Afib Master Class with Dr. Eric Prystowsky — Rhythm Control
January 24, 2019
- Summary: Watch this complimentary Afib Master Class on rhythm control featuring world-renowned electrophysiologist Eric N. Prystowsky, MD
- Reading time: 1 minute
Discover the most important information you need to know about rhythm control. Dr. Prystowsky discusses some of the most common rhythm control medications and which ones are best suited for people who have heart disease. Learn why follow-up tests are essential if you’re taking amiodarone, and how to manage medications when multiple doctors are involved.
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What Is Important to Know in Choosing Rhythm Control Medications?
[00:10] Rhythm control, and I think this is the reason it’s often skipped by non-electrophysiologists, is hard. Let’s make no mistake about it. It is not easy to select the right drug for the right patient and the right follow-up and know when to call it a day on that drug and move on to a different drug or ablation. So, it’s not easy.
[00:33] Rate control is not that difficult — once you’ve got a person under rate control, they usually are fine, and you don’t have to see them frequently.
[00:41] So, let’s say you have a patient who comes in who’s a candidate for rhythm control. You have to sit down and make sure you’ve checked all the boxes. Do they have a thick heart? Do they have coronary disease? Any history of heart failure? All those things go into choosing the right drug.
[00:57] So, now you pick the right drug. Do you have to start it as an outpatient? Do you start it as an inpatient? I’m okay starting a number of these drugs as an outpatient, but not like, “Take the drug, I’ll see you in a year” type thing. I keep in close touch. Sometimes, I give them monitors that they can send me in daily rhythm strips so I can see what’s going on. So, these are sophisticated treatment modules.
[01:18] The problem is, in my experience, a lot of people who have been treated by either a generalist or even general cardiologists who don’t have a lot of sophistication in this area are given a drug. Now, what do they tend to do? They tend to give the lowest dose possible because they don’t want to necessarily give, for example, sotalol 120 milligrams twice a day. So, maybe they’re on 80 milligrams once a day or 80 milligrams twice a day, which may be under-treating that patient. And, then the patient fails the drug, and they say, “that’s it, you need rate control now.”
[01:50] So, the key is, if you jump into the rhythm control game, you’ve got to know what you’re doing. You’ve got to understand each drug. You’ve got to understand drug-drug interactions, you need to know dosing, you need to know who starts in the hospital, who starts at home, and what’s the appropriate follow-up. It’s not easy, and that’s why it’s often not done well, or skipped altogether.
What Are Rhythm Control Medication Options?
[00:10] Well, since we’re going to talk about rhythm control, let’s talk about our drug choices, and let me just in no particular order talk about the drugs.
[00:19] So, you have a drug like dofetilide. Dofetilide can markedly prolong the QT interval in some patients. This is the reason it’s mandated to start in the hospital. There’s a lot of literature on all these drugs, so I’ve treated hundreds of people with drugs for afib. I’m going to give you some of my own personal experiences. Dofetilide has a unique property for me when I have a patient who has a slow heart rate when they’re in normal rhythm. Most of the other antiarrhythmic drugs kind of pile on because their ionic effects also affect the sinus node, so it gets slower and slower, and you get an issue of should I need a pacemaker now to keep the heart rate up.
[01:03] Dofetilide doesn’t do it that much, so it’s one of the drugs that I use to try to get out of that conundrum. It also has a wonderful ability to actually cardiovert the patient. In our experience, 40 to 50 percent of people will be spontaneously cardioverted, and you can avoid a direct shock cardioversion. But, you have to watch for drug-drug interactions. That’s a big thing. I like to use that drug when I’m looking to get cardiovert a patient when I have a patient with a slow sinus rate. They can’t have a thick ventricle, but they can have coronary disease, and they can have even heart failure. So, that’s a drug that I sort of look at in that situation.
[01:41] Sotalol is another common drug I use. It’s both a beta blocker and an antiarrhythmic. And, at the lower doses, there tend to be a little more beta blocker effects. So, if you have somebody whose heart rate is 45 to 50 when they’re in normal rhythm, I’m just telling you, you’re not going to get away with sotalol, because if you give sotalol, now they’re going to be 35 to 40 beats a minute, and they’re just not going to feel good.
