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Lesson Risk of Stroke and Reduce Symptoms

The main goal of treatment of AF is to lessen the risk of stroke and to reduce symptoms caused by a rapid, irregular heartbeat. There are a number of treatment options available to accomplish these goals.

Individualized Treatments

Every individual is different. Your treatment will depend on:

  • How long you've had AF
  • Severity of your symptoms
  • Underlying cause of your problem
  • If you have other heart problems

In many cases, you will have a choice of treatments.

Treatment Goals

Basic Goals

The basic goals of treatment are:

  1. Preventing blood clots that can lead to stroke
  2. Resetting your heart to a normal rhythm
  3. Controlling how many times per minute your ventricles contract (rate control)

You should discuss these with your doctor.

Main Goal

The main goal of treatment of AF is to lessen the risk of stroke and to reduce symptoms caused by a rapid, irregular heartbeat.

Treatment Options

General treatment options include:

  • Medicines
  • Medical procedures
  • Lifestyle changes

Blood-Thinner to Prevent Clots

If you have risk factors for stoke, you should take the blood-thinner Coumadin (warfarin).  This medication thins your blood and prevents it from clotting and causing stroke.

Periodic Blood Tests

If you are taking Coumadin, you must have your blood tested periodically to make sure the drug is thinning your blood to the proper level to prevent stroke.

Side Effects

The medication's major side effect is bleeding. For those in whom this turns out to be a serious problem, there may be alternatives, including taking aspirin or one of a number of new blood thinning agents now in clinical trials, including some in which the CardioVascular Institute is participating.

Paroxysmal Atrial Fibrillation

If you have AF that comes and goes -- paroxysmal atrial fibrillation -- you may need to be on blood thinners even when you are no longer experiencing AF, since the condition can still come back and cause a stroke. This is something to discuss with your doctor if you have this condition.

Symptom Management

Heart Rate Control

Although AF is not a life-threatening arrhythmia, if you have the chronic form of AF, you must control your heart rate and prevent it from becoming too rapid.

  • The goal is to slow it down to 50 to 90 beats per minute.
  • If your heart rate remains too rapid over a long period of time, your heart muscle can be weakened and it can lead to congestive heart failure.
  • Your heart rate can be controlled by the use of one or more of a number of medications:
    • Beta blockers (metoprolol, atenolol, propranolol, nadolol)
    • Calcium channel blockers (diltiazem, verapamil)
    • Digoxin (controls your heart rate at rest, but not as well during activity)

Restoring the Heart's Normal rhythm

Treatment of atrial fibrillation also involves resetting or restoring the heart's normal sinus rhythm. This is called cardioversion.

  • This can be accomplished by the use of medications called anti-arrhythmics or by an electrical shock to your heart.
  • Medications can be given either intravenously or orally and are successful in about 30 to 60 percent of cases, though AF often returns.
  • Electrical shock is successful in about 85 to 95 percent of cases.

Anti-Arrhythmic Medications

There are several anti-arrhythmic medications that help return your heart to its normal rhythm. These include:

  • Quinidine
  • Procainamide
  • Disopyramide
  • Metoprolol
  • Flecainide acetate
  • Propafenone
  • Sotalol
  • Dofetilide
  • Amiodarone
  • Dronedarone

You may have to stay in the hospital when you first start taking these medications so that your heart rhythm and response to the medication can be monitored. These medications work differently in different patients, so several medications may need to be tried before one is found that works for you.

Electrical Cardioversion

Brief, Safe, Routine Outpatient Procedure

This is a brief, safe and routine procedure in which an electrical shock is delivered to your heart through paddles or patches placed on your chest.

Prior to the procedure, you will be given a small amount of anesthesia through an IV line, putting you to sleep briefly so you don't feel the shock.

The electrical current stops your heart's electrical activity momentarily. When it begins again, the AF should be gone and your heart's normal rhythm restored.

At the CardioVascular Institute, this is performed on an outpatient basis.

Prior to Procedure

  • You may be put on the blood thinner Coumadin prior to the procedure to reduce the risk of stroke.
  • You may be checked in advance for risk of stroke by a procedure known as transesophageal echocardiogram (TEE).
    • This test allows your doctor to look inside the heart for blood clots.
    • The test is done under sedation.
    • A tube is passed down your throat to the esophagus, providing detailed ultrasound images of your heart, which sits in front of your esophagus.
    • The TEE test is 99 percent effective in detecting clots.

