ABOUT 'BEAT YOUR A-FIB'...


"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"



ABOUT A-FIB.COM...


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


amiodarone

FAQs A-Fib Drug Therapy: Safety of Multaq [dronedarone] vs amiodarone

 FAQs A-Fib Drug Therapy: Safety dronedarone vs amiodarone

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Safety of dronedarone

25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

Multaq is probably safer than amiodarone, but it isn’t just “amiodarone-lite.”

Higher Death Rates with Dronedarone

Some studies indicate Multaq by Sanofi-Aventis (generic name: dronedarone) has its own set of problems.

In a study of dronedarone in high-risk patients with permanent A-Fib (PALLAS-3,236 patients), patients taking dronedarone were dying at more than twice the rate of those on a placebo. The ratio of stroke and hospitalization for heart failure was also more than twice as high.

The EMA recommends dronedarone not be used in patients still in A-Fib.

Dronedarone Shouldn’t Be Used in Patients in A-Fib

The European Medicines Agency (EMA) has recommended that the antiarrhythmic drug dronedarone not be used in patients still in A-Fib, that it should be discontinued if A-Fib reoccurs, that it shouldn’t be used in patients who have previous liver or lung injury following treatment with amiodarone, and that patients using it should have their liver and lung functions regularly monitored.

Who Should be Taking Dronedarone (If Anyone)?

The Committee for Medicinal Products for Human Use (CHMP) of the EMA said that dronedarone may be a useful option in patients who are in sinus rhythm after a successful cardioversion. But even in this case, dronedarone should only be prescribed after alternate treatment options have been considered.

…Dronedarone should only be prescribed after alternate treatment options have been considered.

About dronedarone, noted A-Fib blogger, Dr. John Mandrola wrote, “I’m surprised that the drug has persisted. I don’t know any of my colleagues who would start a patient out on Multaq [dronedarone]. It just doesn’t work.”

Editor’s Comments
According to these studies and news reports, no one with any type of A-Fib should be taking dronedarone (Multaq).
This is a major change in treatment options for patients with A-Fib.
Dronedarone may be associated with increased strokes, hospitalizations, heart failure, liver damage, lung damage and death. And it may not be very effective anyway.
No antiarrhythmic drug is 100% safe and effective for all A-Fib patients. But until we get more favorable research on dronedarone, all patients with A-Fib should consider not taking it and try alternative options.

References:

Connolly SJ. Dronedarone in High-Risk Permanent Atrial Fibrillation. PALLAS Clinical trial (Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy). New England Journal of Medicine, 2011; 365: 2268-76. http://www.nejm.org/doi/full/10.1056/NEJMoa1109867 DOI: 10.1056/NEJMoa1109867

O’Riordan, Michael. “EMA recommends restricting use of dronedarone” HeartWire, Sept. 22, 2011. http://www.medscape.com/viewarticle/750196

Burton, Thomas M., FDA Reviews Heart-Rhythm Drug. The Wall Street Journal, September 22, 2011. http://www.wsj.com/articles/SB10001424053111904563904576585091471862916

The European Medicines Agency (EMA): a decentralised agency of the European Union (EU) is responsible for the scientific evaluation, supervision and safety monitoring of medicines developed by pharmaceutical companies for use in the EU. http://www.ema.europa.eu/ema/; See: Multaq/dronedarone

Last updated: Wednesday, May 25, 2016 Return to FAQ Drug Therapies

Steve’s Inbox: International Mail & A-Fib Awareness Month

Many people email me for advice and support. This past week was quite the international experience for me. In addition to emails from the US, I also received emails from Syria, South Africa and Ecuador! Let me share a few with you.

The A-Fib Patient in a War Zone: Someone in a war-torn country was trying to find medical help for his A-Fib. A doctor started him on a heavy dose of amiodarone for his A-Fib. I told him about the toxic effects of amiodarone, but recognized that he was lucky to find any kind of medical help in a war zone. I couldn’t find any EPs still practicing in his country, but did find two centers in an adjacent country not at war. But I don’t know if he will be able to travel there. Please think positive thoughts/pray for him.

