What is AF?
Atrial fibrillation (AF) is the most common heart rhythm disturbance affecting adults. Most people with atrial fibrillation have symptoms like palpitations, weakness, lightheadedness, shortness of breath, and exercise intolerance. AF can adversely affect the quality of life in the majority of people who get it. Medical therapy can help control this arrhythmia, but the drugs prescribed may have significant side effects. In addition, recurrent episodes often result in a visit to the emergency room. A recent study now shows that an alternative medical strategy can help avoid these problems.
AF comes in two distinct varieties. Sometimes it will come and go, starting suddenly and lasting anywhere from minutes to days before going away on its own. This type of atrial fibrillation is called “paroxysmal AF.” Other patients can have “persistent atrial fibrillation,” which, as the name implies, does not go away by itself once it occurs. Those patients have to undergo a procedure known as a “Cardioversion” to restore a normal rhythm. Cardioversions are done with deep sedation and restore a normal rhythm using a strong but brief shock applied to the chest.
Patients with persistent AF can be maintained on pills known as “antiarrhythmic” medications, which stablilize the electrical characteristics of the top chamber (atrial) heart muscle cells and keep patients in a normal rhythm. Likewise, patients with paroxysmal atrial fibrillation can also be placed on antiarrhythmic meds to reduce the chances of having an attack and perhaps make the symptoms more tolerable until the rhythm reverts to normal again.
Medical Therapy For AF?
If you have paroxysmal atrial fibrillation, taking a pill every day (or sometimes multiple times a day) to prevent AF is reasonable when the episodes occur frequently or last a long time. But what if someone has AF attacks only once or twice a year? Is it necessary to take meds every day to prevent such an infrequent occurrence? Is there a better way to manage that particular problem? Well, there is, and it is known as the “Pill in the Pocket” approach. In essence, the patient takes the antiarrhythmic medication only when they have an AF attack. The pills are taken in order to shorten the AF episode and work to quickly convert the patient back into a normal rhythm. This is not a new strategy. Cardiologists and electrophysiologists (heart rhythm specialists) have used this approach for decades. However, there is very little data on how well it works.
Now, a recent article from the University of British Columbia in Vancouver, Canada, demonstrated the clinical effectiveness of the “pill in the pocket” approach in the management of paroxysmal atrial fibrillation (PAF).[*] Patients who came to the emergency room with PAF associated with a stable blood pressure were given a regimen including a rate-slowing drug followed by a large dose of an antiarrhythmic drug (either propafenone or flecainide). This technique resulted in conversion of the rhythm to normal in two-thirds of patients.
Some of the other patients had adverse effects from the drugs, including low blood pressure, worsening of the arrhythmia, or excessive slowing of the heart rate. The 30 patients that had effective conversion with no ill effects were given these medications to take at home. The result was that out of a total of 159 episodes of atrial fibrillation that occurred in those 30 patients, the vast majority of the episodes were successfully terminated at home with the “pill in the pocket” medications, thus avoiding the need for an emergency room visit.
If you have paroxysmal atrial fibrillation that occurs on rare occasions, you may be a candidate for this kind of treatment strategy. Ask your cardiologist about the “pill in the pocket” approach, or see a cardiac electrophysiologist about whether this strategy makes sense for you.
[*] Andrade JG, et al. Clinical effectiveness of a systematic “pill-in-the-pocket” approach for the management of paroxysmal atrial fibrillation. Heart Rhythm 2018;15:9-16.