Assessing who should be offered ablation treatment for atrial fibrillation is a specialist task. This means that the assessment must take place in a collaboration between you and a specialist in heart disease, typically called a cardiologist. When consulting with you, your cardiologist will take a number of factors into account, most importantly your risk of blood clots, the status of your heart determined by echo-cardiology, and how badly your atrial fibrillation is impacting your day to day life.
For patients at risk of blood clots the most important treatment is blood thinning medication. This can help to manage the risk of a fatal blood-clot and help to extend the patient’s lifespan.
For other patients treatment is less urgent. In the past there was no compelling evidence that atrial fibrillation treatments of any sort, aside from blood thinning medication, could extend a patient’s life. So treatment recommendations were almost entirely based on how much the atrial fibrillation bothered an individual patient. One exception is if the atrial fibrillation is accompanied with reduced pumping effort of the heart chambers (what is called “heart failure”). Several studies have indicated better outcome and prognosis if patients with both atrial fibrillation and heart failure is offered ablation therapy for their atrial fibrillation.
That approach is changing since the EAST study (read more here). This European study demonstrated that patients with atrial fibrillation who received treatment to reestablish and control sinus rhythm had a markedly lower risk of dying from cardiovascular disease, and a lower risk of a stroke.
This means that there is more reason for patients with atrial fibrillation to seek out treatment than there was previously. Atrial fibrillation treatments are usually either undertaken with medicines or with ablation. Ablation is a procedure that scars tissue in a patient’s heart to block abnormal electrical signals to restore normal heart rhythm, also known as sinus rhythm.
How Do Doctors Decide On a Treatment Course For Atrial Fibrillation
Atrial fibrillation comes in main categories: periodic or constant, this is also known as paroxysmal atrial fibrillation and persistent or permanent atrial fibrillation. Paroxysmal atrial fibrillation should be understood as episodes of atrial fibrillation that “go away on their own”. While constant atrial fibrillation only passes if Direct Current Cardioversion is performed or – sometimes – if medical treatment is given.
Often the atrial fibrillation will initially be periodic with short episodes and long periods in between where the heart rhythm is normal. However over time, a development that can take months or years, seizures become more frequent and of longer duration. In some patients the atrial fibrillation can become constant or even permanent. This means that it will always be present unless Direct Current Cardioversion is performed, or there is intervention in the form of an ablation.
In case of atrial fibrillation, ablation treatment should be considered if:
- Quality of life (often reduced physical capacity, increased tendency to lose breath, feeling of restlessness in the chest, poor ability to concentrate) is affected despite pharmacological treatment.
- Quality of life has been affected due to the side effects of medication prescribed to treat the patient’s atrial fibrillation
- If within the last year you have started to have problems with paroxysmal or persistent atrial fibrillation
- If heart failure is accompanying the atrial fibrillation
In some cases, patients who are healthy apart from episodic atrial fibrillation want to opt for ablation as an alternative to pharmacological treatment. In this case, you should consult carefully with your physician in order to understand the expected outcomes and risks of the procedure.
With constant atrial fibrillation, ablation treatments are considered if:
- The patient’s quality of life has been affected despite pharmacological treatment
- The patient’s quality of life has been affected due to side effects of pharmacological treatment
- If you only have had constant atrial fibrillation for a maximum of 1-2 years.
- If atrial fibrillation is accompanied with heart failure
If a patient has had atrial fibrillation for more than approximately a year or two, ablation treatment may not be the best option. The atria will often become significantly enlarged, which reduces the chances that the procedure will be able to restore normal heart rhythm.
Ablation Treatment Is Often Not Necessary
Often people with atrial fibrillation are happy with a high quality of life and a good level of physical activity if they are treated with medication. However, we must always – as doctors – inquire into possible side effects of the medical treatment. Frequent side effects of medical treatment are increased fatigue, decreased physical capacity, increased tendency to lose breath during physical activity. In other words, symptoms that may be similar to what you experience due to atrial fibrillation. Thus, it can be difficult to distinguish between symptoms due to flicker and symptoms due to side effects of medical treatment.
It is estimated that approximately 5% – or one in twenty – of patients with atrial fibrillation should be offered ablation treatment. As shown above, it is important to treat atrial fibrillation effectively while it is still periodic. Therefore, one should not wait “too long” to consider ablation treatment. The new European study results suggest that we must be more proactive in restoring normal heart rhythm – including ablation treatment.