Airport Rendezvous: A traveler described a chance meeting in an airport with a well-known EP. This was more like a ‘sign’ than a chance occurrence. This wonderful EP answered her A-Fib questions and referred her to another EP near her for an ablation. She wrote that talking with the ‘airport’ EP helped her make the big decision to have a catheter ablation. (She had been looking at another surgery treatment option which I suggested might be overkill for her.)

Our A-Fib Support Volunteers were so supportive and helpful that she decided to become a volunteer, too.

A-Fib Support Volunteers in Action: Another woman described an all too common frustration with her primary care doctors and cardiologists who didn’t take her A-Fib symptoms seriously. They wouldn’t even refer her for a cardioversion. She was helped a lot by getting in touch with five of our great A-Fib Support Volunteers who had widely different experiences. They were so supportive and helpful that she decided to become an A-Fib Support Volunteer herself.

Amiodarone Advice: Another patient wrote that his cardiologist put him on a heavy dose of amiodarone when he first started having A-Fib episodes. I recommended the patient get a second opinion, that amiodarone is a very toxic med usually only prescribed as a last resort or for short periods of time like during the blanking period after a catheter ablation.

Negative Feedback: I warned someone about an EP whom I had heard negative things about. I referred the patient to a ‘master’ EP in his area for his ablation. I also told him to give his long-suffering wife a hug from all of us. All too often spouses of A-Fib patients put up with a lot and often feel alone and overwhelmed. I told them about the wonderful story “The Spouse’s Perspective: A Young Wife and Mother Copes with Husband’s A-Fib” in our book “Beat Your A-Fib: The Essential Guide to Finding Your Cure.”Top 10 Questions Families Ask About A-Fib - 150 pix at 96 res

September is A-Fib Awareness Month: As you see, there are many, many A-Fib patients out there seeking help and answers for their particular situation. A-Fib is not a one-size-all kind of disease. But A-Fib can be Cured! You don’t have to live a life on meds! Won’t you pass on our message to others with A-Fib and their families and friends? Send them a link to our special FREE report: The Top 10 Questions Families Ask About Atrial Fibrillation.

—Your A-Fib friend, Steve

More Bad News About Amiodarone

Amiodarone images

Amiodarone

Though this is only one case, a 71-year-old woman with persistent A-Fib went into “catatonic depression induced by amiodarone.” The doctor was able to restore her to normal health, mainly by withdrawing amiodarone.

Reference: Rajagopal, Sandararajan. Catatonic depression predipitated by amiodarone prescribed for atrial fibrillation. Indian Journal of Psychiatry, 2015 Jan-Mar, 57(1): 105-106. http://www.coolheartafib.com/about-me—my-practice.html. doi:  10.4103/0019-5545.148545

Dr. Carlo Romero A-Fib Patient Story

Dr Carlo Romero from The Philippines

Dr Carlo Romero
from The Philippines

A-Fib Patient Story #79

Philippino Dr. with A-Fib Has Amiodarone Problems—Then ECGI & Ablation at Bordeaux

By Dr. Carlo Romero, The Philippines, February 2015

I am a 49-year-old male from the Philippines. I was diagnosed with A-Fib in 2007 at age 42. It happened after I was dehydrated playing golf. The A-Fib resolved by itself after a few hours. But after a few months, I had another attack. When I went to the ER, an ECG documented the AFIB. I was not given any medication but was advised to stay away from triggers which I did. I even stayed away from cigarettes, drinking, chocolates, food with monosodium glutamate.

After Three Years, Severe Pain Triggers A-Fib—Amiodarone Works, But Thyroid Problems

 I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone.

I had no known A-Fib attacks for three years until I was operated on for a herniated disc in 2010. The severe pain and the medications probably triggered the A-Fib again as I had several attacks. I was referred to an electrophysiologist in Manila which is an hour and half plane ride from our province. This time I was given amiodarone and Coumadin. I did not have any attacks for a year, but my thyroid hormones were becoming abnormal due to the amiodarone. I was shifted to 100mg flecainide bid which again limited my A-Fib to probably one attack per year.

