The normal heart rhythm is regular and results from electrical impulses that the heart itself forms just above the upper chamber on the right side, the right atrium. This electrical impulse travels through specialized tissue in the upper chambers of the heart, causing them to contract and empty most of their blood into the pumping chambers below, the ventricles. The electrical impulse is then transmitted to the lower chambers so that the lower chambers contract shortly after the upper chambers have just emptied their blood into them. This extra blood injected by the upper chambers into the lower pumping chambers (ventricles) gives a boost to their pumping function, enhancing their ability to pump blood to the rest of the body. There are many abnormalities that can disturb this normal, coordinated electrical and mechanical physiology of the heart, with many potentially undesirable consequences.

A trial fibrillation is an abnormal rhythm of the upper chambers in which the electrical activity becomes chaotic so that the upper chambers just tremble instead of contracting. The chaotic electrical activity of the upper chambers is transmitted to the lower chambers also, causing them to contract erratically, usually at a rate faster than desirable. The loss of coordination between the upper and lower chambers of the heart results in inefficient performance. Since the upper chambers of the heart do not contract effectively in atrial fibrillation, there is stasis or pooling of blood in the upper chambers, which promotes the development of blood clots within these upper chambers. These clots may break loose and travel anywhere in the body, including the vital organs, where they may obstruct the flow of blood to the brain, the heart, the kidneys, or any other organ receiving blood from the left ventricle. Such an event may result in a stroke, heart attack, kidney damage, and other very undesirable events. Furthermore, since the heart rate in atrial fibrillation is usually too fast for efficient cardiac function, and since the extra boost to the lower chambers that the upper chambers normally provide is lost in atrial fibrillation, the pumping function of the heart may be significantly impaired. This impairment of the pumping function of the heart may result in symptoms of shortness of breath, fatigue, swelling, exercise intolerance, dizziness, fainting, or even congestive heart failure. Rapid heart rates in atrial fibrillation can sometimes cause the heart to tire and weaken. A fast heart rate demands increased blood flow to the heart itself, but if the blood supply to the heart is not good, the heart muscle may become starved for blood, causing chest discomfort or even a heart attack. Furthermore, the longer a patient stays in atrial fibrillation, the more likely continuing atrial fibrillation becomes. Sometimes the heart rhythm may spontaneously move back and forth between atrial fibrillation and other normal or abnormal cardiac electrical rhythm patterns. The heart rate may alternate between too fast and too slow or may stay too fast or too slow most or all of the time. Sometimes a cardiac pacemaker is useful in these cases. Medication is almost always recommended for patients with atrial fibrillation, with rare exception.

The major strategies for treatment of atrial fibrillation are:

1. Restore and maintain normal rhythm using medication. Anti-clotting medication may still be prescribed.
2. Allow atrial fibrillation to persist or come and go, plus control heart rate and use anti-clotting medication.
3. Try to eliminate atrial fibrillation with intracardiac radiofrequency ablation techniques. If this approach is completely successful, it may be possible to avoid medication entirely.
   If heart rate goes too slow with otherwise appropriate and necessary treatment, it may be necessary to use a pacemaker, but pacemakers in themselves have only a minor effect of preventing atrial fibrillation.

Obviously, atrial fibrillation is an undesirable heart rhythm and requires treatment of some kind in the great majority of patients, but the treatment will not be the same for everyone. There are many different ways of dealing with atrial fibrillation and the choice of the best treatment for an individual patient is sometimes complicated. However, the basic goals are simple. Optimally, it would be best to restore and maintain a normal heart rhythm if this can be accomplished without utilizing a treatment plan that is actually more dangerous than atrial fibrillation itself. Electrical cardioversion is a procedure in which a direct current electrical impulse of shock is delivered under anesthesia to restore normal cardiac rhythm. There are electrical ablation procedures using radio frequency energy that are sometimes recommended to change the electrical properties of the upper chambers of the heart. A variety of medications are sometimes used to try to change the electrical properties of the heart muscle so that atrial fibrillation will be suppressed. However, if atrial fibrillation continues to occur, even intermittently, it is usually necessary use medication to control the heart rate and to prevent the formation of blood clots within the heart. Medication to retard the formation of blood clots is very often recommended even if atrial fibrillation has been successfully suppressed, because if it should return unrecognized, the first symptoms could be a stroke from a blood clot. Coumadin or Warfarin is the medication usually recommended for prevention of blood clot formation within the heart in atrial fibrillation. This medication requires careful monitoring with periodic blood tests to insure that the effects are in the desired range, not too little and not too much. Anti-clotting or anticoagulant medication is sometimes referred to as “blood thinners” although this is somewhat of a misnomer.

