Atrial Fibrillation: Treatment

General measures

  • Avoiding physical inactivity and physical overload.
  • Nicotine restriction (abstaining from tobacco use).
  • Alcohol abstinence (complete abstinence from alcohol) or limited alcohol consumption (men: max. 25 g alcohol per day; women: max. 12 g alcohol per day).
    • Significant dose-dependent deterioration in left ventricular function after alcohol (ejection fraction/ejection fraction (EF): reduction from an average of 58% to an average of 52%; in healthy individuals: to 50-60%)
    • Alcohol abstinence demonstrated significantly lower (p= 0.004) recurrent AF at 53%; it increased time spent without AF by 37% (118 vs. 86 days); mean “AF Burden” (AF Burden: percentage of time in AF out of total time) was also significantly lower (5.6% vs. 8.2%, p= 0.016).
  • Limited caffeine consumption (max 240 mg caffeine per day; equivalent to 2 to 3 cups of coffee or 4 to 6 cups of green/black tea; even lower amounts, if necessary, because of individual sensitivity to caffeine)A systematic review and meta-analysis of observational studies demonstrated that caffeine consumption did not increase the risk of AF.
  • Aim for normal weight!Determine BMI (body mass index) or body composition using electrical impedance analysis.
    • BMI ≥ 25 → Participation in a physician-supervised weight loss program; successful participation in a structured weight management program can reduce disease burden and alleviate symptomsOverweight patients who sustainably lost more than 10% of their body weight through a weight loss program were 46% free of AF after five years.
    • Below the BMI lower limit (from the age of 65: 24) → Participation in a medically supervised program for the underweight.
  • Review of continuous medication due topossible effect on the existing disease: discontinue triggering drug if necessary.
  • Avoidance of psychosocial stress:
    • Emotional stress
    • Frequent sleep deprivation (insomnia/sleep disorder)

Conventional non-surgical therapy methods

  • Drug-induced cardioversion (restoration of sinus rhythm (regular heart rhythm)).
  • Electrical cardioversion (in vital endangered patients also as emergency therapy; note: guideline-compliant thromboembolism prophylaxis).

Surgical therapy

  • Catheter ablation – cardiac catheter-based procedure that can be used to eliminate cardiac arrhythmias after an electrophysiological study; see “Catheter ablation for atrial fibrillation” below.
  • Closure of the left atrial ear by means of an atrial occluder (implant), cardiac catheter-based procedure.

Vaccinations

The following vaccinations are advised, as infection can often lead to worsening of the present disease:

  • Flu vaccination
  • Pneumococcal vaccination

Regular checkups

  • Regular medical checkups

Nutritional medicine

  • Nutritional counseling based on nutritional analysis
  • Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
    • A total of 5 servings of fresh vegetables and fruit daily (≥ 400 g; 3 servings of vegetables and 2 servings of fruit).
    • Once or twice a week fresh sea fish, i.e. fatty marine fish (omega-3 fatty acids) such as salmon, herring, mackerel.
    • High-fiber diet (whole grain products).
  • Observance of the following special dietary recommendations:
    • Avoiding lavish meals
    • Diet rich in:
      • Minerals (potassium, magnesium)
      • Omega-3 fatty acids (marine fish)
      • Protein (egg white) (≥ 65 years: 1.0 g/kg body weight per day)A study based on data from the Women’s Health Initiative (participants: average age 64 years) showed that participants with the lowest protein intake (approximately 0.8 g/kilogram body weight) had the highest incidence of AF.Women who consumed 58 to 74 g of protein per day had a significantly 5 to 8% lower risk of developing atrial fibrillation compared with those who had a lower protein intake. At intakes greater than 74 g of protein, the difference was no longer significant.
  • Note due topossible electrolyte disorders (disorders of blood salts): potassium and magnesium levels should be controlled and maintained above > 4.0 mmol/L (potassium) and > 2.0 mg/dl (magnesium) (optimal: serum potassium level high normal around 4.4 mmol/l (equivalent to 17.2 mg/dl) and serum magnesium level around 0.9 mmol/l (equivalent to 2.2 mg/dl)).
  • Selection of appropriate food based on the nutritional analysis
  • See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
  • Detailed information on nutritional medicine you will receive from us.

Sports Medicine

  • Light endurance training (cardio training).
  • Regular moderate physical training increases vagotonus (state of excitation or tension of the parasympathetic nervous system, which is predominantly influenced by the vagus nerve) and thus leads to a decrease in resting pulse rate. Vagotonus also inhibits AV node excitation conduction (negative dromotropic effect).Regular exercise twice a week can lead to a 12 percent reduction in mean ventricular rate during the day and an eight percent reduction in ventricular rate during exercise in patients with permanent AF. Thus, physical training (e.g., walking; ergometer training with a defined wattage is optimal) can be recommended for ventricular rate control in atrial fibrillation (AF) in individual cases.
  • Aerobic interval training resulted in less AF in patients with paroxysmal or persistent AF than in patients without such training. It thereby led to a reduction in atrial fibrillation time and symptoms.The 12-week training program included the following program three times a week: each session began with a 10-minute warm-up at 60% to 70% of maximum heart rate, followed by running or walking on a treadmill four times for four minutes at 85-95% of maximum heart rate, interspersed with three-minute recovery periods at 60-70% of maximum rate.
  • Preparation of a fitness or training plan with appropriate sports disciplines based on a medical check (health check or athlete check).
  • Detailed information on sports medicine you will receive from us.

Recommendations for athletes with VHF:

  • Note [Guidelines: ESC]:
    • Intensive exercise phase monotherapy with class 1 antiarrhythmic drugs-without evidence that they provide adequate frequency control of AF-is not recommended.
    • If flecainide or propafenone was taken as a pill-in-the-pocket, patients should refrain from intense exercise until two half-lives of the drugs (eg, 2 days) have elapsed.
    • Patients on anticoagulants should avoid sports with direct physical contact or risk of injury.
  • Before a patient without a treatable cause of VCF returns to sports after a first-ever arrhythmia or rare paroxysm, he or she should have three months of stable sinus rhythm. This time limit applies to both the younger competitive athlete and the 60-year-old recreational athlete.
  • For heart-healthy patients with permanent atrial fibrillation, exercise is allowed without restriction if there is assured frequency control and no hemodynamic impairment.
  • In patients with AF and treatable cause (e.g., hyperthyroidism/hyperthyroidism) whose cause has been resolved and who have regained stable sinus rhythm for two months, all sports are allowed.

Psychotherapy

Complementary treatment methods

  • Transcutaneous electrical stimulation of the auricular branch of the vagus nerve (low-level transcutaneous electrical stimulation, LLTS)-LLS has been shown to be effective in patients with paroxysmal AF in a randomized, Sham-controlled, double-blind trial: at 6 months, mean AF burden was 85% significantly lower in the intervention group than in the Sham control group (sham treatment).Limitations: This study was a small collective; further studies are awaited. In particular, it is important to determine in the future which patients with paroxysmal atrial fibrillation (duration of 1 week or less) are particularly suitable for this procedure.