A-Fib Attacks Become More Frequent—Decides To Go To Bordeaux

At this time I was already doing research about what other options were available, because I know that in time, the medications will stop working. In 2010, I was already in touch with Steve Ryan and had already heard of ablation. I had written several big centers and inquired about ablation procedures and cost. I wrote emails to Bordeaux and to the secretary of Dr. Natale. But since the attacks were few and far between, I decided to stick to medication which controlled the symptoms.

 It was a choice between having the ablation in San Francisco or the Bordeaux group…The cost made me decide on Bordeaux, because it cost half that of San Francisco.

However mid-2014, after a bout of flu, the A-Fib symptoms recurred and the attacks became more frequent. I learned that at this time that there was an ablation center here in Manila, but it is still in the infancy stage. So, I decided to go abroad. It was a choice between having the ablation in San Francisco or the Bordeaux group since they have been the most talked about ablationists in the forums. The cost made me decide on Bordeaux, because it cost half that of San Francisco.

Arriving at Bordeaux Hospital

Carlo Romero in Bordeaux hospital room 500 pix at 96 res

Carlo Romero in Bordeaux, France, hospital room

In August 2014, I wrote Bordeaux emails, and they made me answer a questionnaire to determine my status. I sent my reply and was told I would be a good candidate. I was given an ablation date Nov 3, 2014, more than 2 mos. from the time I inquired. I was instructed to do some blood tests and a TEE 2-3 weeks prior to my ablation and to settle the payment for the procedure 1 month before the ablation date. I complied with all of these requirements, got a medical visa from the French Embassy, plane ticket, hotel booking and was all set. I arrived in Bordeaux on Oct 29, 2014. Since we still had time, we first went to Lourdes, France and then back to Bordeaux the next day.

Nov 3, 2014, Monday, I was told to be at the Hospital at 8am. To be sure that we didn’t get lost, we took a cab which cost around 45 euros coming from the center of Bordeaux near the opera house. Admission was a breeze, and I made sure we had internet which you can get in the Admitting section (ask them about it because the nurses are not familiar with it). I made sure of the internet connection to be able to use the app I downloaded which helps me to communicate in French. (Translate App) When you type in English, the app will translate it to French.

I was attached to a holter monitor whose signals were transmitted to the nurse’s station. The first day was spent getting X-rays, lab exams, preparation and shaving of the groin area. They also started injecting heparin. I was told to stop amiodarone 5 days prior to ablation. But since I learned from Steve Ryan that amiodarone has a long half-life, we asked Dr. Jais thru email if the instruction was right. He was able to correct it to 10 days prior to ablation and pradaxa 48 hours prior to ablation.

Ablation with ECGI

Carlo Romero with nurse preparing the ECGI before ablation

Carlo Romero with nurse preparing the ECGI before ablation

The next day, I received IV fluids and was brought down to the CT scan area. I laid down on a bed and was given a vest which I learned later was an ECGI. It’s the new procedure which, according to Dr Haissaguerre, is not yet in use in the US. But they have found it very useful and promising.

His explanation is that it is like an ECG. But instead of 12 leads, it has 252 leads (attached in the vest) The ECGI vest represents the future of the mapping procedure, and according to him will shorten the OR time since they can map out the heart prior to the procedure. (For a further explanation of how the ECGI mapping system works, see “How ECGI [Non-Invasive Electrocardiographic Imaging] Works.”)

I think I was the 2nd case that day since I was brought down at the theatre at 1 pm. I did not see Dr Haissaguerre at that time nor prior to the procedure which made me a little bit anxious. But I was assured by his assistant that He will be doing the ablation. The assistant doctor asked me if it was ok that he start with the insertion of the catheter and that Dr Haissaguerre will be the one doing the ablation later, to which I agreed.

I must have dozed off. Because when I became aware again, I heard that we were about to be finished. Although during the ablation there were instances where I felt my heart going very fast, then they would later massage my neck area. And then after a while, there were two more cycles like that. I was told later that, since I was not in A-Fib, they had to induce me several times. My procedure took almost 4 hours.

