Q: My 62-year-old husband has been having episodes of arrhythmias or atrial fibrillation on and off for close to 10 years. At the direction of his cardiologist he’s tried all of the medicines traditionally used – warfarin, dilantin, flexcanaide, amiodarone and diltiazem among others. Right now he’s on a very expensive drug (Multaq) he must take with meals with fat in them and he’s still having episodes that last from six to 17 hours every six to seven days. Are there other alternatives to these drugs that work and/or the surgery we are considering?
We’ve been told ablation is non-invasive and stimulates the heart chambers but is successful only 50% of the time the first time and from 60 to 70% the second time which is six months later. The first procedure has a hospital fee of $80,000 or $30,000 outpatient, where, while he is currently insured, even the co-pay is beyond our means. How life-threatening are these episodes and would you recommend the surgery?
A: Atrial fibrillation (also known as A-fib) is an irregular heartbeat that results in poor blood flow from the upper chambers of the heart to the lower chambers of the heart. The heart is comprised of four chambers – two upper and two lower. With this condition the two upper chambers of the heart beat in an abnormal pattern that is out of sync with the two lower chambers. Episodes can come and go, much like those your husband experiences. Atrial fibrillation can lead to serious complications including blood clots which can lead to stroke and more. A normal heart (perhaps excluding those of trained athletes and others on a rigid fitness program) beats between 60 and 100 times each minute. During an episode of A-fib, the number can increase up to 175 beats per minute.
Some individuals with this condition have no symptoms at all, while others may experience lightheadedness, a decrease in blood pressure, chest pain, shortness-of-breath, and more. When symptoms occur now and then, they are referred to as being occasional or paroxysmal. When they are constant they are referred to as chronic and indicate the heart rhythm is always abnormal.
Causes include a history of myocardial infarction (heart attack), hypertension (elevated blood pressure readings), lung diseases, sleep apnea, a metabolic imbalance such as an overactive thyroid, having abnormal heart valves, congenital defects, a family history, and more.
There are situations in which surgery or non-invasive procedures may be unnecessary, such as if the condition is caused by a thyroid abnormality. So, if your cardiologist has not ruled out other medical conditions with laboratory testing, X-rays, an echocardiogram or other procedures, he should do so. Considerations include the patient’s age, how long he or she has experienced the problem, the extent of the attacks, and more. Your husband is young at 62 but has had issues for an extended period of time and on an all-too-regular basis. He’s tried numerous prescription drugs that apparently have failed to convert him to a normal pattern or have failed to keep his heart from reverting into atrial fibrillation. When drugs fail, in-hospital cardioversion may follow. The most effective method is electrical cardioversion in which an electrical shock is delivered to the heart through paddles that is preceded many times by an anti-coagulant such as the warfarin he was once prescribed. Following the procedure, still another medication will be necessary. When medications fail to work after this procedure and side effects are present, atrioventricular node ablation may be considered. This procedure applies radio frequency energy through a catheter to the area that connects the upper and lower chambers of the heart. This ablation prevents the atria from sending abnormal or rapid electrical impulses to the ventricles. The procedure will be followed by pacemaker insertion and anticoagulants.
On a different tack, those individuals who do suffer from A-fib but have an otherwise normal heart may be candidates for radiofrequency catheter ablation. In this situation, the A-fib is caused by triggers that make the heart fire too rapidly. A catheter would be inserted into an artery near the groin and threaded up to the heart to destroy abnormal pacemaker cells found to malfunction. The procedure will correct abnormal pacing without the need for medication or a pacemaker. Is this the procedure your cardiologist is referring to?
I don’t know if your husband suffers from any other conditions that could have a bearing on whether or not he should undergo ablation. It depends on many factors and in your faith in the word of the cardiologist performing the procedure. While expensive, how do we put a price on a human life? And, a 50% success rate is difficult to deal with. However, it appears that attempts with medications have failed, so it seems like a reasonable approach to take. If your husband is exercising as much as possible under the direction of his physician, eating a healthful diet, not drinking to excess, not smoking, and essentially doing everything he can to lead a healthy lifestyle, then perhaps ablation is the answer. If not, he might first embrace a healthier lifestyle for a period of time to see if there is any improvement. Discuss your thoughts with your specialist and proceed accordingly.
Readers who would like related information can order Gott’s Health Report “Coronary Artery Disease” by sending a self-addressed, stamped number 10 envelope and a $2 US check or money order to Dr. Gott’s Health Report, PO Box 433, Lakeville, CT 06039. Be sure to mention the title or print an order form from www.AskDrGottMD.com.
