A-Z

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.
 

Dr Tim Holt explains the types of anti-arrhythmic medication used to treat AF.

Dr Tim Holt explains the types of anti-arrhythmic medication used to treat AF.

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There are a number of drug treatments that can be used to either reduce the heart rate and control the heart rate. They’re called rate control measures and then there are other drugs, which are given usually by specialists, that can also actually restore or help to maintain the normal rhythm once it’s been restored. So, in general practice, we often use rate control medications like beta blockers or calcium channel antagonists or digoxin to control the patient’s heart rate and that often relieves a lot of their symptoms. And, when their symptoms are relieved, the next question is whether this person needs to be started on blood thinning treatment to reduce their stroke risk.

There are drugs used which are largely in the remit of specialists and I’m thinking of drugs like amiodarone and dronedarone and also drugs like flecainide, which are prescribed and initiated in a specialist setting. They have side effects that all need to be discussed with the patient. It needs to be clear what the purpose of the drug is, whether it is to stabilise the heart or simply to control the rate. Some of these drugs are only used in the situation where the more commonly used drugs have not succeeded in controlling the heart rate. In other situations they’re used to stabilise the heart and make the cardioversion treatments, where the heart rhythm is restored electrically, to make that process more successful.
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.
 

Chris Y found that a combination of flecainide and bisoprolol has helped reduce his symptoms.

Chris Y found that a combination of flecainide and bisoprolol has helped reduce his symptoms.

Age at interview: 64
Sex: Male
Age at diagnosis: 62
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Yes, I mean I can have it and I know I’ve got it, but I just carry on. I don’t, you know, it doesn’t, it’s not as debilitating as before when I was, [gasping] you know, really breathless, really clammy and any exertion was just too much. Now it’s, obviously the medication has taken those symptoms down to a level where I can I can function. Normally, I can function with it, with, I mean obviously, I don’t sort of jump about and running and doing things like that. I don’t get very active, but I can carry on normal every day activities without it causing me any problems, yeah.
 

After initially resisting going on medication, Jeni found that beta-blockers helped her.

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After initially resisting going on medication, Jeni found that beta-blockers helped her.

Age at interview: 41
Sex: Female
Age at diagnosis: 40
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I’m currently on beta-blockers at the moment, which I didn’t want to be on, because, of course, they lower your blood pressure and my blood pressure is already low, in the meantime, just to keep my heart regular because I was having too many episodes of my palpitations coming. So they decided to give me a small dose, the smallest dose of bisoprolol, which is a beta-blocker. So I’m on those at the moment, which were very interesting to get used to. You felt very drugged, shall I say, and dizzy, for the first few days just not quite, you felt like your body was one place and you were another place because, of course, it’s regulating everything and again, your body has got to get used it. But I haven’t had any big palpitation issues. I get dizzy. I get tired still but I’m not as breathless. Before, after my major palpitation incident, I was constantly breathless. I felt like I was a little old lady, you know.

Now I’m on the beta-blockers it’s also made me realise how poorly I was for a while and how my heart was having to work overtime. So I do feel better now I’m on them, I just don’t want to be on them long term.
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.
 

Dr Tim Holt discusses the side effects people may experience on anti-arrhythmic medication.

Dr Tim Holt discusses the side effects people may experience on anti-arrhythmic medication.

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Yes, there are some side effects. Beta blockers, for instance, are quite commonly associated with the feeling of tiredness and lethargy and an inability to exercise as well as the person could previously. And that’s quite a common quite a common problem, quite a problem for some people. Similarly, calcium channel antagonists can often cause swollen ankles, which is a problem. Either of those two drugs can reduce the blood pressure and that can sometimes be reduced further than is intended so that can cause dizziness. Either of those two can also reduce the heart rate, which, of course, is the purpose of giving them but there’s always some risk of it going down too low. And then for digoxin there are a number of other side effects, which are quite likely to occur if the dose is too high for the patient. So it’s very important to be, if you’re using the drug digoxin, to make sure that the patient isn’t getting too much of it and, as the person gets older and their kidney function perhaps reduces over time, then the dose of the digoxin needs to be reviewed to decide whether it’s still appropriate.

So what sort of side effects might people expect on digoxin?

Well, quite a common side effect is nausea and loss of appetite and weight loss and sometimes this occurs in people who have been taking digoxin for some time and those sorts of symptoms, obviously, can be caused by lots of different conditions but if other conditions have been ruled out, you always need to remember that those symptoms can be related to that drug. And it then may be necessary to either reduce the dose and see whether the person feels better or to actually check their blood levels.
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’.
 

