Treatments for Reduction of Stroke
Reduction of a Stroke from Atrial Fibrillation
A stroke is an interruption of blood supply to the brain, which occurs when there is a blockage in the arteries that lead to the brain. When a blood clot in an artery blocks blood supply to the brain, brain cells begin to die, causing brain damage that can result in speech, movement, or memory problems. Atrial Fibrillation (AF or A-Fib) brings a 500% risk of stroke compared to a person with no AF. This is not trivial. Stroke is the leading cause of disability in the US today—a devastating event.
Stoke risk is the same for patients who are in AF all the time and patients who are only in AF from time to time. Stroke risk is also high for patients with Atrial Flutter, an arrhythmia that causes fast heart rates like AF but in a more organized or regular beating. We believe that the risk of stroke is associated with the poor motion of the heart during these arrhythmias.
Anticoagulation: These medications reduce the ability of the blood to form clots and as a consequence, increasing bleeding and so they are often called” blood thinners”.
- Warfarin (Coumadin, Jantoven) and
New anticoagulation drugs that do not require blood testing and dosage regulation. Use of these drugs is approved by the FDA for use in reducing the risk of stroke for the AF patient. You can ask your doctor if one of these would be appropriate for you.
- Rivaroxaban (Xarelto)
- Dabigatran (Pradaxa)
When none of these medications can be taken or must be stopped because of side effects, such as allergies or bleeding, etc. then risk of clot are high. Devices, such as the Lariat and Watchman (shown at the right), have been developed to help filter blood clots from the arterial side of the heart (left atria) and decrease the risk of clots traveling to the brain where they cause stroke.
Medications are often the first line of therapy however, the antiarrhythmic medication that are most effective are also the most likely to have side effects and/or fail in the long term. Latest research and guidelines have shown that ablation may be used as a first treatment in some patients in preference to having the patient take strong medications such as Amiodarone. The AF Ablation Center physicians are part of the Atrial Fibrillation Center facilitating the process of ablation and follow-up.
The PLAN OF CARE for the patient with atrial fibrillation (AF, A-Fib, fib) calls for evaluation of the cause of AF in each patient.
Treatable Causes: There are many causes of atrial fibrillation that can be treated or managed to reduce AF episodes and potentially eliminate these occurrences.
- Acute episodes of hypothermia, fever or other stressful event
- Asthma or other chronic lung disease
- Coronary Artery Disease
- Heart valve disease
- High Blood Pressure (hypertension)
- Thyroid disorders
Trigger avoidance: Some patients find AF episodes are linked to physical activities such as exercise, eating large meals, bending over, coughing, or other action. Drinking alcohol can trigger episodes in some people. Medications used for colds or allergies that contain decongestants can trigger episodes, While some of these triggers are avoidable, some are unpredictable.
Medication Treatment Goals: The goals of AF treatment with medications are aimed at either controlling the pulse rate (called rate control) during AF, reducing the number of episodes (rhythm control), or both. Breakthroughs of AF occurrences are expected when on medication therapy, even while taking medicines used to control rhythm, because of the many factors that interfere with holding precise levels of medication in the body including changes the metabolism, changes in the body salt and water balances (electrolytes like sodium, potassium or magnesium) and progression of the heart condition.
Common Antiarrhythmic Medications for Atrial Fibrillation
Amiodarone (Cordarone™, Pacerone™)
Amiodarone takes 4-6 weeks to reach its full effect. Amiodarone is a strong medication with side effects that can be seen in the skin, thyroid, liver and lungs.
- Sun sensitivity: Sunscreen (SPF 15 or greater) should be worn in the sun. Amiodarone can cause severe sunburn, sometimes even on days that are not sunny.
- Discoloration: In some persons a blue tinge can be seen in the skin, especially around the nose and cheeks.
- Eyes: Deposits in the eyes can create glare, reducing the ability to see well at night. Drive with caution.