After the Ablation—Time With Dr. Haissagguerre

Wednesday, when I woke up, I had a fever of about 39 degrees and had a difficult time breathing. The nurses upon instruction from the doctor gave me paracetamol which lowered the fever, but I was still in pain if I breathed. I was really worried at that time and kept on reminding the nurses to ask the doctor when will they see me so I can talk with them about these symptoms.

That night, a young doctor came to my room with a portable 2d echo and, after examination, concluded I had fluid around my heart and that the fever and the difficulty of breathing were related to that. I was given an anti-inflammatory which relieved the symptoms in 2 days. At this time my abdomen was black and blue due to the round-the-clock injection of heparin. Towards the evening , I was allowed to start with soup and yogurt and later solid foods if I could tolerate them.

Thursday, the fever and the difficulty of breathing diminished. The nurses also advised me to start pradaxa after my last dose of heparin. I was allowed to sit up already and go to the bathroom. In the afternoon, Dr Haissaguerre was able to visit me which was the first time I met him face-to-face. My wife told me that he visited a few hours after my procedure, but I was mostly asleep at that time. He had an aura of confidence in him that made me feel that I was talking to a very knowledgeable person. He explained that I had 3 problematic areas. 1 in the atrial septum and 2 near the pulmonary veins. He added that since I was not in A-Fib, they had to induce it with isoproterenol.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week.

They started with the atrial septum focus which made the A-Fib stop after they had ablated it. But since they knew that I had 3 problematic areas even before the procedure, they induced me again and ablated the 2 remaining areas near the pulmonary veins. After that I was told they could no longer induce my A-Fib.

Dr Haissaguerre stayed in the room for almost an hour explaining to us what was done and what to expect in the future. I asked him how many international patients they have. He informed that they accept only 2 international patients per week. And I was told that I was the first Filipino patient he had. I was also able to meet for the first time Laurence Bayle, the secretary of the doctors with whom I was in contact most of the time. Sometimes it would take a day or two for my emails to be answered, sometimes a week. But despite that, I was able to arrange and carry out my ablation. Probably the volume of the inquiries made it impossible for them to answer immediately.

Dr. Michele Haissagguerre with Dr. Carlo Romero

Dr. Michele Haissagguerre with Dr. Carlo Romero

Discharge—Questions For Dr. Haissaguerre

The next day, Friday, I was told that I would be discharged. I was given all the instructions. While waiting for our Dr Haissaguerre to meet us prior to discharge, we were able to go around the hospital and outside it. From what I understand, it’s a big hospital building which caters solely for heart patients. We were sent to the admitting section to settle our accounts, but we were told that we would have no additional payments, as everything is included in the package.

When Dr. Haissaguerre arrived to see us in the afternoon, I informed him about skipped beats which bothered me post op. He told me that it was normal for an ablated heart to skip beats especially since I had a pericardial effusion, but that they will go away in time. (the skipped beats slowly went away in a month’s time).

I went back to the hospital in November 10, 2014 for my final check-up prior to being allowed to go home. The next few days, we opted to go to Paris and spent some vacation time just in case there was still a need to see Dr. Haissaguerre prior to our flight back home to the Philippines.

Lessons Learned

The whole “healing journey” was very memorable. I cannot believe that I really went out of country just to have the procedure, but everything went as planned. A lot of anxious moments and hesitancy, but I made it through. A few hitches here and there, but nothing that couldn’t be handled.

In this age of the Internet, we as patients have the power to learn more about our disease and act accordingly. We can opt to just live with it which is not really a bad choice as a lot of A-Fib patients have done successfully. Or we can be proactive about it. Of course the ablation procedure is not 100% curative nor 100% safe, But I made my decision based on my goal that I still wanted to practice my profession as a doctor. I owe it to my patients to try to heal myself by the best possible means so that I can render the best medical service to them.