Elisabeth X felt ‘detached from life’ on beta-blockers.

Elisabeth X felt ‘detached from life’ on beta-blockers.

Age at interview: 74
Sex: Female
Age at diagnosis: 30
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I don’t like being on the beta-blocker very much and it’s all right at the amount I’m on now and I take it at night to minimise the effect on, because I don’t like that kind of glass wall that beta-blockers put between you and the rest of the world.

In what way? How do they, what do you mean by that?

Well, a friend of mine, who used to take them for, when he was facing stressful situations, he called them, ‘don’t care a damn pills’ and that’s what it's like. It’s as if you’re detached from. From life and I don’t like that. I’d rather feel.
 

Carin described the side effects she experienced on the beta-blocker sotalol.

Carin described the side effects she experienced on the beta-blocker sotalol.

Age at interview: 62
Sex: Female
Age at diagnosis: 55
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I was sent home on high dose of sotalol and they gave me terrible side effects. It was horrible being on sotalol. I felt so tired, really exhausted, depressed and but fearful as well that I had to take that medication, because well, it was a preventative sort of measure and there was nothing else that they really would do to me, because my heart rate had reverted but to a to a normal sinus rhythm. But after a few months, after a couple of months, one evening, there it was again, it popped up with, I was on sotalol at the time. And so off I went to hospital again, off I was admitted again and I was, my sotalol levels were increased so I was on such a big dose of that stuff, feeling horrendous with it. I was I was sent home. It was around Christmas time. I was sent home with the heavy, heavy dose of sotalol, and my GP was going to like sort it out. So every three days I the sotalol was increased, and I just felt horrendous with it, until my heart rate reverted again. 
 

Jeni, a teacher, explained how her body gradually became accustomed to beta-blockers after experiencing side effects in the early stages of treatment.

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Jeni, a teacher, explained how her body gradually became accustomed to beta-blockers after experiencing side effects in the early stages of treatment.

Age at interview: 41
Sex: Female
Age at diagnosis: 40
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It’s very common in the first few days. I was warned. I took my first one on a Wednesday morning and went into work and by the afternoon I felt very strange, very dizzy, like being drunk. I felt very drunk and sort of was finding it difficult to think and so I was slurring my words a bit, which the students found very amusing. Luckily, I had another teacher with me so she sort of, “You okay, Jeni. You’re not looking.” I said, “No.” So the next day I got up to go to work and felt very peculiar, very dizzy and odd, took the dog for a walk and nearly fell over. So I thought, “No, maybe it’s not a good idea to drive to work and stand in front of teenagers.” It wouldn’t be very fair on them, especially as I work, I have a practical job and we use machine tools. If I wasn’t fully compos mentis it wouldn’t be very safe. So I took two days off, just adjusting to the tablets. You know, I felt a bit dizzy. They can, when you first start them, give you a bit of a stomach but I didn’t have that issue, which was good. You can get headaches but I haven’t. So the first few days, I mean the arrhythmia nurse actually rang me on the Thursday to check I had collected them and started them. I said, “Yes, I’m on day two and.” “Oh, they’ll make you feel a bit strange.” “Yes.” She said, “Ah.” And her next words to me, “You’re not at school are you?” “No, I decided to take a couple of days.” “Good idea.” And I’m glad I did because it got me used to them.
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’.
 

Noel’s doctor reduced his dose of beta-blockers after he complained of cold hands and feet.

Noel’s doctor reduced his dose of beta-blockers after he complained of cold hands and feet.

Age at interview: 62
Sex: Male
Age at diagnosis: 60
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He reduced the beta-blocker because that would, five, certain beta-blockers and a certain strength of beta-blocker will give you cold hands, cold feet and cold extremities, and that was very true and I just wasn’t sleeping. I was getting pins and needles at night. It was horrible actually. When I think about it, considering I didn’t have cancer or, you know, some horrible disease that that that kills people, I was still feeling absolutely terrible. From going from feeling fit and healthy one and a half years ago to being dependent on all these drugs and getting, you know, feeling freezing cold in my hands and feet at night, when I never was before, and getting pins and needles all the time and severe palpitations, horrible. 
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.
 

Glyn described the side effects he experienced while on amiodarone.

Glyn described the side effects he experienced while on amiodarone.

