Dr. Day is a cardiologist/electrophysiologist at the Intermountain Medical Center Heart Institute in Salt Lake City, Utah. He graduated from Johns Hopkins Medical School and completed his residency and fellowships in cardiology and electrophysiology at Stanford University. He is the former president of the Heart Rhythm Society and currently serves as the president of the Utah chapter of the American College of Cardiology.
Can I Live with A-Fib?
“Can I live with A-Fib?” asked Jeff, a 63 year-old man recently diagnosed with atrial fibrillation (A-Fib). Jeff felt fine. In fact, he had absolutely no symptoms at all from his A-Fib. He exercised regularly without any difficulties.
When his primary care physician picked up his A-Fib on a recent physical he was in a state of shock. “Wouldn’t I feel it if my heart was out of rhythm?” he asked his physician.
Surprisingly, most people with A-Fib don’t ever feel that their heart is out of rhythm. Do these patients need to undergo aggressive treatment for their atrial fibrillation? Can they just live out of rhythm?
Rate vs. Rhythm Control of A-Fib
One of the first questions to answer when someone is diagnosed with A-Fib is whether to pursue a rate control strategy or a rhythm control strategy for managing their A-Fib. Let me explain.
A rate control strategy is where no attempts are made to get the person back into normal rhythm. The only goal is to make sure that the heart rate is not too fast and to prevent strokes. This approach is often best for older patients who don’t have any symptoms and A-Fib is not causing any heart damage.
The other option is a rhythm control strategy to managing A-Fib. With the rhythm control strategy, every attempt is made to keep the person in rhythm. Initially this may involve medications and a cardioversion (electrical shock). When medications or cardioversions are no longer effective, this strategy often means a catheter ablation procedure. This approach is ideal for the person who feels poorly when their heart is out of rhythm.
Rate vs. Rhythm Control Studies
When it comes to which approach to managing A-Fib is best, you would naturally assume that a rhythm control strategy is best. After all, shouldn’t people do best when their hearts are in rhythm?
Interestingly, a rhythm control strategy has never been shown to allow A-Fib patients to live longer or to prevent strokes.
In the most famous rate vs. rhythm control study, the AFFIRM Study, researchers enrolled 4,060 patients and divided them equally into a rate control group or a rhythm control group. In the rate control group, no attempt was made to get these patients back into rhythm. Rather, the rate control group was just treated with medications to slow the heart rate and with warfarin to help prevent strokes.
In contrast, the rhythm control group patients were put on potent rhythm controlling drugs and attempts were made to shock their hearts back into normal rhythm. After following these two groups for an average of 3.5 years, researchers were stunned at the results.
There was no statistical difference in the risk of death or a stroke during the study. Additional studies showed the same results. It should be pointed out that there has not yet been a study comparing a rate control strategy to a catheter ablation approach for the management of A-Fib.
Lessons from the Rate vs. Rhythm Control Studies
What was the message from the rate versus rhythm control studies in managing A-Fib? Whether you pursue a conservative (rate control) or aggressive approach (rhythm control) to A-Fib, here are the results of these studies:
1. There is no difference when in comes to survival.
2. There is no difference when it comes to stroke risk.
3. A conservative treatment approach (rate control) is best for older patients without A-Fib symptoms.
4. An aggressive treatment strategy (rhythm control) is ideal for patients with A-Fib symptoms.
Unfortunately, these studies did not include many younger patients. Thus, the lessons learned from these studies do not apply to younger patients with A-Fib. Also, catheter ablation was not included in these studies so we don’t know how a rate control strategy would stack up against a catheter ablation approach to managing A-Fib.
How Do I Know If I Am Having A-Fib Symptoms?
This is a question that many of my patients struggle with. For many people, they have no idea when their A-Fib began. They may feel tired or fatigued and it is hard for them to know if A-Fib is the cause of this or not.
For these patients I recommend a “trial” of normal rhythm. In other words, I recommend an electrical cardioversion or a shock for these patients to see if they feel better in normal rhythm.
While cardioversions are not long-term solutions, they can at least help patients to know if they feel better in normal rhythm or not. If they do feel better in normal rhythm then we opt for an aggressive treatment approach (rhythm control) to make sure that they stay in rhythm. For those patients who don’t notice any difference in or out of rhythm, our focus is to just make sure their hearts don’t beat too fast and to prevent strokes.
Are There Any Dangers with a Rate Control Approach?
I am often asked if there are any dangers to a rate control strategy. It is important to remember that when you are out of rhythm the upper chambers of your heart are not pumping any blood. Thus, if you are out of rhythm, you are losing 20-30% of your cardiac output.
For sedentary people, losing 20-30% of your cardiac output probably will not be missed. However, for athletes, they will definitely notice this lack of full cardiac output during a race or competition.
Besides preventing strokes with blood thinners, it is important that the heart rate not be too fast with a rate control approach. If the heart beats too fast for too long, people can go into heart failure. For this reason, we used to be very concerned about controlling the heart rate in A-Fib.
However, based on recent research, a more lenient approach to managing the heart rate has also been shown to be safe. In other words, if a faster heart rate with A-Fib is not causing symptoms or heart failure, then we can be much more relaxed in controlling the heart rate.
Can I Live With A-Fib and See How Things Go?
All too often, people think that they’ll just try to live with A-Fib and see how things go. The trouble with this approach is that the longer you are out of rhythm the harder it will ever be to get you back in rhythm if you later change your mind.
Studies show that if you have been continuously out of rhythm for more than a year it is extremely difficult to get you back in rhythm and keep you in rhythm long-term. Thus, if you opt for a rate control strategy this has to be a decision that you will feel comfortable with for the rest of your life.
Should Younger Patients Live with A-Fib?
Most cardiologists agree that our treatment approach to younger patients should be more aggressive. Even though a 50 year-old may feel just fine living in A-Fib, they are so young that we don’t know what their long-term future holds in store for them.
For example, it is possible that these patients may later have a heart attack or other heart problems. They might really miss the lost 20-30% of cardiac output from A-Fib when they get into their 70s.
Thus, even if younger A-Fib patients don’t have any A-Fib symptoms, we often still opt for a more aggressive strategy (rhythm control).
Returning back to Jeff, how should he manage his A-Fib? Even though he feels fine in A-Fib he is still relatively young at 63.
If Jeff was in his 50s or 70s the decision would be very easy. We would recommend an aggressive strategy (rhythm control) if he was in his 50s or a conservative strategy (rate control) if he was in his 70s. As he is only 63, it makes this decision difficult.
We opted for a “trial” of normal rhythm to help him better decide what direction to go. Once we got him back into normal rhythm with a cardioversion, he could not believe how much better he felt. He had been out of rhythm for so long that he had forgotten what it felt like to feel so good.
This was the answer we needed. We opted for an aggressive treatment approach (rhythm control) of his atrial fibrillation. Three years later he is still doing well and maintaining normal rhythm.
Do You Feel Your A-Fib?
Do you know when you go out of rhythm? Please leave your comments below sharing your experiences with either a rate or rhythm control strategy to managing your A-Fib.
Please do not self diagnose or treat based on anything you have read in this article. Please discuss with your cardiologist whether a rate or rhythm control strategy is best for managing your A-Fib.
Disclaimer Policy: This website is intended to give general information and does not provide medical advice. This website does not create a doctor-patient relationship between you and Dr. John Day. If you have a medical problem, immediately contact your healthcare provider. Information on this website is not intended to diagnose or treat any condition. Dr. John Day is not responsible for any losses, damages or claims that may result from your medical decisions.