The Three Types of AFib & Their Treatment Options
Just as there are different types of irregular heartbeats, known as arrhythmias, so too are there different forms of Atrial Fibrillation (AF or Afib)
Paroxysmal AF is a periodic, irregular heartbeat that returns to normal after some time without any medical intervention. Essentially, it is occasional Afib with episodes that always last less than 7 days. The length of time that paroxysmal AFib occurs varies between patients and can be as short as a few seconds, or as long as seven days. After an episode of AFib, the heart will return to normal rhythm but can be stunned and dysfunctional for days to weeks even after normal rhythm returns. Rarely, people have predictable triggers of Afib (like alcohol or exercise), but for most there is no way to predict paroxysmal AF. It’s not unusual for patients who suffer from this condition to develop some degree of anxiety as they anticipate the next episode. The anxiety about when the next episode might disrupt life is often just as bad as the AF itself. Oddly, compared to patients that are in AF all day every day for extended periods (persistent AF) those patients with paroxysmal AF tend to have greater severity of symptoms.
Diagnosing paroxysmal AF may require some degree of trial and error. Unless the patient is experiencing AFib at the time of evaluation, an electrocardiogram or EKG will not pick up the arrhythmia. Similarly, patients may have so much time between episodes that a twenty-four hour monitor would also miss an episode. As a result, an implantable loop recorder might be the best way to diagnose the problem; it is a small device injected under the skin in the office that watches the heart rhythm 24/7 for 3-5 years, remotely transmitting data once a month to Dr. Gidney’s office.
Paroxysmal AF is sometimes the first manifestation of AFib before it progresses to persistent AF and it is important to address it early with a discussion of treatment options include blood thinning medication such as warfarin to reduce the risk of stroke, as well as cardiac catheter ablation and antiarrhythmic drugs.
Persistent AF involves atrial fibrillation in which each episode is longer than 7 days or does not stop without some sort of intervention. Patients with persistent AF are in a constant state of AFib. In fact, because AFib is ongoing 24/7, patients often accept its symptoms as “the new normal” and do not even realize the AF is causing their fatigue or exercise intolerance.
The most common causes of persistent AF are untreated or undertreated paroxysmal (occasional) AF. Because atrial fibrillation is a progressive disease, it is important to have any irregular heartbeat evaluated and treated in its early stages – the earlier the better.
In order for the heart to return to normal rhythm, patients are sometimes brought in for a cardioversion, a procedure in which the heart is given a measured electrical shock while the patient is sedated. This is almost always a temporary fix and AF eventually returns within an unpredictable time frame from minutes later to many years later. Because AF is progressive, sometimes the very first time a patient is cardioverted the heart may remain in normal rhythm for a year whereas the next time it may work for a few days, and the next time not at all.
Since a “successful” cardioversion most often involves a finite period of time in normal rhythm it is important to remain on blood thinners for most patients even after it appears to have worked. Certain drugs, called antiarrhymic drugs, can help extend the period of time a patient stays in normal rhythm after a cardioversion. Finally, a cardioversion with or without an antiarrhymic drug, often works well when combined with a curative cardiac ablation since it can help relieve some symptoms while waiting for the ablation.
Long Standing Persistent AF
Long Standing Persistent AF means that a patient has been in AF for more than a year without return to normal rhythm. AF is progressive and damage known as remodeling is being done to the heart with more extended periods of AF. By defining this type of AF it lets the doctor and patient know that while possible to fix, it may be the most stubborn and require more time, effort, and increased likelihood of repeat ablations and cardioversions with the help of antiarrhymic drugs.
Permanent AF is best thought of as a state of mind. It indicates that a conscious decision has been made by the doctor and the patient that no further attempt to restore normal rhythm will be made. In other words, if one doctor says the patient has “Permanent AF” and the next doctor says it is worth trying to fix, we just stop calling it “Permanent AF” and go back to calling it Persistent AF!