Post Procedure Medications

If electrical cardioversion is successful and AF has been stopped -- or if you have AF that comes and goes (paroxysmal AF) -- anti-arrhythmic medications may be prescribed to try to prevent AF from coming back.

Newer Procedures to Cure or Reduce the Frequency of AF

In recent years, doctors have discovered that the abnormal electrical impulses seen in atrial fibrillation often start in the pulmonary (lung) veins that drain into the heart. These pulmonary veins drain blood from the lungs into the left atrium. The abnormal electrical impulses from these veins travel to the left atrium and then to the right atrium, causing atrial fibrillation.

Now, there are procedures designed to prevent these electrical impulses from traveling from the pulmonary veins into the left atrium. The idea is that by cutting off the electrical activity between the pulmonary veins and the heart, the amount of fibrillation that occurs can be reduced and, in some cases, eliminated completely.
There are two procedures currently available to cut the electrical impulses from the pulmonary veins to the left atrium:

1.   Catheter-based procedure called Catheter Ablation

2.   A surgical procedure called a Maze:

  • Minimally invasive fashion called a MiniMaze
  • Full open heart surgery called a Standard or Conventional Maze

Catheter Ablation

Catheter ablation is a catheter-based procedure designed to reduce the frequency of your atrial fibrillation.

Radiofrequency Ablation Results

In this procedure your doctor inserts long wires, called catheters, into veins in your groin and snakes them into your heart to the area where the pulmonary veins drain into your left atrium. This area is then burned or cauterized using radio waves. The cauterization destroys the tissue around the pulmonary veins so that electrical activity is prevented from entering your heart, thus preventing the start of atrial fibrillation.

This procedure is effective in significantly reducing the frequency of atrial fibrillation as well as the symptoms associated with it about 70 percent of the time. In some cases, AF will be completely cured. About 30 percent of patients will have a recurrence of AF after the procedure. In some cases, these recurrences will quiet down in time. In other cases, patients may need a repeat procedure. The procedure itself takes from three to six hours and may require an overnight stay in the hospital for monitoring the results. You can usually return to work in two to three days after the procedure.

Standard Maze Procedure

In this procedure, your cardiac surgeon makes small cuts or burns in your atria to reduce the chances of chaotic electrical activity happening in that area.

In essence, the operation creates a pattern of scar tissue and since scar tissue does not carry electricity, it interferes with stray electrical impulses that cause AF. The cuts or burns that create the scar tissue can be made with a scalpel or with radiofrequency energy. This procedure can be done along with heart surgery for other reasons, such as coronary artery bypass or valve repair/replacement, or on its own.

MiniMaze Procedure

The minimally invasive version or "MiniMaze" has excellent results for those who qualify for the procedure. The MiniMaze allows for a shorter hospital stay and quicker recovery than a conventional open heart surgical Maze. The type of atrial fibrillation determines whether you are a candidate for the Mini Maze or the traditional open heart surgical Maze.

Both procedures can have success rates of greater than 90 percent in appropriate patients with AF. Please see a cardiac surgeon to determine if you are a candidate for either procedure.

The MiniMaze procedure is performed by a cardiac surgeon as well as an electrophysiologist. The procedure is done through two small (three-inch) incisions on both sides of the chest (under the arms and between the ribs). Your surgeon uses a small camera to find the area where the pulmonary veins drain into the left atrium. He or she then ablates the area with a clamp and radiofrequency energy. Concurrent electrophysiology testing is performed to assure isolation of the atrium from the pulmonary veins.

At the end of the procedure, the left atrial appendage is also removed. The appendage -- a small sack-like structure on the left atrium -- is where most blood clots form in patients with AF. It is thought that by removing the left atrial appendage, patients may have a lower risk of stroke.

The MiniMaze operation lasts between three and four hours but does not involve any radiation exposure. You will probably stay in the hospital for three days following the surgery. It usually takes three to four weeks until your chest wall feels back to normal.

Contact Information

Cardiac Surgery
Division of the CardioVascular Institute
Beth Israel Deaconess Medical Center
Lowry Medical Office Building, 2A
110 Francis Street
Boston, MA 02215
Phone: 617-632-8383