Treatment Insights for A-fib
Sixty-eight-year-old Rick was feeling exceptionally tired, and his heart was beating unusually fast. He hadn’t eaten since breakfast, and it was late in the afternoon. He shrugged it off, had a turkey sandwich, and felt better. Later that week, he again felt a fluttery, uncomfortable feeling in his chest and made an appointment with his doctor.
Heart palpitations have numerous causes, including stress, some medicines, caffeine, low blood sugar, sleep apnea, and thyroid disease. In Rick’s case it turned out to be a symptom of atrial fibrillation, or A-fib, the most common type of arrhythmia, which is a malfunction in the heart’s electrical system causing an irregular heart rhythm. Age is a risk factor for this condition.
“Up to 20 percent of people will experience A-fib during their lifetime,” says cardiac electrophysiologist Eric Buch, MD, UCLA Cardiac Arrhythmia Center. “There are many possible treatment strategies, and it can be helpful for older adults with A-fib to meet with a cardiologist or cardiac electrophysiologist (heart rhythm specialist) with expertise in managing A-fib to talk through these options.”
Untreated A-fib can quadruple stroke risk, as the uncoordinated poor pumping action of the heart may allow blood to pool and form a clot. A dislodged clot can make its way into the arteries that supply the brain, causing a stroke.
Types of and Treatments for A-fib
A-fib most often occurs in people with high blood pressure, coronary artery disease, heart valve disease or cardiomyopathy (disease of the heart muscle). A-fib originates in the upper chambers of the heart (atria). During A-fib episodes, the atria are going so fast that they fail to beat effectively to pump blood. Paroxysmal A-fib may occur without symptoms, or may be felt strongly, but it’s intermittent and stops by itself in less than seven days. When A-fib lasts for more than a week, it is said to be persistent and will likely need treatment. Long-term persistent A-fib lasts for more than a year without stopping, and permanent A-fib means it is resistant to treatment.
Lifestyle changes, medicines, and procedures to help prevent blood clots, slow the heartbeat, or restore the heart’s normal rhythm are all treatment options.
“Rate control drugs work to slow down the heart, which is important because we know that fast heart beating for a long time can cause the heart muscle to become weaker,” says cardiologist Boris Arbit, UCLA Medical Center. “Rhythm medications are designed to change the rhythm of the heart from an erratic to normal sinus pattern. These medications require more training and advanced understanding to administer, as there are significant risks with their use.”
CABANA Trial Outcomes
The results from a 10-year randomized trial known as the CABANA trial (Catheter Ablation versus Antiarrhythmic Drug trial for Atrial Fibrillation) have recently been released. Two important papers reporting on this National Institutes of Health- funded trial were published in the March 2019 issue of the Journal of the American Medical Association. The results are meaningful to older adults because the median age of the 2,200 patients enrolled was 68 years.
According to the study, catheter ablation, a common cardiovascular procedure, appears to be about as effective as drug therapies in preventing strokes, deaths, and other complications in patients with A-fib. However, patients who got the procedure experienced greater symptom relief and long-term improvements in quality of life, including fewer recurrences of the condition and fewer hospitalizations, compared to those who got only drugs.
“It is important to address the quality-of-life outcomes, which are better with ablation,” says Dr. Arbit. “However, this places the focus back on a patient-physician conversation about risks-benefits and goals. In other words, knowing that the procedure won’t make a patient live longer creates a more complicated conversation about what the risks are and evaluating if they are worth the potential symptomatic benefit.”
Ablation success is around 70 percent, defined as no detectable A-fib for one year after ablation. Some of the other 30 percent of patients experience fewer or shorter A-fib episodes after ablation, and so feel better even though the procedure was not completely successful.
Dr. Buch, who worked on the trial agrees, pointing out that both antiarrhythmic drugs and catheter ablation are reasonable options for older adults with A-fib, and the decision about whether to choose one of these treatments must be individualized for each patient.
“Many studies have shown that catheter ablation for A-fib can be done safely in older adults, even over age 80,” says Dr. Buch. “The main indication for the procedure is relief of symptoms, such as palpitations, fatigue, and shortness of breath. Many older adults are less likely to tolerate antiarrhythmic drugs due, to side effects.”
Catheter ablation is considered a minimally invasive procedure. A thin, flexible tube (catheter) is threaded through blood vessels to the heart, and an instrument transmits heat or cold to silence the electrical activity in the heart muscle tissue that’s causing abnormal electrical signals. The procedure may last two to four hours and require an overnight stay in the hospital. A small bandage covers the catheter insertion site; no stitches are needed. After the heart has healed, which can take two to three months, the abnormal heart beats usually diminish.
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