Age at interview: 64
Sex: Male
Age at diagnosis: 56
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Amiodarone, I was on that from twelve months, from December two thousand ten until December two thousand and eleven and then, as I say, in the middle of December last year, they decided for me to, [coughs] excuse me, to come off it. You know, so as I say, the only thing with that is it takes six months to go through your system.

So are you still getting side effects?

I’m still getting side effects from amiodarone. The worst side effects are nightmares, dry mouth and also there’s, the worst side effect of all with amiodarone, is you’ve got to watch direct sunlight. If direct sunlight gets on your arms or your legs or your face you can you can burn your skin. So you be very, very careful when you go out in the sun that you’re well wrapped up, in fact, you know, which I was last summer and I was well you call it creamed up, as they said, you know, with sun cream every time. I got arms, legs, head everywhere, neck everything, even the top of my head, I was putting it on as well. 
 

David X talked about the side effects of dronedarone.

David X talked about the side effects of dronedarone.

Age at interview: 73
Sex: Male
Age at diagnosis: 61
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I know that dronedarone, which was a new AF drug, which everybody was raving about, which it was hoped would be a replacement for amiodarone, but which hasn’t lived up to its expectations. There have been some side effects. I know there was one person who died of liver failure. I think it was liver failure. But generally speaking, all of these new drugs have to be assessed over time, where some of these problems are not going to be manifest until you’ve had them in clinical practice for quite some time. 
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.
 

Elisabeth X realised that she could not control her AF without medication.

Elisabeth X realised that she could not control her AF without medication.

Age at interview: 74
Sex: Female
Age at diagnosis: 30
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I used to try and, in fact, what I didn’t say, which was quite a feature of the early my early days with AF, that I had the kind of feeling that I could control it if only I did it better. So from time to time, I would stop all the medication, just like that. “I can manage this. I can I can deal with this,” I would say to myself. “I’m all right. I don’t need it.” And then, well, I don’t know how long but then it would all start up again and I’d realise that actually it wasn’t within my control. It kind of felt as though it was but it wasn’t.
 

Nuala wanted to live her life without medication but realised that drugs would help stabilise her AF.

Nuala wanted to live her life without medication but realised that drugs would help stabilise her AF.

Age at interview: 60
Sex: Female
Age at diagnosis: 48
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I had a value that I didn’t want to be on medications. I didn’t want to be on drugs. That was my own personal value, you know, was I wanted to be free from medication. I had to work through that and accept that, in fact, quite the reverse I’d say I was right to have them. I’m from a part of the world where we have access to medication and it’s free and all that so I’m okay. I think it was almost like a grieving process for losing my independence. 

Losing my life without medication, if you know what I mean and probably I think it was a grieving process and part of me in denial and then part of me maybe fighting against it as well. 

But now I totally accept my views of well, sure, if you can take something that keeps you stabilised, why not.
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.
 

Nuala, a former nurse, reduced her dose of digoxin ‘very slowly’ and found that this reduced the swelling in her ankles.

Nuala, a former nurse, reduced her dose of digoxin ‘very slowly’ and found that this reduced the swelling in her ankles.

Age at interview: 60
Sex: Female
Age at diagnosis: 48
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So for about a year I was on digoxin only. However, I found that my ankles were swelling and then I was put on a diuretic as well and my hands were swelling. I couldn’t wear rings and I didn’t know what it was but I discovered that it was the digoxin, even though that they said they don’t give it, some of the medics would have said, “No, it wouldn’t cause that.” But I reduced the digoxin myself very, very slowly to an amount that was working okay but my swelling and everything else went down. So this time I went on it I went on a lower dose and along with the sotalol, it works pretty well. And I don’t have any swelling of my ankles from it.
 

Martin found that he could get by with a smaller dose of sotalol if he took it on an empty stomach.

Martin found that he could get by with a smaller dose of sotalol if he took it on an empty stomach.

Age at interview: 73
Sex: Male
Age at diagnosis: 71
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I’m meticulous about taking the sotalol too. And the other thing I wanted to tell you, I take it on an empty stomach. I took the view that if I take it, it says you can take it with food. I took the view that that would slow the absorption and might even prevent some absorption, because food sometimes combines with a drug and it doesn’t get absorbed, especially if you had a lot of bran or something. So I read on an American website that you should take it one hour before food, and I try to do that. And I think half an hour is long enough actually, and I’ve got better results with it. So I, these things you discover as you go along to make the most of the small dose.
(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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