Living with AFib: Drugs & Pacemakers

Instructor: Lacey Russell

Lacey has a Master's of Science in Nursing with a specialization in Acute Care Nurse Practitioner

In this lesson we will discuss atrial fibrillation (AFib) and what happens after diagnosis. We will specifically discuss medications used in treatment as well as surgical options (pacemakers).

What Is AFib?

Meet Tim. He has been diagnosed with atrial fibrillation (AFib), which is an irregular heart rhythm where the heart typically beats faster than it should. It can cause dizziness, fainting, palpitations, low blood pressure, and probably the most dangerous side effect: blood clots. These clots form in the atria of the heart because the blood is not being circulated well enough. If the clots move they can go to the lungs, brain, or other part of the body and cause big problems.

A blood clot can be very dangerous.
blood clot

Tim went to the hospital because he was having palpitations and shortness of breath. At the hospital they diagnosed him and gave him some medication. Let's follow him as he learns to live with AFib.

Anticoagulation

Probably the scariest complication of AFib is blood clots. To help prevent them, Tim must take an anticoagulant, or blood thinners. These medications are designed to thin the blood to prevent clots from occurring. Many of them require lots of education and monitoring. Tim was given two anticoagulants, one while at the hospital, and one for at home:

  • Lovenox - an expensive injection in the abdomen with no dietary requirements
  • Coumadin - an inexpensive, common oral medication with dietary and time requirements

While taking Coumadin, Tim must now watch his vitamin K intake and be sure to take the drug at the same time every day. Too much may make the medication not work as well and he would be at risk for a clot. So Tim must be careful not to eat too many leafy green vegetables like kale or spinach, ease up on green tea, cranberry juice, and lay off the alcohol. He should alert his doctor if he wants to take any other drugs that might negatively interact with Coumadin, like cold medicines.

Because the biggest complication for anticoagulant therapy is bleeding, Tim also has to have his international normalized ratio, or INR, checked regularly. This is the blood level that measures how effective the medicine is in thinning the blood. The ideal level is between 2 and 3. Lower INR levels may be acceptable if the patient is older and at risk for falls. If the INR is too high, Vitamin K can be administered to lower it.

Leafy greens can make medication for AFib less effective.
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There are a few newer anticoagulants out there that do not require dietary restrictions or frequent monitoring, such as Xarelto and Eliquis. However, there has been some controversy over their use because there is currently no reversal agent and it's half life is around 12 hours. If Tim got hurt and began bleeding, he could bleed out before the medication wore off.

Rate and Rhythm Control

Tim also takes a pill to keep his heart rate in the normal limit, which is 60-100 beats per minute. He is taking a calcium channel blocker called diltiazem. This has fewer side effects than another option, digoxin.

The third medication Tim takes is an anti-arrhythmic agent called Amiodarone to keep his heart in sinus rhythm. There are several different anti-arrhythmia medications to choose from, such as Quinidine and Rhythmol, but in general Amiodarone does the trick for most people and has the fewest side effects.

Some patients are given a beta blocker that can occasionally control both the rate and the rhythm.

Pacemakers

Tim's atrial fibrillation is not getting better despite returning to the doctor and changing medications several times. His symptoms are getting worse and it's getting harder for him to go about his daily activities. His cardiologist suggests getting a pacemaker before he develops heart failure.

A pacemaker.
pacemaker

The atrioventricular (AV) node is sort of an electrical relay station for the heart. Tim's cardiologist wants to knock out Tim's haywire node, and replace it with a machine that will regulate things. The cardiologist performs an AV node ablation, which is when a catheter is inserted into a vein and fed through to the AV node where radiofrequency energy will be sent through to disable it.

By removing the action of the AV node, the connection between the atria and the ventricles is severed. This keeps the agitation of the AFib from spreading to the ventricles and causing the increased heart rate. However, it also prevents the action potential from spreading and telling the ventricles to contract. This is why the pacemaker needs to be implanted into Tim's chest to keep things going normally.

pacemaker surgery

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