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When I discuss management of atrial fibrillation with patients I really try to educate them
that there are two independent issues we need to address. The first and arguably the most
important is the inherent thrombobolic, or stroke risk, associated with the condition.
Roughly 20-25% of all strokes in America are likely caused by atrial fibrillation. And
as such, that needs to be the first order of business, making a decision about what,
if anything needs to be done to prevent that. For some patients it’s simply nothing, other
patients it’s aspirin, other patients it’s stronger blood thinners such as Warfarin or
the newer agents dabigatran, rivaroxaban. Once we’ve dealt with the stroke risk associated
with the atrial fibrillation for an individual patient the next decision tree is how to manage
the symptoms. Basically there are two very different but good ways to approach the symptoms.
One is to simply use relatively simple medications to control the heart rate in atrial fibrillation.
These are not thought to necessarily keep one in or out of rhythm but rather they help
patients when they go into Afib to not feel so symptomatic. Those would be called AV Nodal
agents. The second type of medication which is often used for symptomatic patients is
what we call rhythm control medications. There is approximately six medications approved
that the primary job is to keep patients in rhythm. These medications are slightly stronger
medications than the rate control rhythms. But ultimately usually a very reasonable medication
regimen can be found for a patient to keep them in normal rhythm. Or at a minimum control
their symptoms when they go into the arrhythmia. The challenge with medications is that they
effectively put a governor on even normal heart rhythm. And so the biggest single complaint
or concern with the medicines is not that they don’t control the arrhythmia but rather
they limit one’s functioning when they’re in normal rhythm. And that would manifest
classically as someone who’s a conditioned athlete just notices that they can’t perhaps
work out as much or to the same extent, on the medications. It’s hard to put a number
on it but roughly if your peak heart rate is 140 beats a minute if we put you on some
of these agents you might notice it’s only 125 or 130. So it’s not per se a side effect
of the medicine it’s an expected outcome. Although a lot patients really don’t like
that especially if they’re very active patients.