treatment

My husband has recently been diagnosed with paroxsismal atrial fibrillation.  He was place on Verapamil 120mgm.per day. He also takes Depakote,  Paxil and Xanax (bipolar disorder).  Since being placed on Verapamil, it appears that his afib is worse.  He becomes lightheaded, dizzy and feels as though he is going to faint.  His afib appears to be almost constant throughout the day.  When he is at rest, they seem to quiet down and he has longer periods of regular rhythm.  Almost immediately upon any type of exertion ie getting out of bed and walking down the hall, they begin.  His medical history includes a mitral valve prolapse and bradycardia.  He is 58 years of age.

My question to you is what else should we look into since the Verapamil does not seem to be working?

[Cleveland Clinic, MD]

Afib can be a difficult problem to control and there are many treatment options.  There are many other medications that can be tried in addition to verapamil and there are new ablation procedures that are alternatives if medication fails.  I would suggest continuing to work with your doctor or if he is having a difficult time seeing a cardiologist or electrophysiologist (specialist in heart rhythms).

Here is some additional information on afib.

Atrial fibrillation
Definition:
A disorder of heart rate and rhythm in which the upper heart chambers (atria) are stimulated to contract in a very rapid and/or disorganized manner; this usually also affects contraction of the ventricles.

Causes, incidence, and risk factors:
Arrhythmias are caused by a disruption of the normal functioning of the electrical conduction system of the heart. Normally, the atria and ventricles contract in a coordinated manner. In atrial fibrillation and flutter, the atria are stimulated to contract very quickly. This results in ineffective and uncoordinated contraction of the atria.

The impulses may be transmitted to the ventricles in an irregular fashion, or only some of the impulses may be transmitted. This causes the ventricles to beat more rapidly than normal, resulting in a rapid or irregular pulse. The ventricles may fail to pump enough blood to meet the needs of the body.

Causes of atrial fibrillation and flutter include dysfunction of the sinus node (the "natural pacemaker" of the heart) and a number of heart and lung disorders including coronary artery disease, rheumatic heart disease, mitral valve disorders, pericarditis, and others. Hyperthyroidism, hypertension, and other diseases can cause arrhythmias, as can recent heavy alcohol use (binge drinking). Some cases have no identifiable cause. Atrial flutter is most often associated with a heart attack (myocardial infarction) or surgery on the heart.

Atrial fibrillation or flutter affects about 5 out of 1000 people. It can affect either sex. Atrial fibrillation is very common in the elderly, but it can occur in persons of any age.

Prevention:
Follow the health care provider's recommendations for the treatment of underlying disorders. Avoid binge drinking.

Symptoms:

     sensation of feeling heart beat (palpitations)
     pulse may feel rapid, racing, pounding, fluttering,
     pulse may feel regular or irregular
     dizziness, lightheadedness
     fainting
     confusion
     fatigue
     shortness of breath
     breathing difficulty, lying down
     sensation of tightness in the chest

Note: Symptoms may begin and/or stop suddenly.

Signs and tests:
Listening with a stethoscope (auscultation) of the heart shows a rapid or irregular rhythm. The pulse may feel rapid or irregular. The normal heart rate is 60 to 100, but in atrial fibrillation/flutter
the heart rate may be 100 to 175. Blood pressure may be normal or low.

An ECG shows atrial fibrillation or atrial flutter. Continuous ambulatory cardiac monitoring--Holter monitor (24 hour test)-- may be necessary because the condition is often sporadic (sudden beginning and ending of episodes of the arrhythmia).

Tests to determine the cause may include:

     an echocardiogram
     a coronary angiography (rarely)
     an exercise treadmill ECG


Treatment:
Treatment varies depending on the cause of the atrial fibrillation or flutter. Medication may include digitalis or other medications that slow the heart beat or that slow conduction of the impulse
to the ventricles.

Electrical cardioversion may be required to convert the arrhythmia to normal (sinus) rhythm.

There is not a consensus on the best long term management  of atrial fibrillation but many doctors feel it is important to try everything, including cardioversion (shock) to try to get the heart back into regular rhythm.  The risks of staying in afib are stroke (if not on anticoagulation) and decreased heart heart function (tachycardia induced cardiomyopathy).  Not all afib can be maintained in regular rhythm and those patients must live with the afib and take chronic anticoagulation (blood thinners).


Expectations (prognosis):
The disorder is usually controllable with treatment. Atrial fibrillation may become a chronic condition. Atrial flutter is usually a short-term problem.

Complications:

     incomplete emptying of the atria which can reduce the amount of blood the heart can pump
     emboli to the brain (stroke) or elsewhere--rare


Calling your health care provider:
Call your health care provider if symptoms indicate atrial
fibrillation or flutter may be present.

Q: Are there other safe drugs I could take at home to avoid cardioversion?
A: There are many different drugs that are used in the attempt to keep the heart in sinus rhythm (SR) but as with any medication they all have various side-effects.  You doctor can work with you on finding the best drug for your case.

Q:  What are the side effects to Toprol.
A: Toprol XL is a long acting version of metoprolol.  This drug is a beta-blocker.  Potential side-effects of beta-blockers include fatigue, problems with diabetic control, and impotence.

Q:  It seems that the better physical shape I stay in the less I have a problem with A.F. Could exercise have an impact?
A: There is no known effect of exercise on atrial fibrillation (AF).

Q: Is a pacemaker an alternative?
A: In some people who are unable to be controlled with drugs the electrical connection between the atria (upper heart chambers) and ventricles (lower heart chambers) is electrically severed and a pacemaker is placed to control the ventricles.  The atria remain in fibrillation but the side effect of the rapid heart rate is eliminated.  Chronic anticoagulation is required, as there is a risk of blood clots forming in the atria.

Q:  I have an uncle that was diagnosed with IHSS. Are IHSS and Mitral valve prolapse related problems?
A: No.


The links below are good sources of information about atrial fibrillation.

http://www.med-edu.com/patient/arrhythmia/atrial-fib.html
http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/afib.html
http://www.merck.com/!!vDXoe16kTvDXpz08Of/pubs/mmanual_home/chapt16.htm


I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.

If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.