Atrial fibrillation may be primarily related to age or heart disease of any kind. It is important to evaluate the heart and the overall medical condition of the patient through testing to determine whether the atrial fibrillation is associated with significant structural heart disease or other medical conditions that predispose to the development of atrial fibrillation. Atrial fibrillation may also occur in the setting of diseases processes such as excessive thyroid function, electrolyte imbalances in the blood, the stress of medical illness such as pneumonia, or major fractures, or atrial fibrillation may occur following the stress of any kind of major surgery. Atrial fibrillation may be precipitated or caused by a variety of medications which stimulate the heart, including asthma medications. Atrial fibrillation is particularly common in the first few months following heart surgery. If a causative or precipitating factor can be identified, treatment of this factor may result in resolution of atrial fibrillation, even without heart medications on a long-term basis. If an underlying heart condition is present, treatment of this condition may be very useful in controlling or eliminating atrial fibrillation. After a few months, patients who develop atrial fibrillation after heart surgery may experience the resolution of this heart rhythm problem completely and get off medication, but in the interval treatment may be needed.

The cardiologists at Capital Cardiovascular Specialists treat thousands of patients with atrial fibrillation or a history of atrial fibrillation. In some cases our recommendation will include attempt(s) to restore a normal rhythm through electrical cardioversion and / or medications. Long-term treatment with medications to help maintain a normal heart rhythm may be required for many patients. In some cases we will recommend medications to help prevent blood clots from forming in the upper chambers of the heart and medications to control the heart rate if necessary. Even if restoration of a normal heart rhythm is recommended, medications such as Coumadin or Warfarin may be needed for a while until a normal rhythm has been restored and maintained for some time. Some patients may be at high risk for development of recurrences of atrial fibrillation and will be advised to take Coumadin or Warfarin on a long-term basis even though a normal heart rhythm has been restored. These are some of the complex decisions that need to be made in patients with atrial fibrillation or a history of atrial fibrillation on a case-by-case basis. Your physician and the nurses at ACA will attempt to educate you about atrial fibrillation and make recommendations for management. Patients with atrial fibrillation or a history of atrial fibrillation can usually live normal lives with appropriate treatment, but treatment is very important and the complications and consequences of atrial fibrillation can be very serious without proper management.

There are several recommendations that apply to almost all patients with this condition:

1. Learn to check your pulse to determine both regularity and heart rate. The nurses at CCS will be glad to assist you in this regard. It is usually important to maintain a pulse rate more or less in the normal range at rest with atrial fibrillation. This means about 60 to 90 beats per minute ideally.
2. If you are under treatment for atrial fibrillation, and a normal heart rhythm has been restored, tell us immediately if atrial fibrillation returns. It may be necessary to come into the office or pay a visit to the emergency room for an EKG to confirm the presence of atrial fibrillation. Even an experienced physician can not always be sure from examination alone, but it is definitely not possible to determine the presence of atrial fibrillation with confidence over the telephone.
3. If you are prescribed anticoagulant medication Coumadin or Warfarin, be absolutely sure to have the appropriate blood tests done at least once a month (more frequently at first, and whenever the nurse or doctor may order additional blood tests) to insure adequate but not excessive anticoagulant effect. Stroke or serious bleeding may result if you do not follow this recommendation consistently.
4. Report excessive bleeding to your doctor if it occurs. It may be a sign of excessive anticoagulant effect and you may be losing more blood than you realize.
5. Be sure that you are absolutely clear on which medications you are supposed to be taking, the dose, and frequency of administration.
6. Bring your medications with you at each visit to the doctor’s office so your physician can make certain that he or she knows just what you are taking and that your medical records are correct in this regard. We can sometimes make serious mistakes if we do not have correct information on which to base our decisions. At each office visit tell the nurse when your medications are reviewed exactly how you are actually taking the medication in each bottle. Although bringing your medications each time may be inconvenient, it is the only way we have found to be sure we have correct information.
7. If you develop new or progressively increasing fatigue, shortness of breath, inability to perform exercise or normal activities, swelling in the feet or lower legs, dizziness or faintness, sense of heart racing, or chest discomfort, report these symptoms to your doctor.
8. Do not allow yourself to run out of medication or miss prescribed doses of medication. The consequences of missing medications could be serious in this condition.
   Be sure to keep appointments for any scheduled tests or office visits. Careful surveillance and periodic reevaluation are important in patients with atrial fibrillation.