Treatment - Atrial fibrillation

Treatments for atrial fibrillation include medicines to control heart rate and reduce the risk of stroke, and procedures to restore normal heart rhythm.

It may be possible for you to be treated by a GP, or you may be referred to a heart specialist (a cardiologist).

Some cardiologists, known as electrophysiologists, specialise in the management of abnormalities of heart rhythm.

You'll have a treatment plan and work closely with your healthcare team to decide the most suitable and appropriate treatment for you.

Factors that will be taken into consideration include:

• your age
• your overall health
• the type of atrial fibrillation you have
• your symptoms
• whether you have an underlying cause that needs to be treated

The first step is to try to find the cause of the atrial fibrillation. If a cause can be identified, you may only need treatment for this.

For example, if you have an overactive thyroid gland (hyperthyroidism), medicine to treat it may also cure atrial fibrillation.

If no underlying cause can be found, the treatment options are:

• medicines to reduce the risk of a stroke
• medicines to control atrial fibrillation
• cardioversion (electric shock treatment)
• catheter ablation
• having a pacemaker fitted

You'll be quickly referred to your specialist treatment team if one type of treatment fails to control your symptoms of atrial fibrillation and more specialised management is needed.

Medicines to control atrial fibrillation

Medicines called anti-arrhythmics can control atrial fibrillation by:

• restoring a normal heart rhythm
• controlling the rate at which the heart beats

The choice of anti-arrhythmic medicine depends on the type of atrial fibrillation, any other medical conditions you have, side effects of the medicine chosen, and how well the atrial fibrillation responds.

Some people with atrial fibrillation may need more than one anti-arrhythmic medicine to control it.

Restoring a normal heart rhythm

A variety of medicines are available to restore normal heart rhythm, including:

• flecainide
• beta blockers, particularly sotalol

An alternative medicine may be recommended if a particular medicine does not work or the side effects are troublesome.

Controlling the rate of the heartbeat

The aim is to reduce your heart rate to less than 90 beats per minute when you are resting.

A beta blocker, such as bisoprolol or atenolol, or a calcium channel blocker, such as verapamil or diltiazem, will be prescribed.

The medicine you'll be offered will depend on what symptoms you're having and your general health.

A medicine called digoxin may be offered if other drugs are not suitable.

If one medicine is not controlling your symptoms, you may be offered another alongside it.

Side effects

As with any medicine, anti-arrhythmics can cause side effects.

The most common side effects of anti-arrhythmics are:

• beta blockers – tiredness, cold hands and feet, low blood pressure, nightmares and impotence
• flecainide – feeling sick, being sick and heart rhythm disorders
• verapamil – constipation, low blood pressure, ankle swelling and heart failure

Read the patient information leaflet that comes with the medicine for more details.

Medicines to reduce the risk of a stroke

The way the heart beats in atrial fibrillation means there's a risk of blood clots forming in the heart chambers.

If these enter the bloodstream, they can cause a stroke.

Find out more about complications of atrial fibrillation

Your doctor will assess and discuss your risk with you, and try to minimise your chance of having a stroke. 

They'll consider your age and whether you have a history of any of the following:

• stroke or blood clots
• heart valve problems
• heart failure
• high blood pressure (hypertension)
• diabetes
• heart disease

You may be given medicine according to your risk of having a stroke.

Depending on your level of risk, you may be prescribed warfarin or an anticoagulant, such as dabigatran, rivaroxaban, apixaban or edoxaban.

If you're prescribed an anticoagulant, your doctor will assess and discuss your risk of bleeding with you both before you start the medicine and while you're taking it.

Aspirin is not recommended to prevent strokes caused by atrial fibrillation.

Anticoagulants

Anticoagulants stop your blood from clotting and can help lower your risk of having a stroke.

Direct-acting anticoagulants

Direct-acting anticoagulants such as rivaroxaban, dabigatran, apixaban and edoxaban are recommended for people who have a high or moderate risk of having a stroke.

The National Institute for Health and Care Excellence (NICE) states that you should be offered a choice of anticoagulation and the opportunity to discuss the merits of each medicine.

Rivaroxaban, dabigatran, apixaban and edoxaban do not interact with other medicines and do not require regular blood tests.

Warfarin

Warfarin is an anticoagulant that you may be offered if direct-acting anticoagulants are not suitable for you.

There's an increased risk of bleeding in people who take warfarin, but this small risk is usually outweighed by the benefits of preventing a stroke.

It's important to take warfarin as directed by your doctor. If you're prescribed warfarin, you need to have regular blood tests and, after these, your dose may be changed.

Many medicines can interact with warfarin and cause serious problems, so check that any new medicines you're prescribed are safe to take with warfarin.

While taking warfarin, you should be careful about drinking too much alcohol regularly and avoid binge drinking.

Drinking cranberry juice and grapefruit juice can also interact with warfarin and is not recommended.

Cardioversion

Cardioversion may be recommended for some people with atrial fibrillation.

It involves giving the heart a controlled electric shock to try to restore a normal rhythm.

Cardioversion is usually carried out in hospital so the heart can be carefully monitored.

If you have had atrial fibrillation for more than 2 days, cardioversion can increase the risk of a clot forming. 

In this case, you'll be given an anticoagulant for 3 to 4 weeks before cardioversion, and for at least 4 weeks afterwards to minimise the chance of having a stroke. 

In an emergency, pictures of the heart can be taken to check for blood clots, and cardioversion can be carried out without going on medicine first.

Anticoagulation may be stopped if cardioversion is successful.

But you may need to continue taking anticoagulation after cardioversion if the risk of atrial fibrillation returning is high and you have an increased risk of having a stroke.

Catheter ablation

Catheter ablation is a procedure that very carefully destroys the diseased area of your heart and interrupts abnormal electrical circuits.

It's an option if medicine has not been effective or tolerated.

Catheters (thin, soft wires) are guided through one of your veins into your heart, where they record electrical activity.

When the source of the abnormality is found, an energy source, such as high-frequency radio waves that generate heat, is transmitted through one of the catheters to destroy the tissue.

The procedure can be very quick or it may take up to 3 or 4 hours, and may be carried out under general anaesthetic, which means you're unconscious during the procedure.

You should make a quick recovery after having catheter ablation and be able to carry out most of your normal activities the next day.

But you should not lift anything heavy for 2 weeks, and driving should be avoided for the first 2 days.

Although catheter ablation works for most people who have it, there's a small risk the procedure might not work or your symptoms might come back after treatment.

You may be given anti-arrhythmic medicines for 3 months after a catheter ablation to help stop symptoms coming back.

Pacemaker

A pacemaker is a small battery-operated device that's usually implanted in your chest, just below your collarbone.

It's usually used to stop your heart beating too slowly, but in atrial fibrillation it may be used to help your heart beat regularly.

Having a pacemaker fitted is usually a minor surgical procedure carried out under a local anaesthetic (the area being operated on is numbed and you're conscious during the procedure).

This treatment may be used when medicines are not effective or are unsuitable. This tends to be in people aged 80 or over.

Find out more about pacemaker implantation