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Atrial-Fibrillation Patients Have Increasing Options for Treatment

By Jeanne Whalen

The irregular heartbeat known as atrial fibrillation is one of the toughest heart conditions to treat.

Drugs aimed at restoring a normal beat are often ineffective and can have serious side effects.The anticoagulants that many people with A fib, as its known, need to take can react with other

drugs and raise the risk of bleeding.

Now, alternatives are increasing: A new drug was approved this month, and a relatively new

surgical procedure is growing in popularity. But their long-term benefits are still unclear, somedoctors say.

We all groan when we get a patient with A fib, says Dara Lee, a cardiologist at Presbyterian

Heart Group in Albuquerque, N.M.

Atrial fibrillation occurs when the hearts upper chambersthe atriabeat erratically. Blood canstagnate and clot in these chambers, and some clots can travel to the brain, causing strokes.

People with the condition also have a higher risk of developing heart failure. In many people,

atrial fibrillation isnt life-threatening. But it can cause symptoms such as palpitations, shortness

of breath and fatigue.

There is enough confusion about treating the condition that the Institute of Medicine, a National

Academy of Sciences branch that advises the government on health issues, recently

recommended atrial fibrillation as a top priority for federally funded research into the besttreatments.

For doctors, a key dilemma is whether to try to return the heart to a regular beat. Doing so canrelieve symptoms, but there is little evidence that it reduces the risk of stroke, according to

William Maisel, a cardiologist at Beth Israel Deaconess Medical Center in Boston. Also, theanti-arrhythmia drugs traditionally prescribed for this purpose dont work in many patients,

doctors say, and can have bad side effects. Patients who take amiodarone, one widely used

treatment, can develop pulmonary fibrosis, which causes scarring in the lungs. Sometimes,

amiodarone can also make an irregular heartbeat worse.

In some patients, doctors instead try to slow down the irregular heartbeat with beta blockers or

calcium-channel blockers. An influential 2002 study showed that this strategy may have

advantages. Patients who were treated with the aim of restoring a normal heartbeat didnt live

longer than those whose irregular heartbeats were merely slowed down. Also, they werehospitalized more often than the latter group and suffered more side effects from their drugs.

The U.S. Food and Drug Administration this month approved for sale the first new anti-

arrhythmia drug in many years: Multaq, from Sanofi-Aventis SA. In a trial of 4,600 people withatrial fibrillation, the drug reduced a patients risk of death or hospitalization due to

cardiovascular problems when compared to a placebo pill. The drug, also known as dronedarone,

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carries a black-box warning that it shouldnt be used in patients who have recently had severe

heart failure, because it can cause severe problems including death.

Dr. Lee said she would like to see research comparing Multaq to amiodarone to help her decidewhich is a better bet. Dr. Maisel said there are some indications that Multaq may have fewer side

effects. I dont know that it offers a huge advantage, but it offers another alternative, he said.

Surgical procedures are giving doctors more options. In radiofrequency catheter ablation, a long,

flexible tube is fed through the groin or neck to the heart, where it delivers electrical pulses thatdestroy small areas of tissue responsible for generating the irregular heartbeats.

The procedure has been used on only a small proportion of patients, but the drawbacks of drug

therapy have really started causing a migration of patients to ablation therapy, says David

Brown, a cardiologist and professor at SUNY-Stony Brook School of Medicine.

The procedure has been shown to help patients maintain a normal heart rhythm for up to a year,

but little is known about its long-term effects, an agency of the Department of Health and HumanServices said this month, calling for more research.

Reaction:

Atrial fibrillation (AF) is the most common form of arrhythmia encountered in clinical practice,affecting about one in 20 people aged 65 years or over in the UK (Sudlow et al, 1998). It can

affect both men and women, although a higher incidence has been recorded in men (Ruigomez et

al, 2002).

In the broadest sense, AF represents the loss of synchrony between the atria and the ventricles.

Typically, it is characterised as a 'storm' of electrical energy that travels in spinning waveletsacross both atria, causing the upper chambers to quiver - or fibrillate - at a rate of approximately

300-600 times a minute (Prystowsky et al, 1996).

The main goal of treatment is to maintain adequate cardiac output and tissue perfusion and toensure that the patient does not develop a thromboembolism.

To help allay patients' anxiety, the likely causes of their symptoms should be explained to them,

and suggestions made as to what may be done to remedy them. Patients should be asked if they

have any chest discomfort, as this is suggestive of myocardial ischaemia, in which case oxygentherapy may be of use. During the acute stages the patient will require continuous cardiac

monitoring.

Patients with AF can present as acutely ill but usually respond rapidly to treatment. During this

time, nurses can not only provide physical support to patients but also do much to relieve theirfears and anxieties.

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