants’ available.

Did you Know
Interestingly, there is a common misconception amongst AFib patients that ‘aspirin’ is a useful anticoagulant. However, while aspirin has a big role in coronary heart disease and preventing heart attacks, it has no benefit in reducing the risk of clots and strokes in AFib patients.

Common Type of Anticoagulants

Warfarin is one of the most frequently prescribed blood thinners worldwide. It has been considered the ‘gold standard’ medication for decades.

However, there is another newer group of alternative blood thinners on the market called ‘core novel anticoagulation’ or ‘direct acting blood thinners.’ In general, there are three common anticoagulants prescribed in Australia:

  1. Rivaroxaban, sold under the brand name Xarelto among others
  2. Apixaban, sold under the brand name Eliquis
  3. Dabigatran, sold under the brand name Pradaxa among others

According to Dr John Hayes, Director of QCG, these medications do the same job as Warfarin, and have been shown in studies to be equally effective.

“These medications are equivalent to Warfarin at reducing the risk of clots and strokes and atrial fibrillation, so they’re a great alternative. They’re generally well tolerated with minimal side effects,” Dr Hayes explained.

“But the big advantage with these newer medications is that patients don’t need blood testing, unlike with Warfarin, where you might be having a blood test once a week or once a fortnight or once a month,” he said. 

The goal with Warfarin is to reduce your blood’s ability to clot but not stop it clotting completely.  Getting this balance right means careful monitoring is required, in the form of a regular blood test called the international normalised ratio (INR). This measures how long it takes your blood to clot. This regular testing is not needed for the newer medications because their anticoagulant effects are more predictable, which is much more convenient for patients.

Some patients cannot tolerate anticoagulant medications, including Warfarin and new alternatives. Some patients have a high risk of internal bleeding.  Elderly and frail people are at risk of falling and injuring themselves.  In these patients, anticoagulant medication needs to be used with caution.  Other patients may have other medical conditions that increase their risk of bleeding, such as a gastric ulcer, which makes anticoagulants unsuitable for them.

“In most cases, the benefits of being on blood thinners outweigh the risks, however patients who fall frequently will be at high-risk on blood thinner medication, as they are more prone to bleeding into the brain if they fall and hit their head,” Dr Hayes explained.

When anticoagulant ‘blood thinner’ medication is not considered safe to use, then a procedure called Left Atrial Appendage Closure (Left Atrial Appendage Occlusion) may be recommended.

Interesting Fact: Have you heard people refer to Warfarin as ‘rat poison’? Thankfully, the Warfarin prescribed by our EPs is definitely not rat poison – the name relates to its unfortunate history of being used as an active ingredient in rodenticide, after its discovery in North America in the 1920s. Warfarin transitioned into clinical use and was approved for use in humans in 1954. Today Warfarin is widely used to prevent and treat deep-vein thrombosis and pulmonary embolism, and to prevent stroke in patients who have atrial fibrillation, valvular heart disease, or a prosthetic heart valve.

Controlling Heart Rate and Rhythm to Prevent Heart Failure

After minimising the risk of stroke, the next priority of AFib management your doctor will address is preventing heart failure, through controlling the heart rate and rhythm, and associated symptoms.

Controlling Heart Rate with Medication

Your heart may need medications or procedures if it is beating too quickly, too slowly, or irregularly. Some people may experience a combination of all three of these symptoms at different times.

Beta-Blockers and Calcium Channel Blockers are two main categories of medications commonly used to slow down your heart rate and improve blood flow through your body. Your doctor will advise you on specific medications that are useful for rate control depending on your specific symptoms.

Beta blockers, also known as beta-adrenergic blocking agents, help reduce blood pressure by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers make the heart to beat more slowly, which lowers blood pressure.

There is a range of those beta blockers, which achieve similar results. Some commonly prescribed beta blockers in Australia include:

  • Atenolol
  • Metoprolol
  • Bisoprolol
  • Carvedilol
  • Nebivolol
  • Propranolol
  • Nadolol

 

Like all medications, these each have their own potential side effects. Some people tolerate one medication type better than another, so they may need to trial more than one type to determine the most suitable option for them.

“Beta blockers can potentially upset asthma, for example, and can sometimes fatigue people. And there are other things like funny dreams and nightmares but overall, they’re very good and safe AFib medications,” Dr Hayes said.

The other category of rate control medication is Calcium Channel Blockers. These  lower blood pressure by preventing calcium from entering the cells of the heart and arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open. They are good at blocking the atrioventricular (AV) node and slowing the ventricular rate.

“Calcium Channel Blockers have a different set of side effects; they don’t affect the asthma, they don’t have the fatiguing effects,” Dr Hayes said.

‘Some patients however do experience constipation, and some dizziness,” he said.

There are two calcium channel blockers which slow the heart rate:

  • Diltiazem
  • Verapamil

 

A third potential option is Digoxin, which is a cardiac glycoside, which has proven success particularly in treating older people with atrial fibrillation, who do not exercise often.

“Digoxin is sometimes much better tolerated than beta blockers or calcium antagonists, particularly in elderly patients.  But if you’re younger, beta blockers and calcium antagonists would achieve better rate control,” Dr Hayes said

“Choosing a medication for rate control depends a lot on the individual patient; it must be tailored to them, and consider any side effects they have experienced,” he said.

Controlling Heart Rhythm with Medication

Even with their heart rate well controlled, some AFib patients continue to have symptoms such as palpitations, shortness of breath, fainting spells and night sweats. In this scenario, your doctor may recommend a rhythm control strategy by using antiarrhythmic medication to return the heart to a sinus rhythm (a normal rhythm).

Antiarrhythmic medications are used to try to prevent and reduce the amount of Atrial Fibrillation episodes a person gets, as well as to help the heart rhythm return to normal whenever an Atrial Fibrillation episode occurs.

In Australia, there are three main groups of antiarrhythmic medication available:

  1. Sotalol
  2. Flecainide
  3. Amiodarone

 

Each of these medications have their own distinct effectiveness and set of side effects.

Taking Medications for Managing Atrial Fibrillation

Many heart rhythm disorders such as AFib respond well to medications. Several drugs are now available and more are being developed and tested globally. These drugs can’t cure the arrhythmia, but they can improve symptoms. They do this by preventing the AFib episodes from starting, decreasing the heart rate during the episode, or shortening how long the episode lasts.

Sometimes several drugs may need to be tried before the right one for you is found. It’s important to discuss all of the drugs you take with your doctor and understand their desired effects and possible side effects.

All medications have side effects, including drugs to treat arrhythmias. Most of the side effects aren’t serious and disappear when the dose or type of medication is changed. 

Speak to your doctor if you experience any side effects because everyone responds differently to medication, and there are other options available.

Other important tips include:

  • Take all medications exactly as prescribed.
  • Never stop taking a medication and never change your dose or frequency of use without first consulting your doctor. Doing so may increase your risk of stroke or heart attack.
  • Tell your doctor about all other drugs and supplements you are taking. These may interact or interfere with your heart medication.
  • In many cases a procedure such as an ablation may be beneficial, in addition to your medication strategy, to help manage your AFib symptoms
  • There are many lifestyle modifications you can make to help improve the effectiveness of your medication strategy. Your medical team can help you with strategies and referrals