I am now exactly 100 days post ablation. I’m still on anticoagulants, but am A-Fib free. In the last conversation I had with Dr Haissaguerre, I asked him if there are things that I am prohibited to do or food that I am not allowed to eat, and he told me no prohibitions.

“Live a Normal life” and that’s what I plan to do.

Carlo Romero
Email: cadromero1170@yahoo.com

Editor’s Comments:
Because Dr. Carlo had been in A-Fib for some time, his ablation probably was more challenging. It took four hours which was longer than usual considering that the mapping had been done already by the ECGI system. He had a minor pericardial effusion which is often unavoidable in more extensive ablations.
The ablation Dr. Carlo had represents a radical, transformative change in ablation therapy and may alter the way ablations are done. Normal catheter ablation for A-Fib usually starts with isolating the pulmonary vein openings. But Dr. Haissaguerre instead started with the atrial septum area as indicated by the ECGI system. Only later did he go to the pulmonary vein areas. ECGI will certainly change the way catheter ablations are performed.
Dr. Carlo Romero is a great example of a proactive A-Fib patient who educated himself about A-Fib, researched all his options, found the right doctor for him, and wouldn’t settle for less than the opportunity for a complete cure of his A-Fib.

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If you find any errors on this page, email us. Y Last updated: Sunday, July 17, 2016

FAQs A-Fib Treatments: Medicines and Drug Therapies

FAQs A-Fib Treatments: Medicines and Drug Therapies

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Drug Therapies for Atrial Fibrillation

Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?

2. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?”

3. “I take atenolol, a beta-blocker. Will it stop my A-Fib.”

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

5. Should everyone who has A-Fib be on a blood thinner like warfarin (Coumadin)?”

6. Which is the better anticoagulant to prevent stroke—warfarin (Coumadin) or aspirin?

7. What’s the difference between warfarin and Coumadin?

8. I’m on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn’t that give me more protection from an A-Fib (ischemic) stroke?

9. “What are my chances of getting an A-Fib stroke?

10. “I’m worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?

11. “I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?” UPDATED

12. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?

13. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?

14. Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”

15. “How long do I have to be in A-Fib before I develop a clot and have a stroke?

16. I have to be on aspirin for stroke prevention. Which is better—the low-dose baby aspirin (81 mg) or a high dose (325 mg)? Should I take the immediate-release (uncoated) or the enteric-coated aspirin?

17. I don’t want to be on blood thinners for the rest of my life. I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of.  Is there anything I can do to get off of blood thinners?

18. “My last cardiologist had me on Pradaxa. My new cardiologist wants me to switch to Eliquis. Is Eliquis easier to deal with if bleeding occurs?

19. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.

20. “I hate taking Coumadin. Is there a way to get off blood thinners all together? I know I’m at risk of an A-Fib stroke.”

21. “I”ve read about a new anticoagulant, edoxaban, as an alternative to warfarin (Coumadin) for reducing risk of stroke. For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?

22. “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?

23. Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

24. I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?

25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

Last updated: Wednesday, May 25, 2016

Back to FAQs by Patients with Atrial Fibrillation

FAQs A-Fib Drug Therapy: Amiodarone & Toxic Side Effects

 FAQs A-Fib Drug Therapy: Amiodarone

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

You are correct to be concerned about toxic effects. Amiodarone is considered one of the most effective antiarrhythmic meds, but it’s also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system.

Also, amiodarone has a long half-life. It is retained in the body for up to 45 days after the drug has been discontinued.

(Be advised that a newer drug dronedarone (brand name Multaq) is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer. However, some studies indicate that dronedarone may have problems.)

If you are taking amiodarone, you should by monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What’s important is not so much whether you are within a “normal” range, but whether your measurements are going up and how fast. Note: it’s important that baseline values for organ systems should be documented before you start taking amiodarone.

Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.

The recommended maintenance dose of amiodarone is 200 mg/day. A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.

For a more in depth discussion, see Amiodarone: Most Effective and Most Toxic.

 Thanks to Lee Abdullah for this question.

Resources:

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Return to FAQ Drug Therapies

FAQs A-Fib Drug Therapy: Medications with Heart Condition

 FAQs A-Fib Drug Therapy: Medications

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

1. “Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?”

