16. “I am 69 years old, in permanent A-Fib for 15 years, but non-symptomatic. My left atrium is over 55mm and several cardioversions have failed. My EP won’t even try a catheter ablation. I exercise regularly and have met some self-imposed extreme goals. What more can I do?
As you already know, being in permanent (long-standing persistent) Atrial Fibrillation can cause other long term problems like fibrosis, increased risks of heart failure and dementia. So you are wise to be concerned.
I’m not surprised your electrophysiologist (EP) is reluctant about a catheter ablation. Being asymptomatic with 15 years of long-standing persistent A-Fib and a Left Atrium diameter of 55mm, most EPs wouldn’t recommend or perform a catheter ablation on you.
Drug Therapy Option: Tikosyn
Have you tried the newer antiarrhythmic drug Tikosyn (generic name dofetilide)?
Tikosyn was designed for cases like yours. It’s a Class 1A drug that works by blocking the activity of certain electrical signals in the heart that can cause an irregular heartbeat.
The only inconvenience of Tikosyn drug therapy is you have to be in a hospital for 3 days for observation and to get the dosage right.
Benefits of Activity and Exercise on Your A-Fib
You are truly blessed to be so active and without noticeable symptoms in spite of being in A-Fib. While exercise will not reduce the size of your LA, your activity level may compensate for the lack of pumping of your left atrium. In fact, your ventricles may be acting kind of like a turkey baster sucking blood down from your non-functioning LA before pushing blood out to the rest of your body.
Catheter Ablation and Surgical Options
Catheter ablation: Studies of non-paroxysmal A-Fib have shown that a successful catheter ablation can significantly reduce atrial dilation and improve ejection fraction. But, with your A-Fib being persistent long-standing, this may not apply.
Surgery: A Cox Maze IV surgery may reduce the volume and size of your left atrium while hopefully making you A-Fib free, but surgeons may be reluctant to tackle your case since the success rate is under 80%. A Cox Radial Maze is open heart surgery which is very traumatic and risky. It may be hard to justify open heart surgery if you’re symptomaric.
1. If you haven’t tried it yet, ask your EP about taking the newer antiarrhythmic drug Tikosyn.
2. If you’ve tried Tikosyn and it doesn’t help you, I recommend you consult an EP who specializes in longstanding persistent A-Fib. See Steve’s Lists. You may need to travel, but it may be worth it to you for your peace of mind. Also, ask the EP if surgery may be a helpful option.
Making an Informed Choice
Armed with the above information you will be able to determine how you want to proceed. This is a decision only you can make.
With no A-Fib symptoms and a fulfilled life with plenty of body and soul enriching exercise, you may decide you are content with your present A-Fib status.
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.)
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?“
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?“
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?”
Last updated: Wednesday, May 25, 2016
19. “My doctor told me about the Tikosyn [generic name dofetilide] 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.”
Tikosyn made by Pfizer (generic name dofetilide) is a class III antiarrhythmic agent and certainly deserves its own discussion on A-Fib.com. (See also the first question in this section “Which medications are best to control my Atrial Fibrillation?” )
In Hospital for Three Days
Tikosyn is a newer antiarrhythmic med that works really well in some people. It’s approved for use in cases of persistent A-Fib. When starting Tikosyn, you have to be hospitalized for at least three days for observation. This is so that doctors can monitor you for bad effects (such as Torsades de Pointes, a special type of rapid heart rate which can be dangerous) due to its pro-arrhythmic potential (can cause arrhythmias instead of stopping them). Doctors also use this three-day hospitalization to determine the best dosage of Tikosyn for you. Importantly, short-term response does not necessarily predict long-term effectiveness.
How Tikosyn Works
For you technical types, Tikosyn works by selectively blocking the rapid component of the delayed rectifier outward potassium current (Iĸг). It causes the refractory period of atrial tissue to increase making your heart less susceptible to A-Fib signals. It’s 80% excluded by the kidneys, which means that anyone with kidney problems has to be carefully monitored or shouldn’t be taking it. Tikosyn has a half-life of roughly ten hours, which means it takes that long for your body to clear it from your system.
Tikosyn Somewhat Hard to Obtain
Not all doctors can prescribe Tikosyn. Only doctors who have gone through Tikosyn training from Pfizer can prescribe it. Depending on where you live, you may have a hard time finding a doctor who can prescribe Tikosyn. Call Pfizer for help in finding a doctor at 800-879-3477. Pfizer also has a special program if you are uninsured, call 866-706-2400.
Tikosyn and Persistent A-Fib
Persistent A-Fib is the hardest to cure. Catheter ablation success rates for Persistent A-Fib are usually lower than for Paroxysmal (occasional) A-Fib. This is because people in persistent A-Fib have probably been in A-Fib for a long time and have developed multiple areas of A-Fib producing spots in the heart other than in the Pulmonary Veins. These areas are harder to locate and ablate (isolate). Some people in persistent A-Fib who have had failed catheter ablations or surgeries are restored to normal sinus rhythm by taking Tikosyn. Tikosyn may work for you, though obviously it’s not guaranteed.
What Patient are Saying About Being on Tikosyn
In general, my non-scientific survey of these comments suggests that Tikosyn has more successes than failures, but that it’s a potentially dangerous drug. For some people, Tikosyn works when ablation has failed and when one has been in persistent A-Fib, even for a long time. It is expensive. And few people have been on Tikosyn for a lifetime. Since Tikosyn has potentially very bad side effects, so much so that one has to be hospitalized for three days when starting it, one wonders what a lifetime on Tikosyn will eventually do to one’s heart and body. But for people who’ve had failed ablations, surgeries, cardioversions and are in persistent symptomatic A-Fib, Tikosyn is a valid (welcome) option probably worth trying.
Thanks to Sam Matier for this question.
Banchs, Javier E., et al. Efficacy and safety of dofetilide in patients with atrial fibrillation and atrial flutter. Journal of Interventional Cardiac Electrophysiology November 2008, Volume 23, Issue 2, pp 111-115 Last accessed March 13, 2014 URL: http://link.springer.com/article/10.1007/s10840-008-9290-6
Roukoz H, Saliba W (January 2007).”Dofetilide: a new class III antiarrhythmic agent”. Expert Rev Cardiovasc Ther 5 (1): 9–19. doi:10.1586/14779072.5.1.9. PMID 17187453
Return to FAQ Drug Therapies
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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