Medications Versus Catheter Ablation
Very often, when a patient complains of heart rhythm issues, their primary care physician or cardiologist will start them on medication to try to improve symptoms or restore normal rhythm. Medications are, after all, easy to prescribe and widely understood by patients as the first course of action in treating diseases and disorders.
Commonly prescribed drugs include:
- Rate control medications (these include beta blockers and calcium channel blockers). These medications lower the pulse rate in those patients that happen to have a fast pulse (average >110bpm) in AF. They do not fix the other consequences of AF such as stroke, earlier onset dementia, and shorter lifespan (mortality). Importantly, many of them have side effects that only serve to compound the symptoms of AF such as fatigue and swelling of the legs.Digoxin, an older medication, is rarely used anymore since it is associated with an increased risk of death. Only special circumstances would justify this risk.
- Rhythm control medications also called antiarrhythmia drugs or AAD are intended to make episodes of AF shorter and further between. They are not expected to make AF stop altogether. As with rate controlling medications, even if AF is suppressed, most replace the symptoms and consequences of AF with side effects of the drug. Thus, the ECG and pulse may be improved but the drug may make the patient feel just as bad or worse than from the AF itself. The effects of AADs often diminish over time, such that AF can worsen even though early on the drugs seem effective. Importantly, most of these drugs are associated with an increased risk of earlier death (mortality) or severe long term consequences with amiodarone. They are not prescribed lightly and require as much of a detailed consent process to insure patient understanding of risks, benefits and alternatives similar to consent for surgery or procedures.
- Anticoagulants (blood thinners) are drugs used to reduce the risk or stroke from AF. They reduce the risk of stroke in clinical trials by about 65% so patients must understand that they do not eliminate stroke risk. They come at the price of increased bleeding risk. This is much improved with newer blood thinners called direct acting oral anticoagulants (DOAC) as compared with warfarin, a vitamin K antagonist. DOACs do not require frequent blood tests or adjustments. The bleeding they cause can make a minor injury have severe consequences and limit a patient’s ability to engage in activities such as snow-skiing. Less well appreciated by patients is that spontaneous bleeding in the brain (intracranial hemorrhage) or bleeding in the stomach or intestines (GI Bleeding) happens without any warning and may be fatal or require transfusion. It is critical to eliminate any other blood thinners if possible, such as ibuprofen and aspirin as well as blood thinning supplements like fish oil, vitamin E, gingko biloba, and even some antidepressants (SSRI drugs).Stroke risk extends well into the days to weeks after an episode of AF resolves. As a result of the fact that a stroke can happen when a patient is in normal rhythm, months after an AF episode ends, we never condone starting and stopping anticoagulants based on symptoms or just because the pulse normalizes.
There are two very significant considerations when looking at medication as a treatment for atrial fibrillation and other arrhythmias. First is that only about 50% of patients receive significant benefit from their medication. That means a full half of patients will not get the relief that they need or expect. Medications also come with oftentimes significant side effects. Of course, the overarching problem with medications is that they only treat the symptoms of arrhythmia and are not effective if the patient does not continue to take them indefinitely.
Catheter Ablation as A Curative Option
Catheter ablation represents a relatively low risk and highly effective curative procedure for many common heart arrhythmias including atrial fibrillation. It is particularly suitable for patients who do not wish to begin or continue a medication regimen or for whom medication is causing significant side effects or unacceptable results.1
Because of the success rate of cardiac catheter ablation, many patients will see significant, often permanent, relief from their symptoms within weeks. Touch ups are easily performed, if needed, during the follow-up process. In many cases, patients will no longer have to take their rate or rhythm control medications. In centers unable to offer this, radiation exposure can be high enough to increase the risk of cancer in the long term, and even cause burns in the short term. This virtually eliminates one of the greatest concerns of patients undergoing a traditional cardiac ablation when a patient has a specialized EP perform their ablation.
Of course, some abnormal heart rhythms require alternate solutions such as a pacemaker with an AV node ablation. Fortunately, options are improving at an astounding pace and now include leadless pacemakers that require no incision and are delivered through a catheter. In addition, some cardiac surgeons specialize in an effective, albeit invasive, option that can address some of the most difficult AF. In certain patients the combination of catheter ablation along with a surgical approach (VATS-MAZE or convergent) may be the best option.
To understand all the options available to you, it is important that you speak to a qualified electrophysiologist – a physician that specializes in disorders involving the heart’s rhythm. Most patients will find they have many options available to them, from minimally invasive implants to outpatient procedures and even certain medications. With a shared decision-making approach in which a patient is educated about each option and arrives at a treatment option that best suits them; the patient becomes an integral part of their own medical team.
1January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary, Journal of the American College of Cardiology (2014), doi: 10.1016/j.jacc.2014.03.021.