A doctor’s choice of drug therapy depends on one’s overall heart health, i.e., if there’s a heart condition other than Atrial Fibrillation.

In general, current medications don’t always work on A-Fib. People tend to react differently to meds. What works for one person may be terrible for another. What medications are best for you is a judgment call only you and your doctor can make..

When trying a new med, there is a fine line between allowing time for your body to adjust to it versus recognizing that this drug is causing bad, unacceptable side effects.

When starting a new med, your doctor may hospitalize you in order to monitor how the drug affects you and to get the dosage right.

If you’ve just been diagnosed with paroxysmal (occasional) A-Fib, flecainide (brand name Tambocor) or propafenone (Rythmol) might work for you. Some people have had good luck with the relatively new drugs dofetilide (brand name Tikosyn) and Rhythmol SR (propafenone sustained release). The newest antiarrhythmic med is Multaq (dronedarone) which is a less toxic substitute for amiodarone. Also see Treatments/Drug Therapies.

Guidelines from the ACC/AHA/ESC based on one’s overall heart health and heart conditions other than Atrial Fibrillation:

•  Minimal or no heart disease. Flecainide, propafenone, sotalol. The object is to “minimize organ toxicity,” to select drugs that will not harm the rest of the body. The above drugs can cause “proarrhythmia” (an increase in heart rhythm problems), “but in patients without heart disease, this risk is extremely small.”
•  If these drugs don’t work, then dofetilide and amiodarone can be considered. And “in experienced hands one might choose (Pulmonary Vein) Ablation (Isolation) for a primary cure.”
•  Congestive heart failure. Only dofetilide and amiodarone have been demonstrated to be safe in randomized trials.
•  Congestive heart failure and significant lung disease. “I would likely consider dofetilide as my first choice.”
•  Congestive heart failure who are “hypokalemic” (have low levels of potassium). Amiodarone.
•  Coronary artery disease. Sotalol is recommended because of its beta blocking and antiarrhythmic effects. Amiodarone or dofetilide combined with a beta blocker can also be used. Propafenone and flecainide aren’t recommended.
•  Hypertension. Propafenone or flecainide.
•  Hypertension and substantial left ventricular “hypertrophy” (increase in size). Amiodarone, because it has the least proarrhythmic effect.

(These guidelines are based on a presentation by Dr. Eric Prystowsky, see Boston AF/2003/ Prystowsky.)

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Louis Therrien – A-Fib Patient Story

Louis Therrien Personal Experience A-Fib.com

Louis Therrien

A-Fib Patient Story #74

Amiodarone Damages Thyroid—A-Fib Free After 2 Ablations by Dr. Marc Dubuc,  Montreal Heart Institute

By Louis Therrien, Montreal, Canada, June 2014

“Silent” A-Fib Discovered

My A-Fib was diagnosed during an annual checkup with my GP in 2008. When going through the ECG, they found that my heart was going over 200 BPM. So I was sent to the ER and then the hospital for eight days where they tried medication and a cardioversion to convert me back to a regular rhythm, without any success. I was sent back home with medication and finally converted back to regular rhythm after another week.

Amiodarone damages thyroid,  NSR with Rythmol

One of the medications was Amiodarone, which after a few months caused a thyroid problem and put me back into A-Fib. At that point, I was referred to the Montreal Heart Institute (MHI) where I met Dr Marc Dubuc, a specialist in irregular heart rhythms. He immediately took me off the Amiodarone and put me on Rythmol. I went back into normal sinus rhythm.

ablation, then 3 years later cyroballoon ablation

The Rythmol worked well until 2010 when I developed a Flutter arrhythmia. I then went through my first ablation in the right atrium by Dr Dubuc of the MHI. This went well, and my A-Fib and Flutter did not reappear for several years. The summer of 2013, my A-Fib started up and became more and more constant (3 to 4 episodes of 1 to 2 hours a day). Dr Dubuc scheduled me for a CryoBalloon ablation of the left atrium which was done in October 2013.

