The Last Word: A Cardiologist Perspective: Treatment Considerations for Atrial Fibrillation
Atrial fibrillation (Afib) is the most common heart rhythm abnormality, affecting 10% of the population older than 80 years and approximately 5 million Americans.1,2 In Afib, the atria do not fully contract, and blood clots can form in a thin sac that arises from the left atrium called the left atrial appendage.3 Patients with Afib are at a five times greater risk of having a stroke.4
There are two main decisions to be made when treating a patient with Afib: first, determining whether there’s a need to employ strategies to maintain (normal) sinus rhythm, and second, to manage the stroke risk associated with this arrhythmia. One simplified approach when deciding to treat with rate control and anticoagulation (blood thinners) or trying to reestablish sinus rhythm is to take a detailed history to determine whether a patient is symptomatic.4 One must also consider the likelihood of maintaining sinus rhythm. Key factors are length of time in Afib and presence of underlying structural changes to the heart.5,6 If a patient is symptomatic from Afib, it may be appropriate to attempt to restore sinus rhythm through cardioversion, antiarrhythmic medications, or Afib ablations, especially if the onset of Afib was recent and the patient has a relatively normal heart.6
The second and possibly more important concern is stroke reduction. There are multiple algorithms based on risk factors used to determine likelihood of a stroke. The most commonly used scoring system is CHA2DS2-VASc, which accounts for risk factors such as age, sex, heart failure, high blood pressure, hypertension, previous stroke or transient ischemic attack, vascular disease, and diabetes. If a patient scores greater than or equal to 1 for males or 2 for females, anticoagulation strategies need to be considered.1 Oral anticoagulants, however, are not a benign treatment. Multiple studies report a major bleeding rate of roughly 2% annually.7
When developing a treatment plan, it’s paramount to engage the patient and family in making decisions. In order to be successful, health care providers need to understand the patients’ viewpoints and concerns. The patient education initiative Watch Us Now (www.watchusnow.com) recently published insights from a Harris Poll examining how people living with Afib feel about their condition and oral anticoagulation treatment.8 According to the survey, more than one-third of the patients said they felt trapped between their bleeding risk and stroke risk. More than one-half (56%) of patients were concerned that they would be a burden to their family if they suffered a stroke. Despite this emotional toll, about 2 in 5 people with Afib (41%) say they rarely or never discuss these risks with their health care professionals, and 43% of patients on oral anticoagulation wished their health care providers talked with them more about the risks associated with this treatment. In this survey, the majority of people taking an oral anticoagulant (82%) wished there were a treatment as effective as oral anticoagulants in reducing their chance of having a stroke that was not accompanied by the risk of bleeding.
Fortunately, an alternative treatment was approved by the FDA in March 2015 for patients with nonvalvular Afib who are not good candidates for long-term anticoagulation but who can tolerate short-term use of a blood thinner. The WATCHMAN Left Atrial Appendage Closure Device is a percutaneous method to close the left atrial appendage, thereby eliminating the space in which 90% of blood clots in the heart form.3 Clinical research on the five-year data using the WATCHMAN device shows efficacy similar to the anticoagulant warfarin with regard to ischemic stroke reduction. The WATCHMAN device also provided patients with a comparable protection against all-cause stroke and statistically superior reductions in hemorrhagic stroke, disabling stroke, and cardiovascular-related death compared with warfarin over long-term follow-up.9
Bottom line, the management of Afib is complex and has to be individually tailored to each patient. Health care professionals should openly address patients’ fears and concerns and educate them about all their treatment options. In the appropriate patient population, the WATCHMAN device fills an unmet need for patients who cannot tolerate long-term anticoagulation due to bleeding or who have had negative drug reactions while on oral anticoagulants.
— Jeffrey Chambers, MD, a cardiologist in Minneapolis, has been with Metropolitan Heart & Vascular Institute since 1995. He received his medical degree from Wayne State University School of Medicine, completed a residency at University of Wisconsin Hospital, and has been in practice for 30 years.
Note: Boston Scientific reviewed this article for technical accuracy.
2. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847.
3. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61(2):755-759.
4. Holmes DR. Atrial fibrillation and stroke management: present and future. Semin Neurol. 2010;30(5):528-536.
5. Rosenthal L. Atrial fibrillation treatment & management. Medscape website. https://emedicine.medscape.com/article/151066-treatment. Updated July 18, 2018.
6. Palareti G, Manotti C, DAngelo A, et al. Thrombotic events during oral anticoagulant treatment: results of the inception-cohort, prospective, collaborative ISCOAT study: ISCOAT study group (Italian Study on Complications of Oral Anticoagulant Therapy). Thromb Haemost. 1997;78(6):1438-1443.
7. New survey reveals people with atrial fibrillation prioritize stroke risk reduction, seek more education on treatment options. StopAfib.org website. https://www.stopafib.org/newsitem.cfm/NEWSID/633/atrial-fibrillation-patients-prioritize-stroke-risk-reduction/afib-treatment-options. Updated September 20, 2018.
8. Watch Us Now website. https://www.watchusnow.com. Accessed December 18, 2018.
9. Reddy V, Doshi K, Kar S, et al. 5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964-2975.