Ask Dr. Keith Roach M.D
There is more than one approach to atrial fibrillation
DEAR DR. ROACH: I am trying to decide if it would be beneficial for me to get a second opinion about atrial fibrillation treatment. I was diagnosed in May after my doctor discovered that I was in atrial fibrillation while taking my blood pressure and heart rate at a routine appointment. I was given Xarelto in the emergency room and cardio- converted with flecainide. I was sent home with a prescription for Xarelto to be taken daily, and instructions to return to the ER if I felt dizzy or had fluttering, pounding, pressure or pain in my chest.
Eleven days later, I was out of state and felt many of those symptoms. At that ER, the doctors were incredulous and shaking their heads about the fact that I was not prescribed metoprolol the first time; they gave me a prescription to take daily. At my follow-up appointment with my cardiologist, he said it was fine to take both, that Xarelto is a new blood thinner and metoprolol is an old-school treatment, a beta-blocker for regulating the heart rate. He also said not to go to the ER unless I felt like I was having a heart attack, with very strong symptoms, since I was taking medications. If I felt uncomfortable, I should call his office and wait several hours to do so, if I felt them in the middle of the night.
Several days later, I felt dizzy and my heart rate was clearly erratic, so I called his office. He called in a prescription for flecainide and told me to take three pills right away and if I didn't return to normal in a few hours to go to the ER on an empty stomach and get the paddle treatment to restore my heart rate. At a follow-up appointment he explained that I should carry the flecainide with me to take as needed. If necessary, he would adjust the dosages so I would take all three medicines daily, and if that failed, the next course of treatment would be ablation. Should I get another opinion? — P.D.
ANSWER: Atrial fibrillation is a common problem in older adults. It's a chaotic rhythm disturbance, and problems can arise from both too fast a heartbeat and from the possibility of clots. People with AFib often are treated with medication to reduce stroke risk (warfarin or a new medicine like Xarelto is most common, but a few people need only aspirin), and the atrial fibrillation itself is treated in one of two ways: rate control or rhythm control.
In rate control, a medicine is used to slow the heart rate. Beta blockers such as metoprolol are a common treatment, as is a calcium channel blocker like verapamil. (Digoxin, a preparation of the foxglove leaf, is REALLY old-school treatment.) In rate control, people stay in AFib but the heart rate is kept at a safe level.
Flecainide, on the other hand, is used for rhythm control, to try to keep people out of the AFib entirely. Your cardiologist has chosen rhythm control for you, and it sounds like you have had at least two episodes where you went back into AFib (probably with a fast heart rate) — which means that it's not working so far, and that's why he may be adjusting the dose. Some cardiologists do prescribe flecainide to allow patients to self-convert if they go into AFib: It's controversial, and other cardiologists prefer their patients to be in a monitored setting before getting flecainide. Some cardiologists will try a different rhythm agent (such as sotalol or amiodarone).
Ablation is a possibility as well, but it doesn't work for everybody. Anticoagulation remains necessary for most people with atrial fibrillation, but can be discontinued if rhythm control is proven successful.