Atrial fibrillation, on the basis of which criteria is the most suitable therapy chosen for the individual patient? – time.news

2023-06-23 06:52:13

by Fabrizio Tundo

If the effectiveness of the drugs is progressively reduced, ablation can be used, a now routine operation that allows you to control arrhythmic recurrences with an excellent probability of success

I am 58 years old, I have had episodes of atrial fibrillation for 21 years and since 2016, given the increase in episodes, I have been on chronic therapy with flecainide and atenolol. Since then I have had long periods without fibrillation, even a year and a half, alternating with periods with 4/5 episodes a year. For three months now I have had 3/4 monthly episodes, lasting up to three hours, strangely after having Covid. In the two days of high fever (during Sars-CoV-2 infection) four episodes occurred, even lasting 15 hours. Annual heart checks are always good, my arrhythmologist recommended ablation (minimally invasive procedure capable of treating atrial fibrillation or reducing the number of episodes, ed). The doctor suggested that I replace the atenolol with sotalol, but I’ve read conflicting things and I’m afraid. After a two hour nocturnal episode, I decided to stop all therapy. While waiting to be visited by my arrhythmologist, what advice would you give me? My fibrillation is always due to acidity or difficult or heavy digestion. Perhaps, if I fasted in the evening, I would have fewer episodes. I have no thromboembolic risk factors and I don’t take anticoagulants, with the exception of heparin but only if the episode lasts a long time.

Answered by Fabrizio Tundo, Department of Arrhythmology, Monzino Cardiology Center, Milan (VAI AL FORUM)

Atrial fibrillation is a very frequent arrhythmia, which increases in incidence with increasing age and with the presence of predisposing factors such as arterial hypertension, heart disease or previous myocardial infarctions, diabetes mellitus, renal insufficiency. Even in the absence of these conditions, less frequently even in young patients with a healthy heart, probably genetically predisposed to greater electrical instability of the heart, episodes of atrial fibrillation can occur. The natural history of atrial fibrillation, as in its case, provides for the onset with very sporadic episodes and even years apart, with a subsequent progressive increase and intensification of the frequency or duration of the episodes, which can also become daily with a tendency to constant persistence of the ‘arrhythmia.

Diet

Among the direct triggering effects, beyond the predisposition due to underlying pathologies, hyperthyroidism, excessive alcohol intake or even an abundant diet or with more difficult to digest foods have been recognized. High fever and infections, especially with respiratory involvement, as in the case of Covid, can increase the incidence of arrhythmias, even in patients who have never previously experienced them. In his case, there seems to be a certain correlation with nutrition, having noticed that fibrillation occurs more in conjunction with gastric symptoms. However, this can be a triggering or favoring mechanism, but not the main cause. While it is certainly recommended to avoid taking heavier foods, a therapeutic strategy involving fasting is not viable, which, in addition to being not recommended in the long run, does not in any case ensure the absence of relapses.

Regular checkups

The therapy recommended by her arrhythmologist seems to me to be adequate, as well as the indication for ablation surgery. If flecainide isn’t as effective as it used to be, it makes perfect sense to ask whether another drug might work better. If your colleague has decided to recommend sotalol to you, he will certainly have evaluated the possible contraindications or potential side effects for your case. The advice I would like to give you in the first place is to trust your GP more, possibly not letting so much time pass between one check-up and the next. It is true that these antiarrhythmic drugs have a favorable safety profile, but the best way to prevent possible side effects is to monitor the potential negative effects as well as their efficacy, undergoing regular (at least annual) checkups with electrocardiograms (Ecg ) or 24-hour Holter ECG.

Catheter ablation

The second piece of advice is to seriously consider performing transcatheter ablation surgery. He has been suffering from atrial fibrillation for many years, but still very young. Since the drugs begin to be ineffective, with even very prolonged episodes, the possibility of continuing to treat and successfully prevent arrhythmias with the pharmacological option alone will progressively decrease. Ablation, if performed by expert hands, is now a routine operation with a decidedly reduced risk of major complications (<1%), which requires short-term hospitalization (2-3 days maximum) and offers the possibility of being able to control arrhythmic recurrences with an excellent probability of success, variable from 70 to 90%, to be estimated more precisely on the basis of your specific clinical situation.

Early intervention

Surely the idea of ​​undergoing surgery rather than continuing with pharmacological therapy can be frightening, but several international studies on tens of thousands of patients have now demonstrated the safety of the intervention and the superiority of the ablation efficacy compared to pharmacological therapy . Furthermore, postponing the execution of the intervention over the years could reduce the probability of success. The evidence of recent years, also suggested in the latest reference guidelines of the various scientific societies, recommend the early execution of an ablation operation after the failure of a single antiarrhythmic drug or even as first line therapy in young patients without associated pathologies .

June 23, 2023 (change June 23, 2023 | 06:51)

© Time.News