Reasons to treat arrhythmias
The first decision is whether to treat at all. There are only three reasons to treat arrhythmias. The first is to prolong life. This only applies to life-threatening arrhythmias such as ventricular tachycardia or ventricular fibrillation. The treatment of such arrhythmias is expected to prolong life since the risks of treatment are less that the risk of the arrhythmia being treated. The second reason to treat an arrhythmia is to alleviate symptoms of the arrhythmia and/or eliminate side effects of medications used to control the arrhythmia. This can be achieved assuming that the treatment risk and side effects are not worse than the arrhythmia being treated. The last reason to treat an arrhythmia would be to prevent future problems that the arrhythmia could lead to – this is rare and usually not a consideration.
Is no therapy a good option?
Patients with non-life-threatening arrhythmias may opt for no therapy to prevent or cure their arrhythmia. This is a good option for patients with rare episodes that are associated with lower heart rates (usually less than 150 beats per minute) and only minor symptoms. Such patients when they experience arrhythmia may stay at home or even try to fall asleep in hopes that they will convert spontaneously. In some the so-called “pill in the pocket” approach can be used. This involves the patient taking a single large dose of an antiarrhythmic medication and then waiting for a few hours to see if they will convert. Flecainide or propafenone are the most common medications used. This approach is only safe for patients who have no structural heart disease and tolerate their arrhythmia well with minimal symptoms. After some period of time if the arrhythmia does not convert, patients usually choose to go to the emergency room. Intravenous medicines or even cardioversion may be required to stop the arrhythmia. Frequent visits to the emergency room are inconvenient and expensive, such that many patients eventually decide on some form of therapy.
Daily heart rhythm medication is a better option if the arrhythmia is not as well tolerated by the patient. In this empiric approach, the physician starts an antiarrhythmic medication and asks the patient to notify him or her if any side effects occur. If none occurs, the dose is increased until there is a good chance that it might work for the patient. If the arrhythmia never recurs, the patient takes that dose of the medication for the rest of their life. If arrhythmia recurs, the physician has the option of increasing the dose or trying another medication. The milder medications (digitalis, beta blockers, calcium channel blockers) are the safest and the least expensive, but they tend to have more side effects are not very effective. However some patients need to be on such medications for other reasons such as hypertension or migraine headaches. In these patients, such medications should generally be tried before considering other medications or ablation.
There are true antiarrhythmic medications for patients who fail the above medications. These medications consist of sodium or potassium channel blockers: flecainide, propafenone, and sotalol. Flecainide and propafenone, sodium channel blockers cannot be given to patients with any significant diminution of left ventricular systolic function, history of myocardial infarction or any degree of coronary disease. Sotalol, however, is safe in such patients. These three medications have higher efficacy. However, rarely in patients with arrhythmias, such medications may cause a cardiac arrest. Estimates of this risk are in the 2-3% range, but many physicians consider this to be too high of as estimate.
Curative ablation for arrhythmias
Ablation is the option selected by the many patients. The chance of success and risk of ablation depends to a large extent on which arrhythmia is being treated. The most common personal reason(s) given by patients as to why they chose ablation are a follows:
- Wanting to get fixed definitively
- Not wanting to take heart rhythm medications the rest of their lives
- Not wanting to go to the emergency room any more
- Not wanting to worry about their arrhythmia occurring when they cannot easily get to the hospital – overseas travel, camping in wilderness areas etc.