A Common Error in the Treatment of Atrial Fibrillation

We have got to get back to AF.

I enjoyed some fun text messages today–from a really smart primary care doctor out yonder, in the hinterlands of Kentucky. We text and exchange quick pics a lot. Call it iTeleMedicine.

PCP: “I have a patient on [AF-drug X] (guess) who has diarrhea.”

Me: “Stop the drug…It’s a typical adverse effect.”

PCP: “How do I keep him out of AF?”

Me: “Ha…That’s funny.”

PCP: “I’m serious.”

Me: “I know u r. If I could keep patients out of AF, I might make the big dollars.”

PCP: “K, I’ll get the patient an appointment with you.”

All kidding aside, this string of text messages highlights two important principles about treating AF. The first is that AF treatment often has adverse effects. In this case, the drug used to prevent AF episodes was disrupting bowel function. That’s not good. No further explanation is warranted. AF isn’t cancer; we should not expect patients to endure toxicity from treatment.

Next…

The other slightly more subtle issue here is that treating AF with rhythm-controlling drugs does not modify the disease or improve outcomes. It’s different than treating high blood pressure or diabetes. The purpose of AF drugs is to decrease the burden of symptoms. No study has conclusively shown that taking an AF rhythm drug lowers the chance of CHF-congestive heart failure or stroke. (Don’t even start with the Greek-named trials.)

Let me explain this concept with an example: Take the patient with long-standing high blood pressure—not responsive to lifestyle changes–who develops an adverse effect with a BP-medicine. In this case, it’s frequently a good idea (after a suitable washout) to substitute another drug. You would start another medicine here because the disease of high blood pressure is still present and you don’t want to risk complications from untreated high pressures.

I rarely use AF drugs this way. In the patient discussed in the text string, I would have stopped the offending AF drug and then waited to see if (or how much) AF recurs. If it did indeed come back, we’d have a conversation about what to do next. The choices would range from tolerating intermittent episodes, trying another medicine or considering ablation. This approach helps prevent over-treating—a problem I work very hard to avoid. I am always asking myself whether the patient with AF still requires treatment.

Since I see it nearly everyday, it bears repeating: Never make the treatment of AF worse than the disease.

JMM

Important disclosure: When writing briefly about medical treatments, I always worry about the dangers of oversimplification. These posts, this blog, my ramblings, should NEVER substitute for the patient-doctor relationship. Rather, my aim is to help–with information. In fact, sometimes I wonder whether my white boards in the office exam rooms help nearly as much as does making 75 burns in the left atrium. In the treatment of AF, knowledge fosters wellness.