Post ablation flutter & cardioversion

The operation went well, but the following day a Flutter appeared; so back to the hospital after a few days at home to see if it would resolve by itself. Since the Flutter was still present after a few days, Dr Dubuc debated between going back for a touch up procedure. But after discussing with the team at the MHI, he decided that this Flutter was probably caused by the A-Fib operation and originated in the left side of the heart versus a true flutter coming from the right side. The decision was to give me a cardioversion to bring the heart back to sinus rhythm, and this procedure was a success.

a-fib free

I am happy to report that after 7 months, I have had no A-Fib episode. I have resumed exercising. And the only symptoms I get are the rare extra-systoles [premature beats] which seem to occur less and less often as time goes by. All in all, I was not sure about the operation. And when faced with it, Dr Dubuc did not leave me a chance to decide. But I must say that I have no regrets and should have done the ablation earlier. The operation was a breeze. And the team along with Dr Marc Dubuc at the Montreal Heart Institute are excellent and very knowledgeable. MHI is, in my opinion, one of the top-notch institutions in the world.

Living with fear but the confidence is coming back

This has been quite an adventure of ups and downs in the last 6 years for someone my age (45 years old and a very active cyclist). Living with this fear of when and where the A-Fib will strike. Now that the procedure is done, the more time goes by, the more the confidence is coming back. I must admit that right after the operation, there is always the doubt of will I be in the percentage rate where the operation is not a success? And I am reminded of that every time someone asks me ”So, how are you after the operation? Was it a success?” and my answer is ”So far it is, but time will tell” as this is not the condition where you can be told you are cured, but you can only know until the next A-Fib episode, which in my case, I hope is never! I try the keep a positive attitude so that my body will follow.

Louis Therrien louis-therrien(a)hotmail.com Montreal, Canada

Editor’s Comments:
As Louis experienced, it’s unfortunately all too common for the drug amiodarone to cause thyroid and other serious side effects. Amiodarone is usually only given for short periods of time such as after an ablation and with careful monitoring for side effects.
It’s still a topic of debate among doctors whether to do a left atrium ablation if a patient only has right atrium flutter. Since doctors are in your heart already, many will do an A-Fib ablation in the left atrium as well as a right atrium A-Flutter ablation. A-Fib often coexists with A-Flutter or lurks behind it. In a small study people did much better if they had both an A-Fib and an A-Flutter ablation at the same time even though they only seemed to have A-Flutter.1
Louis’ case was more difficult than most in that he developed left atrium flutter after an A-Fib ablation. Usually Flutter comes from the right atrium and is easily fixed. Happily in Louis’ case an electrocardioversion shocked him out of the left atrium flutter. But he may eventually have to go back for a touch-up ablation if his left atrium flutter returns. However, this should be a much easier and quicker ablation than his original left atrium A-Fib ablation.

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References    (↵ returns to text)
  1. Navarrete, A. et al. “Ablation of atrial fibrillation at the time of cavotricuspid isthmus ablation in patients with atrial flutter without documented atrial fibrillation derives a better long-term benefit.” Journal of Cardiovascular Electrophysiology, July 19, 2010. Navarrete A, Conte F, Moran M, Ali I, Milikan N. Ablation of atrial fibrillation at the time of cavotricuspid isthmus ablation in patients with atrial flutter without documented atrial fibrillation derives a better long-term benefit. J Cardiovasc Electrophysiol. 2011 Jan;22(1):34-8. doi: 10.1111/j.1540-8167.2010.01845.x. PubMed PMID: 20662976.

Amiodarone: Most Effective and Most Toxic

Amiodarone: an antiarrhythmic medication

Amiodarone: an antiarrhythmic medication

Amiodarone: Most Effective and Most Toxic

By Steve S. Ryan, PhD, Updated May 2016

Amiodarone is considered one of the most effective antiarrhythmic meds, but it’s also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system. Also, amiodarone has a long half-life. It is retained in the body for up to 45 days after the drug has been discontinued. It’s usually considered a drug of last resort or a drug that should only be used for a short time.

