Q: I Have Afib, Medications Aren’t Working, What’s My Next Step?

I think that we can answer the second part of the last patient’s question and answer that question. So, rhythm controlling drugs are reasonable to take, so the last patient’s question was whether or not it’s reasonable to take rhythm controlling medications before ablation. Some of those rhythm controlling medications will make atrial fibrillation stop altogether and never come back again, as long as the patient takes that medication.

Generally though, they don’t fix the root of the problem, so when the patient stops the rhythm controlling medication, the atrial fibrillation will unfortunately come right back. The rhythm controlling medications may not cause any symptoms or side effects, so they may be very tolerable, but for others it makes it so that the EKG is pretty and they no longer have atrial fibrillation on their EKG. But, they’ve traded the symptoms from atrial fibrillation for the symptoms that come with the side effects of taking the medication.

If the medications aren’t working, then there are a lot of different medications that can be tried, but we don’t always want to just keep trying additional, different medications. Sometimes we actually have to give up on medications as an option and realize that we either have to accept atrial fibrillation for being there all the time, without medications, or going to ablation as an option. So, we don’t always have to leave ablation as the last ditch effort to salvage someone’s atrial fibrillation, after they failed multiple drugs. We may go to it early on, but certainly we don’t want to just keep changing from one rhythm controlling drug to another. Generally, if one rhythm controlling drug fails, we now realize that it’s unlikely that another rhythm controlling drug will work.

And, since we’re talking about it, there’s a distinction between the two ways we approach atrial fibrillation – whether we try and fix the heart rate when someone’s in AFib or we fix the heart rhythm. So, some of the drugs are called rate controlling drugs and their job isn’t to right the ship and push the patient’s rhythm back to normal rhythm, all they’re designed to do is to make it so there’s less symptoms and when they’re in AFib the heart rate isn’t too fast. Those are rate controlling drugs. Rhythm controlling drugs are the ones we’ve focused on mostly today, and those are the drugs that are really designed to fix the rhythm and help it stay in normal rhythm. They don’t cure atrial fibrillation, the idea is that rhythm controlling drugs make the episodes of atrial fibrillation fewer and further between. Typically, the bar that we set for ablation is a little bit different, so we look for rhythm controlling drugs to make it so you have fewer and further between episodes that are less symptomatic, where as ablation, we set the bar at we’re trying to cure atrial fibrillation so that you don’t need to take a medication and so that it never comes back.

Now, we may not achieve that, that’s the bar we set. We may have to settle for fewer and further between as the outcome of ablation, and that may be reasonable for some patients. So, if you’re having AFib for an hour a day and you have an ablation and then you’re having it for an hour once a month, that might be a good end point. And, maybe we didn’t cure it, but that patient might be actually happy with that outcome and not having to take a rhythm controlling medication. And other patients, the rhythm controlling drug may not be working, so we go for an ablation, and, after the ablation, there might be a synergistic effect for that drug that used to not work, it actually may work. So, it’s not unreasonable to go back to those drugs after an ablation, and it may be that the two were required together, in order to make someone’s atrial fibrillation go away and stay away.

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