"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"


"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


FAQs Understanding A-Fib: Options for Asymptomatic Longstanding Persistent A-Fib

 FAQs Understanding A-Fib: Asymptomatic Longstanding Persistent A-Fib

FAQs Understanding Your A-Fib A-Fib.com16. “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

Tikosyn (dofetilide) for long-standing persistent atrial fibrillation at A-Fib.com

Tikosyn (dofetilide)

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.

My Recommendations

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.

3. Based on the results of the EP consult, I’d seek the opinion of a cardiac surgeon who performs the Cox Maze IV surgery. (See Steve’s Lists of surgeons who treat A-Fib patients.)

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.

Resources for this article

If you find any errors on this page, email us. Last updated: Friday, December 9, 2016‘
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Go back to FAQ Understanding A-Fib

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: The Tikosyn Drug Option

 FAQs A-Fib Drug Therapy: Tikosyn 

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

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

On the WebMD site I found User Reviews & Ratings from A-Fib patients who are using or have tried 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

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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