Drug Therapies & Medicines: Treatments for Atrial Fibrillation

The various medications, or drugs, for treatment of Atrial Fibrillation can be overwhelming. What they are for, how they work and how they might affect you can be confusing. We’ll give you a basic understanding of the various ‘drug therapies’ you may be prescribed, so that you can become an intelligent participant in your own healing process.

A Two-Pronged Approach

Drug therapy treatment of Atrial Fibrillation is a two-pronged approach:

•  Management of increased risk of clots and stroke
•  Drugs to control the heart rate (rate control), or to regain and maintain normal heart rhythm (rhythm control).

Word of Caution About Prescription Medications

Always be cautious when taking prescription medications. Adverse drug events (ADEs) are now the third leading cause of death in the United States with approximately 250,000 deaths each year. That’s a greater number than deaths caused by stroke and respiratory disease.

Treatment for stroke Risk

Stroke is the leading cause of death worldwide. In the United States, stroke is the leading cause of disability with approximately 795,000 people each year experiencing a new or recurrent stroke costing an estimated $34 billion annually.

Called a thrombosis, a stroke is the formation of a blood clot inside a blood vessel that slows or blocks normal blood flow. When a clot travels out of the heart and into the brain, it can block an artery and cause an ischemic stroke (pronounced iss-KEE-mick).

Atrial Fibrillation accounts for roughly 15% to 30% of all ischemic strokes. Having A-Fib makes a person about 3 to 5 times more likely to suffer a stroke. A-Fib-related strokes are often more severe and disabling than strokes from other causes.

For A-Fib patients, blood thinners (anticoagulants) may be recommended to lower the risk of stroke. Anticoagulants make it harder for blood clots to form. Stroke risk assessment tools such as the CHA2DS2-VASc Risk Score are used to access your risk of stroke. Not everyone with A-Fib needs a blood thinner. Your doctor will help you decide if they’re right for you.

For more about stroke risk assessment tools, see my article, The CHADS2 & CHA2DS-VASc Stroke-Risk Grading Systems.

VIDEO: A-Fib Related Strokes (click on center of screen to watch): Through animation, this video describes how A-Fib strokes are more deadly and debilitating, how they form blood clots that can travel to the brain, causing a life-threatening ischemic stroke. Published by CardioVisual. Oct 21, 2024 (:28 sec). Or click Watch on YouTube.

Anticoagulants

For more than 50 years, oral vitamin K antagonists (such as warfarin) were the choice of anticoagulant. However, achieving a stable, therapeutic dosage proved challenging.

Direct Oral Anticoagulants: The first Direct Oral Anticoagulant (Pradaxa) was approved in 2010 by the U.S. Food and Drug Administration (FDA). Followed in 2011–2015 were rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa).

There are two types of DOACs: Factor Xa inhibitors (apixaban, edoxaban, and rivaroxaban) and Direct thrombin inhibitors (DTIs), such as dabigatran (Pradaxa).

Injectables: Today’s blood thinners also include injectables such as Lovenox and Heparin which are used for hospitalized patients.

Like all prescription drugs, blood thinners have their own set of risks and side effects. However, preventing a stroke is a welcome trade-off for most people. (Note: Most “blood thinners” do not actually thin the blood, but work to make blood less likely to form clots.)

DOACs—Direct Oral Anticoagulants

Direct Oral Anticoagulants (DOACs) simplified oral anticoagulation therapy and replaced vitamin K antagonists for many indications. DOACs, like Xarelto and Eliquis, have revolutionized clinical practice as they can be used in fixed doses without routine laboratory monitoring.

In early use, DOAC-treated patients experienced life threatening bleeding or required emergency major surgery. Subsequently, specific reversal agents were developed that effectively neutralized the anticoagulant effect.

Today’s DOACs act quickly, provide rapid anticoagulation, and have predictable responses, simplifying dosing. (It’s unnecessary to monitor blood clotting levels as with warfarin.) They are associated with lower risks of major bleeding, including intracranial hemorrhage. But DOACs may not be suitable for everyone, and can have risks such as kidney function impairment.

In addition to treating the risk of stroke in Atrial Fibrillation patients, DOACs are also used to treat and prevent deep vein thrombosis and pulmonary embolism.

Most are now available in generic form, and as such, initial cost barriers have been significantly reduced.

Be aware, blood thinners reduce but do not totally eliminate the risk of stroke.

An Alternative to Blood Thinners

Illustration: Positioning the Watchman device.

