Question

I am 40, male, exercise regularly, don't smoke or use drugs. I drink 2 glasses of wine a day. I have had 5 incidents of atrial fibrillation in the past 15 years. The first 3 reverted spontaneously within 2 days. The 4th was reversed with Quinidex. This time my doctor would not prescribe Quinidex, but prescribed Atenolol. This didn't work and I was hospitalized for electrical inversion. I now take Sotalol twice a day. Should I be concerned about taking this medicine long-term?

Answer

Atrial fibrillation is an abnormal heart rhythm that can make you feel bad, but it's not necessarily serious (in the sense of you dying suddenly). It is caused by the top chambers (atria) of the heart quivering, and thereby bombarding the main pumping chambers with electrical signals. The main pumping chambers (ventricles) then tend to beat rapidly and without any rhythmic pattern (an irregular-irregular rhythm). Also, because the top chambers are quivering, they aren't working as effectively as usual. For these two reasons, folks can feel tired, fatigues, short of breath, dizzy, etc. The one bad thing that can occur with a-fib, as doctors sometimes call it, is that blood can tend to swirl in the top chambers, and run the risk of forming a blood clot. That's okay as long as the blood clot stays in the heart; but if it gets spit out, it can cause, for instance, a stroke - which is obviously bad. I therefore regard it not as a "bad" heart rhythm, but it can make you feel bad, and there are some bad things associated with it. I look at it both by symptoms and risk of stroke - with the two things totally separate.

We use blood thinners to help prevent stroke, but even with coumadin (the most potent one), there is still a small risk. What kind of thinner used depends on what the heart looks like on echocardiography (echo), and how likely it is to go back into a-fib.

There is still some controversy about which is better- heart rate control vs. maintaining a normal rhythm. My personal approach is always to try maintaining a normal rhythm (because of the blood thinner issue). There are various medicines available, but none is perfect. The most potent one available (and the one with the most potential long-term side-effects) only works about 70% of the time to maintain normal rhythm. Of the ones available, the most commonly used are flecanide (Tambocor), sotolol (Betapace), and amiodarone (Cordarone, Pacerone). They all have their plusses and minuses, and are chosen based on the clinical history, echo findings, and other medical conditions going on. There are many others, but we tend not to use them much anymore because of decreased efficacy or side effects. Quinedex is an older one and many folks develop diarrhea on it.

In your particular case, it may have been that your echo seemed to demonstrate a predisposition to a-fib and the doctor felt that there was an increased likelihood that you would go back into it without an anti-arrhythmic medicine on board. It is a personal decision about what medicine to use. I personally prefer to avoid sotolol in younger folks because of its potential to cause fatigue (and rarely impotence) as it can also slow down the heart rate/etc. Other than that, it is a good medicine and usually tolerated fairly well. You might talk with your cardiologist about the need of medication as your episodes are so rare (and especially if you were symptomatic with them so that you could immediately react if they became recurrent).

Finally, there was just something published yesterday about even small amounts of drinking (1 drink per day) predisposing vulnerable folks to atrial fibrillation. We always knew that binge drinking could cause a-fib, but this paper retrospectively looked at thousands of folks and found an association with low to moderate alcohol consumption like yours. You may want to cut down.

Links

• Atrial Fibrillation - What's New?