Medical and Non Surgical Treatment Of Arrhythmias

Digitalis: Digitalis preparations (for example, digoxin) may be prescribed to treat atrial arrhythmias. Digitalis slows the transmission of the heart’s electrical impulses, thereby helping restore normal heart rate and rhythm. Digoxin also is used to increase the efficiency of the pumping action of the heart.

Quinidine, Tocainide, and Procainamide: These drugs work to control abnormal heart rhythms, including atrial fibrillation, atrial flutter, and paroxysmal tachycardia. Each of these drugs functions by slowing the activity in the heart’s control system (the sinus node in the right atrium) and by delaying the rate at which electrical impulses are transmitted to other chambers of the heart.

Calcium Channel Blockers: These drugs decrease the frequency and force of the heart’s contractions, resulting in a decrease in its oxygen needs. They function by blocking the entry of calcium into your cells. Two of the calcium channel agents, verapamil and diltiazem, are used to treat arrhythmias.

Atropine: This drug is used to increase the heart rate. It may be used in treating the decreased heart rate (bradycardia) that results from heart attack or other disorders.

Beta-Adrenergic Blocking Drugs (Beta Blockers):  These drugs block the stimulating effect the hormone epinephrine has on your heart. In treating arrhythmia, the beta adrenergic blockers slow the speed at which the nerve impulses travel from the sinus node to the rest of the heart muscle.

Other Drugs: When conventional medications for treating ventricular arrhythmia have failed, amiodarone frequently has been effective. There is a likelihood, however, of side effects that may be serious.

Electrical Cardioversion:

Electrical cardioversion is a procedure in which an electric shock is delivered to the chest wall, in order to restore a normal heart rhythm in a patient with atrial fibrillation. It is an effective and useful way to restore a normal rhythm, but only if the atrial fibrillation has not been present for a long time. If the atrial fibrillation has been present for more than a few months, there is a high probability that it will return shortly after cardioversion.

If there is a blood clot in the atria, cardioversion may cause the clot to leave the heart and travel to the brain or to some other part of the body. This can cause complications such as a stroke. Blood clots become a concern whenever atrial fibrillation has been present for more than 48 hours. Therefore, if the atrial fibrillation has been present for more than 48 hours, the blood must be thinned out before cardioversion. This requires taking warfarin before cardioversion, with at least 3 weeks of an INR (a blood test that indicates how thinned out the blood is) between 2 and 3. If quick cardioversion without waiting a few weeks is desired, this can be safely performed as long as a transesophageal echocardiogram shows that there are no blood clots in the heart. The blood still needs to be thinned out with warfarin for at least 1 month after cardioversion.

In some patients, medications to prevent a recurrence of atrial fibrillation may not be needed after cardioversion. But in many patients, medications are needed to prevent an early recurrence of atrial fibrillation after cardioversion.

The following are some important points about electrical cardioversion:

1. Electrical cardioversion terminates an episode of atrial fibrillation and restores a normal heart rhythm, but does nothing to prevent the atrial fibrillation from returning. Therefore, it should not be considered a “cure” for atrial fibrillation.
2. The longer the atrial fibrillation has been present, the greater the tendency for it to return shortly after cardioversion. The best chance for maintaining a normal rhythm after cardioversion is when the atrial fibrillation has been present for less than 3-4 months.
3. In many patients, a return of atrial fibrillation after cardioversion is inevitable. The goal of treatment is to maintain a normal heart rhythm for as long as possible, (hopefully for as long as 1 year), realizing that the atrial fibrillation will eventually come back. If necessary cardioversion can be repeated many times, as long as the intervals of normal rhythm are at least 6 months.
4. Patients who can’t tell whether or not atrial fibrillation is present may need to continue taking a blood thinner indefinitely after cardioversion. Otherwise a stroke may occur if atrial fibrillation returns and is undetected.

Radiofrequency Ablation:

Radiofrequency ablation is a non-surgical procedure designed to locate abnormal conduction pathways in the heart and eliminate them by delivering burning or freezing energy to that area. The procedure is performed in the Cardiac Catheterization Laboratory and can be done on an inpatient or outpatient basis. The radiofrequency ablation procedure is similar to a cardiac catheterization in that catheters (small thin wires) are placed into different areas of the heart by entering through the groin, and commonly the neck. Once the abnormal pathway is found, energy is applied to that area through the catheter. Several applications of radiofrequency or cryo energy (a freezing technique to burn tissue) may be needed to eliminate any abnormal heart rhythm disturbances. You may be asleep during the entire procedure, which can take from two to eight hours.

AV Node Ablation & Pacemaker Implantation:

In some patients with atrial fibrillation, medications are not effective in preventing episodes or in controlling the heart rate. Patients who have a rapid rate during atrial fibrillation are often troubled by uncomfortable palpitations, shortness of breath during exertion, dizziness, and exercise intolerance. Another bad effect of the rapid rate is that it can weaken the heart muscle after a few months.

AV node ablation is very effective at eliminating the rapid and irregular heart beat that may accompany atrial fibrillation. This procedure is performed only in patients who do not respond to medications or cannot take them because of side effects, or who are not good candidates for a curative procedure.

A catheter is inserted into a vein in the area of the groin and positioned near the AV node, a nerve that conducts electrical impulses from the top chambers to the bottom chambers of the heart. Radiofrequency energy is passed through the catheter to destroy the AV node. This eliminates the rapid and irregular heart beats caused by atrial fibrillation. The pulse rate usually drops to 30 beats per minute, and a pacemaker must be implanted to maintain a normal heart rate. The pacemaker will increase the heart rate during exertion or exercise, simulating a normal heart rhythm.

The pacemaker is an electronic device that is implanted on the upper chest, under the skin. It is connected to 1 or 2 wires that are inserted through a vein and sit in the heart. The pacemaker delivers painless electric pulses that stimulate the heart to beat. There is a 1-2% risk of a complication during the pacemaker implantation procedure, with the most common complications being infection, puncture of a lung (pneumothorax) which may require insertion of a chest tube for a few days, and displacement of one of the pacemaker wires necessitating another procedure to reposition the wire in the heart.

The procedure (including implantation of the pacemaker) takes about 3 hours to perform. The patient spends 2 nights in the hospital before going home. The wound will be checked approximately 1 week after the procedure. It takes about 4 weeks for complete healing of the incision, during which time certain activities that involve the arms and shoulders (for example golf, swimming, calisthenics) should be avoided. There are very few restrictions for patients with a pacemaker. Strong electromagnetic fields (such as arc welding or strong magnets) must be avoided, because they can interfere with the normal operation of the pacemaker. When passing through security stations at the airport, you must tell an agent that you have a pacemaker.

Pacemakers must be checked every few months to make sure they are functioning properly. The pacemaker checks can be done in person in a pacemaker clinic, by telephone, or by computer. The pacemaker battery usually lasts about 6 years. Once it is near its end-of-life, a minor surgical procedure is required to take out the pacemaker and replace it with a new one.