Heart Arrhythmia: Are We Making Progress?

New drugs make managing a-fib easier, but half of patients at high risk for stroke don't get needed meds.

Atrial fibrillation (a-fib)—an irregular heart rhythm caused by abnormal electrical impulses in the heart—is known to dramatically increase the risk of strokes caused by blood clots that develop in the heart and travel to the brain. Untreated a-fib is also associated with higher risk for cognitive decline, dementia, and mood disorders such as depression and anxiety.

It’s estimated that one out of four Americans over 40 will one day develop a-fib. For most people, proper management of a-fib can significantly reduce the possibility of negative consequences, an MGH expert says.

“Lifestyle interventions (see What You Can Do) can go a long way toward preventing a-fib or reducing its impact,” explains MGH cardiologist and researcher Steven Lubitz, MD, MPH. “And for individuals whose a-fib may be more serious, there are a number of new treatment options.”

Getting Optimal Treatment

Advances in the treatment of a-fib have been promising, Dr. Lubitz says: “A new generation of blood-thinning oral anticoagulant drugs has been developed that has proven to be simple to take, fast acting, and at least as good—or better—than the widely used drug warfarin (Coumadin). Genetics research, which is increasing our understanding of the mechanisms behind a-fib, may one day lead to new treatments. These are significant advances.”

WHAT YOU CAN DO

The lifestyle interventions listed below can help prevent you from developing a-fib  or reduce its impact:

  • Control blood pressure
  • Get regular moderate exercise
  • Maintain a healthy weight
  • Eat a nutritious, low-fat diet:
  • Avoid smoking, and use caffeine and alcohol in moderation.

In spite of this recent progress, however, some patients may be missing out on treatments that offer the greatest protection for the heart and brain. A four-year study, published in the March 16, 2016 online edition of JAMA Cardiology, tracked more than 400,000 a-fib patients, assessing the severity of their stroke risk and determining whether they were receiving treatment in line with guidelines that encourage the prescription of oral anticoagulant drugs—warfarin and newer FDA-approved drugs such as Pradaxa (dabigatran) and Xarelto (rivaroxaban), which are associated with a significant reduction in risk for bleeding.

“We found that less than half of the participants at the highest risk for stroke were getting prescriptions for anticoagulants,” says Dr. Lubitz, a co-author of the study. “The findings were surprising, given the fact that these patients were receiving care from cardiovascular specialists, and they indicate that there are important gaps in our treatment of a-fib patients at the highest risk of stroke.”

It is not clear why so many high-risk patients—including adults over 75 who have high blood pressure, diabetes, or a history of stroke—are not getting anticoagulant drugs, Dr. Lubitz says: “Whatever the cause, it would be advisable for individuals with a-fib who are at high risk of stroke to speak with their health care providers about the possibility of taking an oral anticoagulant.”

Appropriate care for people with a-fib focuses on three major objectives—to prevent stroke, to help the patient feel better, and if feasible, to prevent recurrence of a-fib episodes. In some cases, normal heart rhythms can be restored by recognizing and receiving treatment for underlying medical conditions that increase risk for a-fib.

For people whose a-fib is recurring, doctors may recommend restoring normal heart rhythms through anti-arrhythmic drugs (cardioversion with drugs), electrical shocks to the heart (electrical cardioversion), or procedures involving cardiac catheterization or surgery. For many patients, simply controlling the heart rate with drugs such as digoxin (Lanoxin), calcium channel blockers, or beta blockers produces a satisfactory outcome, and aspirin may also be advised for some patients. People at high risk for blood clots usually require oral anticoagulants.

Are You At Risk?

Important risk factors for a-fib include:

▶  Age (55 and older)

▶  Hypertension or a history of
stroke

▶  Diabetes

▶  Heart disease (e.g., a history of   heart attack, heart defects, heart surgery, or heart valve problems)

▶  Chronic conditions such as sleep apnea or thyroid problems

▶  Acute medical stressors, such as pneumonia or pulmonary embolism

▶  A high BMI or obesity

▶  Lack of regular physical activity

“Genetics also plays a significant role, with about a 40-percent increase in a-fib risk among people with a close relative who has had the condition,” says Dr. Lubitz. “It’s likely that more than one factor is involved in the development of a-fib in most individuals.”

A-fib can be persistent (does not stop without treatment), paroxysmal, (episodes of a-fib in which the heart resumes it normal rhythms on its own), or chronic. Many people with paroxysmal a-fib are not aware that they have this common form of heart arrhythmia. Symptoms of a-fib that require medical assessment may include palpitations (an uncomfortably rapid or irregular heartbeat), lightheadedness, shortness of breath, or momentary weakness.

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