- Thyroid and liver will be checked with blood tests every 6 months.
- Lungs will be checked on chest x-rays once a year or if you report problems with breathing.
- Warfarin dosage must be lowered while taking Amiodarone.
Few people have serious side-effects. A 48-hour hospital stay is required when sotalol is started to observe for a potentially lethal heart rhythm possible in 2% of people.
- Fatigue is the most frequently reported discomfort.
A serious side-effect is a change in the heart’s electricity that can cause a lethal heart rhythm during the first few doses. Hospitalization is required to monitor the drug at start-up.
- Less severe but discomforting side-effects include headache, chest discomfort and flu-like symptoms.
Flecainide cannot be given to patients with coronary artery disease. Lethal arrhythmias have occurred in persons who have had heart attacks.
- Less severe reactions are dizziness, blurred vision, shortness of breath and headache.
Serious lethal arrhythmias can occur with this medication making hospitalization important at start-up.
- Serious reactions include congestive heart failure and heart block.
- Constipation, anxiety, upper respiratory infections and headaches are side-effects.
Rate versus Rhythm Control
You and your physician need to discuss these two choices. Sometimes the process to change your heart rhythm back to normal requires time and effort. This can be discouraging if you are not prepared. Many people find the effort to be worth it. Our patients often tell us they feel better when their heart beats in a normal rhythm.
Antiarrhythmic medications for rhythm control work in different ways and may be stronger than the ones used for rate control. This means they may have side-effects that are more significant. Close follow-up is recommended. Some medications can only be started during hospital stays.
Rhythm control is not for everyone, however. Sometimes the AF cannot be stopped and sometimes the patient has side-effects from the medication. The electrophysiologist has the most experience in using antiarrhythmic medications. Sometimes newer medications are only available from the electrophysiologist.
Restoring Normal Rhythm
There are some drugs used to change the electricity in the heart. Some intravenous (IV) solutions such as Ibutilide (Corvert) act quickly. Others (such as procainamide or amiodarone) can be given in intravenous drips over several hours or days. They are used in the emergency room or hospital if necessary to bring the rate and rhythm under control quickly. Most of the time the medication needs to be taken by mouth regularly for several days or weeks before the change in rhythm can take place.
Electrical cardioversion is a controlled jolt of electricity (shock) delivered to the heart through the chest wall by adhesive patch electrodes or metal paddles. The shock stops all electrical activity in the heart for an instant and this allows the normal heart rhythm to take over.
Before a cardioversion, care must be taken to protect against stroke. If the AF episode has lasted longer than 48 hours, warfarin is started to keep INR values between 2.0-3.0 for two to three weeks before the cardioversion can be done.
In some situations, a TEE (transesophageal echocardiogram) will be done before a cardioversion to look for blood clots or slowly moving blood in the heart that could dislodge and move to the brain causing a stroke. The TEE is done while a person is sedated. A tube is passed through the mouth into the passage (esophagus or swallowing tube) that leads to the stomach. Since the esophagus is directly behind the heart, this test permits a good view of the inside of the heart. If the TEE does not show blood clots, the cardioversion can be considered before warfarin.
Side-effects of an electrical cardioversion usually relate to skin reactions at the adhesive electrode sites because of the electrical energy that passed through to the heart. The skin can look irritated or red. If this is discomforting, ask your doctor for lotions, ointments or creams that will assist in healing.
Why Choose Aurora for Stroke Reduction?
Only a few centers in the US have the resources (electrophysiologists and surgeons, as well as the technology) to implant these. The risks of implant include perforation of the heart and backup open heart surgical teams need to be available. The special resources of a tertiary care, cardiovascular specialty center at Aurora support this service.
Aurora doctors are conveniently located throughout eastern Wisconsin and northeastern Illinois. Find a doctor or heart specialist near you. To get a second opinion or if you need assistance finding a provider, please call 888-649-6892.