What is Atrial Fibrillation
Atrial fibrillation is an irregular and often rapid heart rate that can increase your risk of strokes, heart failure and other heart-related complications.
During atrial fibrillation, the heart’s two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms often include heart palpitations, shortness of breath and weakness.
How A Pharmacist Can Help AF Patients Choose The Right Blood Thinner
Atrial fibrillation is a situation where the two top chambers of the heart – the atria – begin to beat irregularly. The problem with that is small blood clots can form in the atria, and those blood clots can float out and travel to various parts of the body.
If they travel to the brain they can cause a stroke, and stroke is a devastating complication. People with atrial fibrillation are more likely to have a stroke than those without. Blood thinners, or anticoagulants are very effective in decreasing the risk of stroke. And pharmacists can work with you to find the blood thinner that works best for you.
Now typically these drugs reduce the risk by two thirds or more. Traditionally, we’ve used Warfarin as our blood thinner of choice. More recently, we’ve had some new blood thinners come on the market that are more convenient, easier to use, as effective or more effective than Warfarin, as safe or safer than Warfarin, and it can make your journey just a little bit easier in managing your AFib.
The key though, is to take your medications regularly for the rest of your life. Taking medications regularly isn’t always easy, and that’s a behaviour that’s sometimes we have to learn. Atrial fibrillation is a chronic condition. That means that we’re going to have to take medications for the rest of our life.
The Link Between Poor Sleep and Atrial Fibrillation
I think sleep patterns are – you know, when you talk to the patients and we talk about sleep patterns – patients don’t sleep anymore. You know, we go to bed later, we’re up earlier, so we’re not having a restful sleep.
All our patients are screened for obstructive sleep apnea, because as we know, as research shows, that atrial fibrillation can be caused by sleep apnea. So you may not look the type for obstructive sleep apnea, but when you do the screening, you know, do you get a restful sleep? Do you snore at night? Do you wake other people up while you’re snoring? Do you stop breathing? All those questions are asked to rule out any sleep apnea, which is a trigger for atrial fibrillation.
The Link Between Atrial Fibrillation and Alcohol Consumption
Dehydration, you know patients with atrial fibrillation, you know, are dehydrated. They drink too much coffee, alcohol definitely can be a trigger. You know, around the holidays we see more atrial fibrillation coming through our emergency departments, and trying to manage has, you know, a huge impact on our healthcare system.
Atrial Fibrillation and Treatment Options
The symptoms of atrial fibrillation can be very variable. Firstly, the most frequent symptom a patient can have is palpitations. They feel their heart beating fast, they feel their heart beating rapidly, hard, irregularly. These are the symptoms that people usually complain about.
Some atrial fibrillation, though, can have no symptoms at all. And then you can have people who feel shortness of breath, who are tired, or who have chest pains. Atrial fibrillation can have different patterns. Sometimes it can be intermittent, which means that it starts beating irregularly and then goes back to normal rhythm on its own.
Sometimes atrial fibrillation can be more persistent. That means it stays in that irregular rhythm for days, weeks, sometimes months or years, and can eventually become permanent, so the heart will always be in atrial fibrillation.
The first and most important thing when treating atrial fibrillation is to make sure that we prevent the risk of stroke. And that’s usually done by giving blood thinners. Once that is done then we have two different strategies. Either we control the rate, which means we make sure that the heart rate is not excessively rapid, or we try to control the rhythm. That means that we will try to make sure that the patient stays in a normal rhythm and doesn’t go back into atrial fibrillation.
The way we decide on keeping a patient in atrial fibrillation and just controlling the heart rate is mostly based on the patient’s symptoms. So if the patient doesn’t feel the atrial fibrillation – and a lot of patients don’t feel their atrial fibrillation – we concentrate on making sure that the heart rate is not too rapid.
And that’s what we call rate control. Usually this can be achieved with medications, so we give medications that slow down the heart rate. In cases where that’s difficult, in cases where the heart rate is excessively rapid, we sometimes have to put in a pacemaker and burn the normal electrical activity of the heart, and therefore with that we’re able to control the heart rate.
When patients have a lot of symptoms from their atrial fibrillation, we have to adopt a different strategy, which is a strategy of rhythm control. What this means is we try to keep the patient in normal rhythm. The way we do this, firstly if a patient is in atrial fibrillation, we will do a cardioversion. Cardioversion involves putting a patient to sleep for about five minutes and applying an electrical shock to reset the rhythm back to normal.
This is usually just a temporary solution. The atrial fibrillation can come back. So now we have to use strategies to prevent the atrial fibrillation from coming back, and the way we do this is there are different types of medications that we can give that will help prevent what we call recurrences of atrial fibrillation. There’s a wide variety of medications we can use for this purpose. They have different levels of effectiveness, and that’s usually our first step in the strategy of rhythm control.
Sometimes medications are not effective in keeping the patients in normal rhythm. Sometimes medications can have side effects, and the patients don’t tolerate them. So then we have to do something different in order to try to maintain normal heart rhythm, and what we can do in that case is a procedure called an ablation, an ablation which is aimed at keeping the heart in a normal rhythm.
It’s done in one of two ways: either with heat, which we call radiofrequency ablation, or with cold, which we call cryoablation. Now, both of these procedures have the same kind of success rate. We talk about 80 percent success rate in order to keep the patient in normal rhythm for patients who have the intermittent form of atrial fibrillation, that is to say once in awhile. If a patient is in atrial fibrillation all of the time, the success rates are a little lower, somewhere in the order of about 50 percent.
These procedures are done in a specialized electrophysiology laboratory, where we do an intervention by passing catheters through the grain, bringing them to the heart, and burning or freezing the short circuits that cause atrial fibrillation.
These type of procedures obviously also have some risks. Fortunately the risks are very low, somewhere in the order of two to three percent. The most important risk that we’re concerned about with one of these procedures is the risk of stroke, which is in the order of about one percent. Some patients do require more than one intervention in order to get these types of success rates. However, we’re talking about overall procedures with very good success rates, and complication rates that are fairly low.
If you’d like more information on atrial fibrillation and how we manage it and treat it, speak to your doctor. You may need a referral to your cardiologist, and then they would be able to answer more of these questions on this very frequent arrhythmia. The most important thing if you suffer from atrial fibrillation, particularly if you feel it and have symptoms from it, speak to your cardiologist.
There are treatments, including medications, including a pacemaker, and if you want to be evaluated to see if you are a candidate for an ablation procedure, then you can be seen at the atrial fibrillation clinic at the Montreal Heart Institute.
Presenter: Dr. Peter Guerra, Cardiologist, Montréal, QC
Bill Semchuk, BSP, M.Sc., Pharm D, FCSHP, Pharmacist, discusses Atrial Fibrillation, stroke prevention and how a pharmacist can help AFib patients choose the right blood thinner.