Atrial-Fibrillation Patients Have Increasing Options for Treatment

The irregular heartbeat known as atrial fibrillation is one of the toughest heart conditions to treat. Drugs aimed at restoring a normal beat are often ineffective and can have serious side effects. The anticoagulants that many people with A fib, as it’s known, need to take can react with other drugs and raise the risk of bleeding.

Now, alternatives are increasing: A new drug was approved this month, and a relatively new surgical procedure is growing in popularity. But their long-term benefits are still unclear, some doctors say.

“We all groan when we get a patient with A fib,” says Dara Lee, a cardiologist at Presbyterian Heart Group in Albuquerque, N.M.

Atrial fibrillation occurs when the heart’s upper chambers—the atria—beat erratically. Blood can stagnate and clot in these chambers, and some clots can travel to the brain, causing strokes. People with the condition also have a higher risk of developing heart failure. In many people, atrial fibrillation isn’t life-threatening. But it can cause symptoms such as palpitations, shortness of breath and fatigue.

There is enough confusion about treating the condition that the Institute of Medicine, a National Academy of Sciences branch that advises the government on health issues, recently recommended atrial fibrillation as a top priority for federally funded research into the best treatments.

For doctors, a key dilemma is whether to try to return the heart to a regular beat. Doing so can relieve symptoms, but there is little evidence that it reduces the risk of stroke, according to William Maisel, a cardiologist at Beth Israel Deaconess Medical Center in Boston. Also, the anti-arrhythmia drugs traditionally prescribed for this purpose don’t work in many patients, doctors say, and can have bad side effects. Patients who take amiodarone, one widely used treatment, can develop pulmonary fibrosis, which causes scarring in the lungs. Sometimes, amiodarone can also make an irregular heartbeat worse.

In some patients, doctors instead try to slow down the irregular heartbeat with beta blockers or calcium-channel blockers. An influential 2002 study showed that this strategy may have advantages. Patients who were treated with the aim of restoring a normal heartbeat didn’t live longer than those whose irregular heartbeats were merely slowed down. Also, they were hospitalized more often than the latter group and suffered more side effects from their drugs.

The U.S. Food and Drug Administration this month approved for sale the first new anti-arrhythmia drug in many years: Multaq, from Sanofi-Aventis SA. In a trial of 4,600 people with atrial fibrillation, the drug reduced a patient’s risk of death or hospitalization due to cardiovascular problems when compared to a placebo pill. The drug, also known as dronedarone, carries a black-box warning that it shouldn’t be used in patients who have recently had severe heart failure, because it can cause severe problems including death.

Dr. Lee said she would like to see research comparing Multaq to amiodarone to help her decide which is a better bet. Dr. Maisel said there are some indications that Multaq may have fewer side effects. “I don’t know that it offers a huge advantage, but it offers another alternative,” he said.

Surgical procedures are giving doctors more options. In radiofrequency catheter ablation, a long, flexible tube is fed through the groin or neck to the heart, where it delivers electrical pulses that destroy small areas of tissue responsible for generating the irregular heartbeats.

The procedure has been used on only a small proportion of patients, but the drawbacks of drug therapy have “really started causing a migration of patients to ablation therapy,” says David Brown, a cardiologist and professor at SUNY-Stony Brook School of Medicine.

The procedure has been shown to help patients maintain a normal heart rhythm for up to a year, but little is known about its long-term effects, an agency of the Department of Health and Human Services said this month, calling for more research.

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