Be advised: A newer drug, dronedarone (brand name Multaq), is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer. But some studies indicate that donedarone (Multaq) may have problems. 

Monitor and Test Frequently

If you are taking amiodarone, you should be monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What’s important is not so much whether you are within a “normal” range, but whether your measurements are going up and how fast.

Note: it’s important that baseline values for organ systems should be documented before you start taking Amiodarone.

Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.

The recommended maintenance dose of amiodarone is 200 mg/day. A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.

Susan Grider, of AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer, emailed me this observation:

“While you do point out that amiodarone is dangerous, you’re not nearly emphatic enough about it. A patient could easily justify taking amiodarone after reading your description calculating that when symptoms present themselves, they will simply stop treatment. It’s not that easy as some have suffered permanently as a result of only one dose. In addition, the symptoms of amiodarone toxicity are not always recognized (even by the medical community) before it is too late. Amiodarone is a drug of last resort and that’s according to the FDA. Patients who take this drug should have exhausted every other treatment possibility.” See also the website: AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer.

Damage and Toxicity to Organ Systems

LUNGS: Perhaps the most important test is for the lungs. “Amiodarone-induced pulmonary toxicity can be progressive and fatal if not recognized and treated.” You should have a chest X-Ray and Pulmonary function testing with diffusion capacity (DLCO) before starting and at least every year you are on amiodarone.

THYROID: Thyroid problems from amiodarone are all too common and can occur in as many as 22% of patients. Decreased energy, cold intolerance and weight gain are among the most common effects of decreased thyroid function. You should test for blood levels of TSH (Thyroid Stimulating Hormone), as well as the thyroid hormones free T4 and total T3. Amiodarone can also increase thyroid function with symptoms such as atrial rhythm disturbances, elevated heart rate, heat intolerance, and weight loss.

EYES: Corneal microdeposits occur in the majority of patients who take amiodarone, but they usually don’t cause any ill effects. More substantial microdeposits, however, can cause visual disturbances and even severe damage/inflammation of the optic nerve which can cause blindness. On taking amiodarone, you should have yearly eye exams. Report any visual changes immediately to your Electrophysiologist.

LIVER: Amiodarone commonly causes liver toxicity, but usually only mild increases in blood liver function tests (LFTs). The liver function tests are AST (SGOT), ALT (SGPT), and bilirubin. More severe cases can result in liver failure signaled by jaundice, abdominal pain, and distension.

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SKIN: Amiodarone increases sensitivity to the sun and sun burning. This increased sensitivity to the sun can be severe in approximately 10% of patients. Avoid the sun, apply sunscreen, and wear additional clothing.
It also can produce a blue or gray discoloration of the skin if one takes heavy doses and/or for long periods. This discoloration can persist after stopping amiodarone, but may fade very gradually (often years) after drug discontinuation.

HEART: Amiodarone can cause slow heart rhythm disorders such as slowing of the sinus rate and AV block. You may feel fatigued, lethargic, have poor exercise tolerance, and may experience dizziness and fainting. Less commonly, amiodarone may induce ventricular arrhythmias such as polymorphic ventricular tachycardias called “Torsades de Pointes” or TdP which can cause death.

You should have a 12 lead EKG before starting amiodarone and at six-month intervals in order to assess baseline heart rate, rhythm, and EKG signal intervals (PR, QRS, QTc). 

FETUS/NURSING INFANT: Amiodarone is known to cross the placenta and enter the fetus, and is excreted in breast milk. Use of amiodarone should be avoided if at all possible in women who are pregnant or likely to become pregnant. Lactating women who are taking amiodarone should not breastfeed. Due to the likelihood of toxicity if amiodarone is taken for decades, amiodarone use is strongly discouraged in children, unless there are no acceptable alternatives.

Keep in Mind

Amiodarone is a drug of last resort and that’s according to the FDA. Patients who take this drug should have exhausted every other treatment possibility.” See also the website: AmiodaroneToxicity: The Drug Amiodarone Is a Deadly Killer.

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Last updated: Tuesday, July 26, 2016

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