If you can’t or don’t want to take blood thinners, an option is to have a device installed to close off the Left Atrial Appendage where 90-95% of A-Fib strokes come from.

Removing or closing off the Left Atrial Appendage (LAA) may affect how well the heart pumps and is of special concern to athletes and to those with heart pumping problems.

The LAA is like a surge tank on a hot water heater. When the Mitral Valve closes, the LAA absorbs the surge of blood. When the LAA is amputated or closed off, this may cause increased pressure in the Pulmonary Veins and exercise intolerance. 

To learn more, see my article: Watchman: the Alternative to Blood Thinners.

Back to Top

Drug Therapies: Rate control versus Rhythm control

Drug Therapies for A-Fib

There are two basic approaches to managing Atrial Fibrillation with medications:

• Rate Control drugs
• Rhythm Control drugs

Rate control drugs slow down a fast heart rate by blocking electrical signals through the heart’s AV node. They try to control the heart rate of the ventricles, but generally leave the heart in A-Fib.

Rhythm control drugs try to stop the A-Fib signals in the atria and make your heart beat in normal rhythm.

Note: When listing medications, we list the generic name first, then the Brand name is in parentheses.

Method 1: Rate Control

Though rate control drugs slow the rate of the ventricles, they usually leave you in A-Fib. They generally don’t reduce A-Fib attacks. They may alleviate some A-Fib symptoms, but do not address the primary risks of stroke and death associated with A-Fib. Their main purpose is to avoid rapid A-Fib rates whenever possible and practical.

Over time, the heart can “wear out” if the rate is too fast for too long. An elevated heart rate for a long period of time (weeks to months) can cause ventricular dysfunction leading to heart failure. When using rate control drugs, you should aim for a resting heart rate below 110 beats.

Categories of Rate Control Medications 

Medications used for rate control can be categorized as:

• Calcium-channel blockers
• Beta-blockers
• Cardiac Glycosides

Calcium Channel Blockers

Calcium channel blockers prevent or slow the flow of calcium ions into smooth muscle cells such as the heart and blood vessels. They slow heart rate and lower blood pressure. Common side effects are the heart beats too slowly, constipation, low blood pressure and heart failure. They also cause swelling in the legs.

Calcium-channel blockers include: diltiazem (Dilt, Cardizem, Tilazem, Cartia XT) and verapamil (Calan, Isoptin).

Beta-Blockers

Beta blockers are classified into two types: selective or non-selective. Selective beta blockers specifically target your heart. Non-selective beta blockers target additional organs and tissues, including the lungs and blood vessels.

Beta-blockers block the action of adrenaline on beta receptors in the cells of heart muscle. They slow down conduction through the heart and make the AV Node less sensitive to A-Fib impulses. They also are said to reduce the frequency of premature beats which may trigger A-Fib.

Because they lower adrenaline, they can help maintain sinus rhythm, but also cause fatigue and put you to sleep. Unlike antiarrhythmic drugs, they are not specifically designed to stop or reduce episodes of A-Fib but are generally safe.  

Beta-blockers are better for active or young people than the other rate control medicines.

Common Side Effects of Beta-Blockers Include: the heart beats too slowly, low blood pressure, tiredness, cold fingers and toes, thinning hair, erectile dysfunction, and loss of sex-drive. Long-term side effects may include disorientation, short-term memory loss, emotional lability (rapid, extreme changes in mood), inability to concentrate or think clearly, and decreased performance on neuropsychological tests used to measure psychological function.

In many people, beta-blockers can reduce heart rate by 10 to 30 beats per minute. Beta-blockers like metoprolol can be particularly dangerous for older people (over 60) and cause symptoms similar to aging, Beta blockers also carry substantial risk for psychiatric side effects, particularly depression.

When using beta blockers, a person’s psychiatric health should be monitored carefully. They can also cause vivid dreams and insomnia, aggravate asthma, and impair blood sugar. Beta-blockers are notorious for causing impotence, fatigue, and depression.

Beta-blockers by Name (Brand Name): While brand names may differ, it’s easy to pick out beta-blockers. Most of them have generic drug names that end with “lol.”

Acebutolol (Sectral), Atenolol (Tenormin), Betaxolol (Kerlone), Bisoprolol fumarate (Zebeta), Carteolol hydrochloride, (Cartrol), Carvedilol (Coreg), Metoprolol tartrate (Lopressor), Metoprolol succinate (Toprol-XL), Nadolol (Corgard), Penbutolol sulfate (Levatol), Pindolol (Visken), Propranolol hydrochloride (Inderal), Sotalol hydrochloride (Betapace) andTimolol maleate (Blocadren).

