Changes include adding new clot-preventing drugs and using less aspirin.
If you have atrial fibrillation (also called afib), your doctor may recommend changes to your treatment based on recently updated guidelines for managing this common heart disorder.
Atrial fibrillation—a rapid quivering in your heart’s upper chambers (atria)—can cause dizziness, shortness of breath, and fatigue. It also interferes with the atria’s ability to pump blood to the lower chambers, causing blood to pool in the atria. As blood sits, it can form clots. If such a clot gets into the bloodstream and blocks a vessel supplying your brain, a stroke may occur. As a result, a major focus of afib treatment is preventing those clots, using anticoagulant drugs. Until just a few years ago, the only option for this clot prevention was warfarin (Coumadin).
Newer anticoagulants added
“The biggest change in the new guidelines is the recommendation for using new oral anticoagulants, which are just as effective but safer than warfarin,” says Dr. Christian Ruff, a cardiologist at Harvard-affiliated Brigham and Women’s Hospital. These new medications (see “New oral anticoagulants”) don’t require regular blood tests to measure clotting function for possible dose adjustments, as is required with warfarin. The new drugs also have fewer interactions with drugs and foods than warfarin does. But they have some downsides. They wear off quickly, so if you miss a dose, your clot risk rises. (Warfarin is long-acting, so missing a dose or two is less risky.) They also cost considerably more, which could mean higher out-of-pocket costs. And when they cause bleeding, the bleeding is harder to stop than when bleeding is caused by warfarin, as there are no antidotes currently.
Lower risk of bleeding in the brain
For someone who’s doing well on warfarin, is there any reason to switch? Yes, says Dr. Ruff. Compared with warfarin, the new drugs pose about half the risk of bleeding in the brain—what doctors call intracranial hemorrhage. That can mean anything from a bleed that occurs just under the brain’s tough outer covering to a potentially fatal hemorrhagic stroke deep within the brain. “An intracranial hemorrhage is usually irreversible and devastating,” says Dr. Ruff. Like warfarin, the new anticoagulants can also cause gastrointestinal bleeding, but it is usually treatable and reversible.
In atrial fibrillation,
Illustration: Scott Leighton
Aspirin: Falling out of favor
Another treatment shift is a move away from aspirin, which also helps prevent clots. In the past, aspirin was recommended for people with afib considered to have a low to moderate risk of stroke. But the bleeding risk seen with aspirin is actually similar to that of warfarin, says Dr. Ruff. “Aspirin is falling out of favor, especially in older people, who have the highest risk from afib. If you have afib and want to prevent stroke, you should be on an anticoagulant, not aspirin,” he says.
The guidelines also feature a new risk score to better predict a person’s odds of complications from atrial fibrillation. The new score adds new factors (including being female and having a disease that affects the blood vessels) to fine-tune risk prediction. “We now know that there are many more people who would likely benefit from anticoagulation,” explains Dr. Ruff. With that in mind, he adds, choosing which agent matters less than simply making sure you’re taking an anticoagulant in the first place.
Ablation: Not a cure
The new guidelines also put more emphasis on ablation procedures for nonvalvular afib (rhythm problems that do not result from heart valve disease). If medications to slow or regulate the heartbeat aren’t effective, ablation may help. In an ablation procedure, doctors zap tiny areas in the heart that are firing off abnormal electrical signals responsible for the condition. But while ablation may ease or even eliminate symptoms, it’s not a cure, cautions Dr. Ruff. Most people still need to take anticoagulants following an ablation procedure, unless they’re young and have few risk factors for a stroke, he says.