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Treatment options in atrial fibrillation

After eliminating (removing; identifying) the root cause (underlying cause) of atrial fibrillation, the options include drug therapy , catheter ablation or surgical procedureAtrial fibrillation can be caused by various underlying diseases. The most common causes, high blood pressure and coronary heart disease also include valvular heart disease, thyroid disease and an electrolyte imbalance.
 
These underlying conditions and diseases should be thoroughly examined (clarified) and treated. Blood pressure measurement, stress test, cardiac ultrasound (echocardiography), Holter-long term ECG, pulmonary function test, thyroid function test - all these and other tools  are important diagnostic measures put to use here at IHC. In some cases, further diagnostic cardiac catheterization or electrophysiological examination  (rhythm cardiac catheterization) is necessary (required).
 

Pharmacological Treatment

In a drug therapy, as with all other treatment strategies, it is important to distinguish between the rhythm-sustaining from the frequency-regulating approach. In each individual case which strategy has the potential for success depends on many different factors. (Which strategy makes the most sense and can bring the best results in each individual case depends on many different factors.) If, for example, only short-term episodes of atrial fibrillation occur, a therapy with beta-blockers (e.g., bisoprolol) symptoms can often be alleviated to a large degree permanently. For many patients, however, a permanent suppression of atrial fibrillation simply by using beta blockers will not succeed. In order to achieve a rapid return to a normal sinus rhythm, additional medications are generally required. 
 
To keep additional side effects to a minimum in the first stage of "medication escalation" the additional medication is often taken using the "pill in the pocket" principle.  This treatment strategy can be useful for patients who themselves notice the atrial fibrillation. 
 
Through either an additional intake of an antiarrhythmic drug, or a short-term dosage increase, a conversion (return) to a healthy sinus rhythm can be achieved using this strategy. If the duration of the atrial fibrillation episode is unclear, this strategy should not be used since blood clots in the atrium may have been formed by the atrial fibrillation. As an alternative or addition to beta-blocker therapy, anti-arrhythmic medication may be used. In extensive clinical trials they have been shown to lead to a stabilization of the sinus rhythm. The probability of achieving a permanent sinus rhythm can be doubled with certain anti-arrhythmic medications. However, since many antiarrhythmic drugs also cause significant side effects, the use of these medications must be closely monitored.Some drugs cannot be used due to certain underlying diseases (such as coronary heart disease), therefore, certain preliminary tests must be performed. Since atrial fibrillation very often becomes a chronic condition, anti-arrhythmic medication often needs to be administered on a permanent basis. An anticoagulation therapy ("blood thinner") for stroke prevention needs frequently to be administered. If a particular (individual) combined therapy does not bring about a lasting result, or side effects are evident, then ablation is called for, either as an additional or alternative treatment.
 

Ablation Therapy

If drug therapy is insufficient, an ablation treatment called sclerotherapy can be performed. The common goal of the various ablation methods currently available is the induction of sclerotic lesions. As part of an electrophysiological examination, using special catheters, the areas can be accessed in the tissue of the left atrium from which the atrial fibrillation originates. With either heat generated by radio-frequencies, cold (cryo-ablation) or laser light, rows of many small points of hardened tissue can be set in such a way as to form a barrier for the fibrillation waves.  Since atrial fibrillation impulses egress from the pulmonary veins, a major goal of ablation therapy is the isolation of the pulmonary veins (red lines in Figure 1).An exact computer-tomographic depiction of the anatomy of the heart is made beforehand. Thus, the pulmonary veins for a possible ablation can be represented. This allows for a thorough examination planning well in advance. The results of the CTL exam are also used as orientation during ablation therapy (see mapping method).
 

Rhythm Surgery

Atrial fibrillation can also be effectively eliminated with surgical techniques. In contrast to interventional ablation therapy, the lesions are set via a surgical access route with the opening of the chest cavity. Often this is the method of choice if cardiac surgery for the patient (e.g. as part of valve surgery) has already been planned. The instruments for such surgery are continually becoming more miniaturized, and often current surgical ablation procedures can be performed without the use of a heart-lung machine. Therefore, surgical procedures can also be performed on patients who do not need to undergo surgery for other reasons. 
 

Drug therapy for permanent atrial fibrillation

If a sinus rhythm cannot be maintained, a treatment strategy is then frequency regulation. If the heartbeat rate remains too high for a longer period of time, the heart muscle can sustain damage and the pumping power decreases. This condition is referred to in German as tachymyopathy.  But even if the condition has not caused damage or injury, the cardiac output decreases due to persistent tachycardia. This important phase when the heart fills with blood (the diastolic phase) is too short. This situation is especially crucial in patients who already have heart muscle weakness, in their case, the diastolic phase before the heartbeat is decisively important. Therefore, in addition to maintaining sinus rhythm, different treatment strategies must be established to regulate frequency. To do this, medications are used primarily that lower the heart rate or inhibit impulses being conducted from the atria to the chambers in the AV node. In addition to beta-blockers, which have a role in atrial fibrillation therapy and serve as a relapse prophylactic, calcium antagonists and digitalis compounds are often administered. The goal of treatment is to lower the heart rate below 100 beats per minute; ideally, as a rule, the heart rate should be even lower.
 
It is especially important for patients with coronary heart disease (CHD) to lower their heart rate. It is also should be noted: most antiarrhythmic drugs have a delaying effect in the AV node, thus, they are also able to lower the heart rate. For each patient, the attending cardiologist should individually determine the ideal heart rate because not every patient tolerates a low heart rate.
 

AV Node Ablation

If no other available therapeutic options are applicable, rapid conduction of impulses from the atria into the main chambers may also be modified by an ablation. In this procedure using electrical current generated by radio frequencies, connections between the AV nodes and the main chambers are separated. This interrupts or significantly reduces the rapid conduction of impulses from the atria. This treatment method requires the implantation of a cardiac pacemaker. This therapeutic step can be considered a method of last resort in regulating heartbeat frequency. Therefore, this therapy is only for patients in whom the sinus rhythm neither can be restored, nor heart-rate medication be adequately controlled. AV node ablation cannot be undone.
 
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