Cardiac Glycosides

Cardiac Glycosides slow down and control the heart rate by blocking the electrical conduction between the atria and ventricles.

The most widely prescribed Glycoside is digoxin (a Digitalis [foxglove] compound, brand names Lanoxin, Digitek), but medical authorities consider it the least effective. 

Digoxin is usually not prescribed as a first-line therapy.

While Digoxin is a commonly used drug for rate control, it is only effective at controlling heart rate at rest, e.g. when you are in the doctor’s office. But when you leave, your heart rate may go too high. It’s not as effective at controlling heart rate during physical activity or when stressed (when the sympathetic nervous system is more active).

Beta-blockers and calcium-channel blockers are generally more effective than Digoxin.

Warnings About Digoxin: Digoxin carries a serious risk of poisoning or dangerous heart rhythm changes because it has a very narrow safety window.

Major Warnings:

• Digoxin Toxicity: Too much medicine can build up in your bloodstream, which can become life-threatening.
• Heart Rhythm Changes: The drug can slow your heart too much or cause irregular, dangerous beats

Key Risk Factors:

• Kidney Problems: Damaged kidneys clear the drug slowly, causing it to build up.
• Low Electrolytes: Low potassium or low magnesium levels make your body react too strongly to the medicine.
• Other Medicines: Drugs like amiodarone, quinidine, and certain antibiotics can raise digoxin levels in your blood

According to researcher Dr. Renato Lopes, professor of medicine and member of the Duke Clinical Research Institute. Digoxin should be avoided in patients with A-Fib, particularly if symptoms can be alleviated with other treatments.

If You’re Taking Digoxin

Talk to your doctor about switching to beta-blockers or calcium channel blockers to slow down fast heart rate. If you and your doctor conclude digoxin is the best drug for you, try to use the lowest possible dose and make sure you are closely monitored.

Rate Control Drugs: Only Control the Ventricles

If you are using any rate control drug, only your lower heart (the ventricles) is controlled. Be advised that you will usually still have A-Fib. You are still at risk of stroke and must continue taking anticoagulants.

If using rate control drugs, be advised that you will still have A-Fib.

Back to Top

Method 2: Rhythm Control

Rhythm control medications called antiarrhythmic drugs have been available for nearly 100 years and remain a mainstay in the management of atrial fibrillation. These drugs target a reduction in the frequency and duration of episodes of arrhythmia.

There hasn’t been any major advancement in rhythm control meds in decades: amiodarone (approved in 1985), flecainide (1985), sotalol (1992), and dofetilide (1999). Even the most “recent” standard oral addition, dronedarone (Multaq), was approved all the way back in 2009.

Bad Side Effects & Less Effective Over Time

Many rhythm control drugs require you to be hospitalized for 3-4 days when they are initially administered, in order to monitor you for bad side effects. Some rhythm control meds can have a “pro-arrhythmic” effect, i.e., creates a brand-new heart rhythm problem or make an existing heart rhythm problem much worse.

In general, antiarrhythmic drugs aren’t always effective and tend to have bad side effects such as pulmonary fibrosis and impaired liver function. They also become less effective over time, with approximately half of the patients eventually developing resistance to them. Up to 50% of patients experience a recurrence of A-Fib after 1-year of antiarrhythmic treatment, and up-to 85% experience a recurrence after 2-years.

If one rhythm control drug fails to control your A-Fib, it’s unlikely any of the others will work, with the possible exception of amiodarone, the most toxic and dangerous of the rhythm control drugs.

Antiarrhythmics are not a long-term solution for most people. Be aware that all antiarrhythmics may increase your risk of a life-threatening ventricular arrhythmia.

In addition, most patients managed using a rhythm control strategy also require medications for rate control.

According to Drs. Irina Savelieva and John Camm of St. George’s University of London, “The plethora of antiarrhythmic drugs currently available for the treatment of A-Fib is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability.”

Classes of Antiarrhythmic Drugs

Antiarrhythmic drugs are grouped in “classes” according to how they work:

1. Class I are Sodium Channel Blockers which decrease the speed of electrical conduction in the heart muscle.

2. Class II are Beta-Adrenergic or Beta-Blockers which slow down conduction through the heart and make the AV node less sensitive to A-Fib impulses.

