Rhythm Control Strategies for Atrial Fibrillation

Medically Reviewed by James Beckerman, MD, FACC on July 08, 2022
5 min read

The first step to manage your atrial fibrillation (AFib) is to talk to your doctor about treatments that will control your heart rate or heart rhythm.

One way to control your AFib is to take rhythm control medication, which helps your heart return to and stay in a normal rhythm. This is also known as drug cardioversion or chemical cardioversion.

Rhythm control drugs carry risks and require that your heart be monitored closely. It may also take at least a year for them to fully work. But they can be very effective.

There are also medical procedures that can help, such as ablation, pacemaker implantation, and even surgery. But you may still need to take medication.

If you do have an underlying medical condition that causes your AFib, such as hyperthyroidism, high blood pressure, heart failure, sleep apnea, or excess alcohol use, your doctor will most likely want to get those all under control before they move on to more traditional AFib therapies.

Here’s a look at some of the most common approaches.

Your doctor may first want to slow down your heart rate with medications such as beta-blockers or calcium channel blockers. But once that’s under control, they will want to treat your abnormal heart rhythm.

There are two main classes of drugs that they will usually try to help your heart’s rhythm:

  • Sodium channel blockers slow your heart's ability to conduct electricity. Examples include flecainide (Tambocor) and propafenone (Rythmol).
  • Potassium channel blockers slow down the electrical signals that cause AFib. These include amiodarone (Cordarone or Pacerone), dofetilide, or sotalol (Betapace).

Research suggests that amiodarone is the most effective, but it also carries the highest risk of long-term complications. One report found a link between amiodarone use in patients who also took the blood thinner warfarin and an increased risk of stroke.

The following three drugs used to be prescribed for rhythm control for patients with AFib. But they are usually no longer recommended as they can sometimes make symptoms worse:

  • Disopyramide
  • Procainamide
  • Quinidine

Here are some other things doctors keep in mind when they prescribe an antiarrhythmic drug.

No existing heart disease. If you are under the age of 70 and don’t have heart disease, your doctor will probably prescribe flecainide or propafenone. These drugs are very effective, easy to take, and have minimal side effects in otherwise healthy people.

Structural heart disease. If you have this condition, which is a defect or abnormality in at least one of your heart chambers, your doctor will usually recommend amiodarone, dofetilide, and sotalol. One study of patients with AFib who also had heart disease or high blood pressure found that while amiodarone was more effective overall, sotalol had the best results in the subgroup of people who had heart disease.

Coronary heart disease. If you don’t also have heart failure, amiodarone, dofetilide, dronedarone, and sotalol are among the best choices. You won’t be able to take flecainide and propafenone.

Heart failure. Doctors usually recommend amiodarone and dofetilide. Your doctor may also want you to have a device called an implantable defibrillator, which is a small battery-powered device that’s placed in your chest that shocks your heart when it has an irregular heart rhythm. You should avoid dronedarone, flecainide, propafenone, and sotalol. They have all been shown to increase risk of death among people with heart failure.

There are other, nondrug treatments that are very effective for rhythm control for AFib. They include:

Electrical cardioversion. Your doctor uses a defibrillator – a device that delivers an electric current via chest paddles – to reset your heart’s irregular rhythm. This may also happen if you’re in an emergency situation where your AFib makes it hard for your heart to supply blood and oxygen to your organs.

Some people can have this done immediately. But others need to wait until they have started anticoagulation therapy with a drug such as warfarin or one of the newer anticoagulation drugs, such as dabigatran (Pradaxa) or rivaroxaban (Xarelto). This is to reduce the risk of stroke from blood clots lodged in the left upper chamber of your heart. You’ll usually need to be on anticoagulant medication for 3 to 4 weeks before cardioversion, and stay on it indefinitely even after the procedure.

Electrical cardioversion is often done early in the process to stop your AFib and put your heart back into its normal rhythm. Studies show it’s over 90% effective. But you may need to have it done multiple times, and you may also still require rhythm control medications. Studies show that about 70% of patients find that their AFib returns if they don’t take antiarrhythmic drugs. It's also less effective in patients who have a very large left atrium – bigger than 5 centimeters or about the size of a lemon – or who have had AFib for more than a year.

Catheter ablation. This is a procedure that can sometimes cure AFib entirely. It involves using either heat or cold to destroy the heart tissue that is sending abnormal electrical signals. It’s often considered an initial option in young adults who have AFib but don’t want to be on medications for the long term. Some studies suggest that it could have up to an 80% success rate when it comes to the treatment of AFib. You’re more likely to have a good response if you haven’t had AFib for a long time, if you’re at a healthy weight, and if you don’t have sleep apnea.

Pacemaker. These are electronic devices that stimulate your heart with electrical impulses to restore your heart’s regular rhythm. It can be done alone or along with catheter ablation if you have AFib but you haven’t responded to any other treatment.

Surgery. The most common surgery for rhythm control for AFib is the “maze procedure.” Your surgeon will create a pattern or maze of scar tissue in your heart’s upper chambers with a scalpel that delivers either heat or cold energy. Since the scar tissue doesn't conduct electricity, it interferes with the electrical heart signals that cause AFib. This is usually done along with catheter ablation as a way to try to cure AFib, or at the same time as other heart surgery. It’s not usually done alone.

There are a few things you can do to help with your AFib besides medical treatment. They include:

  • Stay at a healthy weight.
  • Get tested and treated for sleep apnea.
  • Get blood pressure and type 2 diabetes under control.
  • Don’t smoke or drink excessively.
  • Get regular exercise.