Atrial fibrillation

Heart rate and rhythm medication for atrial fibrillation

People with atrial fibrillation (AF) have a range of treatment options available. These include anticoagulant (blood thinning) medicines to reduce the risk of stroke and anti-arrhythmic medicines to control the symptoms of AF and restore normal heartbeat and rhythm. In some cases surgical procedures such as cardioversion, catheter ablation, pulmonary vein isolation ablation, AV node ablation and having a pacemaker fitted may be used when medication proves unsuccessful or unsuitable. Treatment depends on things like the person’s age, general health, symptoms and type of AF. 

Here we look at anti-arrhythmic medication. This is designed to control heart rate (how fast it beats) and rhythm (how regularly it beats). Prescription medicines can help control both the rate and rhythm of the heart and for most people with AF taking medicine is part of everyday life. Which medication is best for a particular person depends on many things, including their symptoms and how long they have had AF. Rate control lowers the heart rate closer to normal, usually 60 to 100 beats per minute, without trying to convert it to a regular rhythm. It can be achieved with beta-blockers (such as atenolol and bisoprolol), calcium channel blockers (such as diltiazem and verapamil), or cardiac glycosides (such as digoxin, which is often used in sedentary patients). Rhythm control aims to restore normal heart rhythm and maintains this with beta-blockers (such as sotalol), and other anti-arrhythmic drugs such as flecainide, amiodarone and dronedarone.
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People we interviewed spoke of the positive effects of medication in helping to control their AF. Elisabeth X, in permanent AF, takes digoxin, a beta-blocker, and blood pressure medication; a combination which, while not stopping her AF, gives her ‘a reasonably firm heartbeat’. Nuala found a combination of digoxin and sotalol worked well in controlling her symptoms; while Eileen spoke of how candesartan, a blood pressure medication, and diltiazem ‘sort of worked in tandem’ to keep her well. If she stopped taking either one, or forgot to take it, it caused problems.
Some people with paroxysmal AF (episodes which come and go) spoke of their use of ‘pill in the pocket’ rhythm medication (such as flecainide) which they took when they had an episode of AF. They said it gave them increased confidence and feelings of ‘being in control’. 

Like any medication, drugs for AF can have side effects.
Elisabeth X described herself as ‘an awful patient’ who couldn’t get on with any drugs, Eileen had ‘tried every drug in the book’ only to find that they either had side effects or had no effect on her symptoms. This story was reiterated by a number of people. Others spoke of the side effects of beta-blockers, including dizziness (especially a problem for those with low blood pressure), sleeplessness, feeling tired and breathless, being ‘slowed down’, feeling ‘washed out’, depression, a dry, hacking cough, and psoriasis. Paul tried a number of beta-blockers, settling on bisoprolol, but found it disconcerting that he could not raise his heart rate a great deal, even when exercising. Bob said he was wheezy, ‘felt dreadful’ and ‘like the six million dollar man in slow motion all the time’ while taking atenolol. David X found he did not get on well taking the beta-blocker bisoprolol: ‘I just couldn’t exist. I couldn’t operate, I was so laid back I just didn’t want to do anything. It was a hopeless situation’.
After taking the beta-blocker sotalol for two years, Carin had an operation which required her to stop taking the medication. She said that she felt so much better that she decided not to restart it. She had recently started using homeopathic medicine but had not noticed an improvement in her symptoms as yet. Pauline said she felt that one brand of sotalol was more effective than another despite her doctor telling her that there should not be a difference. Dot, who experienced cold extremities (e.g. hands and feet), lack of energy and nightmares on beta-blockers, continued to take them as she felt the side effects were ‘absolutely worth putting up with’.
People also talked about the side effects they had experienced on anti-arrhythmic drugs, (such as amiodarone and dronedarone), including swollen ankles, heavy legs, nausea, breathlessness and lack of appetite. Eileen found herself ‘up and down to outpatients’ when amiodarone caused a flare-up of irritable bowel symptoms. Chris X spoke of his frustration at having been put on amiodarone straight away, rather than being started off on more ‘benign’ drugs. He described it as a ‘truly awful drug’ which affected his sight and his thyroid, made his skin turn ‘slate grey’, and made him feel ‘fairly depressed’. George Y, however, found amiodarone to be very effective, and was disappointed when told he could not stay on it long term due to potential effects on his liver. Geoff had tried dronedarone, which had been hailed as a ‘wonder drug’. He called it ‘an absolute total disaster’ which made him constipated and increased his AF symptoms.
While many people we interviewed accepted the important role that medication could play in managing their symptoms and minimising stroke risk, some spoke of their initial resistance to taking drugs.
Others explained how they had tried to gain a sense of control over managing their condition by not taking recommended drugs, adjusting the dosage or stopping the medication altogether. Dave chose not to take beta-blockers when he heard that he would have to ‘continue taking them’ for the rest of his life. Ginny stopped taking beta-blockers for a short while before an ablation because they were disturbing her sleep.
(For more see ‘Atrial fibrillation, stroke risk and blood thinning medication’, ‘What is it like being on warfarin for atrial fibrillation’, and ‘Alternatives to warfarin for atrial fibrillation: the new anticoagulants’).


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