3. Class III are Potassium Channel Blockers which slow nerve impulses in the heart.

4. Class IV are Calcium Channel Blockers which prevent or slow the flow of calcium ions into smooth muscle cells such as the heart. This impedes muscle cell contraction, thereby allowing blood vessels to expand and carry more blood and oxygen to tissues.

Most Common Antiarrhythmic Drugs

The most commonly prescribed antiarrhythmic drugs to restore and maintain a normal heart rhythm in atrial fibrillation include amiodarone, sotalol, flecainide, propafenone, and dofetilide.

Also, antiarrhythmic drugs become less effective over time, with approximately half of the patients eventually developing resistance to them.

Back to Top

“Pill-in-the-Pocket”: For Patients With Infrequent, but Symptomatic A-Fib Fibrillation

Pill-in-the-Pocket Treatment

The “Pill-in-the-Pocket” (PIP) treatment refers to only taking an antiarrhythmic medication at the time of an A-Fib attack to try and stop it versus taking a daily antiarrhythmic med.

This strategy is useful for A-Fib patients that cannot tolerate antiarrhythmic meds on a regular basis.

A variation of the “Pill-In-The-Pocket” treatment is for someone who is regularly taking an antiarrhythmic to then take a higher dose at the time of an A-Fib attack.

One objection to this treatment strategy is that, like a fire, it’s better to keep A-Fib from starting in the first place.

Post Ablation Application of Pill-in-the Pocket Anticoagulation

Dr. John D. Day, cardiac electrophysiologist, St. Mark’s Hospital in Salt Lake City, Utah, described a less common use of the Pill-in-the-Pocket strategy for motivated A-Fib patients after a successful catheter ablation with no recurrence.

Current post-ablation Management Guidelines require A-Fib patients to take an anticoagulant for several months up to a year after a successful catheter ablation. (Note: this post anticoagulation requirement may change based on findings from the OCEAN trial).

His approach is for those patients who don’t want to take a blood thinner and who have rejected installation of a Watchman device.

He requires they commit to taking a daily ECG of their heart with a Smartwatch (such as the Apple Watch with its automatic features). If they are in A-Fib, they add a blood thinner (Eliquis or Xarelto) for one month, and then they contact the doctor for follow-up steps. This strategy is only for educated, highly motivated patients who understand and take full responsibility for their choice.

Which Antiarrhythmic for “Pill-In-The-Pocket”

There are a few antiarrhythmics which can be used for the ‘pill-in-the-pocket’ approach. Which medication you use will depend on any underlying heart disease, such as coronary heart disease, heart failure and hypertension. It will also depend on the known side effects and how effective the drug may be.

When initiating this approach with medications such as flecainide, your doctor will monitor the effects of high doses for acute toxicity.

The Pill-in-the-Pocket” treatment is not a “cure” for A-Fib, but is a stop-gap measure to get the patient out of an A-Fib attack.

Conclusion: Drug Therapies & Medicine Treatments A-Fib

In general, don’t expect  miracles from current medications. To date, the magic pill that will cure your A-Fib doesn’t exist. As heart rhythm specialist, Dr. Dhiraj Gupta says, “Drugs don’t cure A-Fib but merely keep it at bay.”

Sir William Osler, first Physician-in-Chief of the Johns Hopkins Hospital, and considered to be the “Father of Modern Medicine” made this sobering warning, “One of the first duties of the physician is to educate the masses not to take medicine.”

Medicines, by definition, are almost all unnatural. They need to be taken with caution. Our bodies see most medications as toxins and try to eliminate or clear them. (Medications are not like taking vitamins as a precaution against a possible deficiency.) But if one has A-Fib, medications may sometimes offer hope of stopping A-Fib episodes or making them more bearable.

Additional Readings

♥ Frequently Asked Questions: Drug Therapies and Medicines
♥ Anticoagulant Therapy after Successful A-Fib Catheter Ablation: Is it Right for Me?
♥ Amiodarone: Most Effective and Most Toxic
♥ Watchman: the Alternative to Blood Thinners

“One of the first duties of the physician is to educate the masses not to take medicine.”

– Sir William Osler, first Physician-in-Chief of the Johns Hopkins Hospital, considered to be the “Father of Modern Medicine”

Back to the Top
Return to Treatments for Atrial Fibrillation
Last updated: Monday, September 7, 2026

Related Posts