[02:00] Now, maybe you could add a pacemaker, that’s a brady-tachy syndrome, and now you can advance the dose. The problem is, you use too little of it, it doesn’t work, and then you say, “Ahh, the drugs don’t work.” Well, the drug isn’t working because you didn’t use the appropriate dose, but I get it.
[02:14] But, if a person has reasonable sinus rates, and they have a normal heart, I often will start it as an outpatient if they’re not in atrial fib. I know that some people don’t like to do that, so if you don’t, you can start it in the hospital. But, I don’t start it as an outpatient at 120 milligrams twice a day. I start low, like 80 milligrams twice a day. I either have them come back for an ECG or I have them send me in rhythm strips. If they do fine, and they’re keeping a normal rhythm, I stop. If not, I might up the dose.
[02:48] Dronedarone? It’s an interesting drug in my experience. It’s safe to use as an outpatient in multiple situations, not heart failure, but I’ve used it in coronary disease. It’s an interesting drug because, for me, it’s like a yes or no drug. I do not know why this is so, but in my own experience, it either has a remarkable ability to suppress someone’s afib, or it does almost nothing, and you usually figure that out within the first week or two of using the drug. The patient will call and say, “nothing’s happening, Dr. P.” and I say, “okay, we’ll switch to something else.” Or, I’ll call them, or they’ll call me and say, “Wow, I don’t have any more episodes!” I’m not exactly sure why that happens, but at least in my experience, it’s almost like a switch. It either works, or it doesn’t work.
[03:29] Then, you have the drugs like flecainide and propafenone. They’re kind of similar in my experience. They’re excellent drugs. I use them mostly in patients who have, almost in fact exclusively in patients who have normal hearts. I also want to make sure those patients have a beta blocker or calcium channel blockers, so they don’t go real fast if they go into atrial fib or flutter. But, they’re safe to start as an outpatient, if you’re in normal rhythm. They don’t have a lot of drug-drug interactions, and they’re quite successful. And, I sometimes will start flecainide even at low doses, at 50 milligrams twice a day. It’s amazing to see how some people are so sensitive to the drug that you can get away with a really low dose.
[04:10] Last of all, you have amiodarone. So, amiodarone is the kingpin of drugs in the fact of effectiveness; it’s also the kingpin in side effects.
[04:20] So, amiodarone has multiple ways it can affect atrial fib. It affects a lot of different channels in the heart. It’s extremely effective. It can be started safely as an outpatient in almost any situation. The downside of amiodarone? It does have a lot of drug-drug interactions. You have to check what else patients are on — warfarin, certain statins — you’ve got to be aware of that. And, it can have a [something strange here] three to five percent chance of causing toxicity to the lungs, liver, and thyroid.
[04:48] So, you can see, you have a lot of choices. You’ve got to know the drugs, you got to know the patient, you got to know the doses, but you can usually, with a little time and effort with each patient, pick the best one-two-punch for that patient.
[05:04] And, if that’s not working, in my experience, if you fail a couple of drugs, you might as well go on to ablation, unless you haven’t tried amio. If you fail one or two of the non-amio drugs, my experience has been the third one’s not going to work, and either go amiodarone or ablation.
[05:22] But don’t forget, ablation could also be used as an upfront therapy.
What Rhythm Control Medication Options Are There for Those With Heart Disease?
[00:10] You have less choices of selecting an antiarrhythmic drug when you have certain heart conditions.
[00:15] First of all, if you have a very thick heart, and it has to be pretty thick, most of the drugs haven’t been proven safe there. Amiodarone is probably the only drug I feel comfortable with there, so I don’t really use most of the other drugs in that situation.
[00:30] If you have coronary artery disease — and I don’t mean, and this is a problem, you know everyone now is into the era of I’m going to go get a calcium scan, well, and you find a little calcium in your vessel — that’s not what we mean by coronary artery disease, okay? Or, a huge swath of the population will be labeled that way.
[00:50] I mean, you have had clinical coronary disease. The drugs that are considered safe there are sotalol, dofetilide, dronedarone, amiodarone. They’re okay to use in that situation.
[01:02] If you have heart failure, you’re pretty much looking at amiodarone. With some people, I’ll use dofetilide, but mostly amiodarone.
How Should Amiodarone Be Started and Managed?
[00:10] Amiodarone is truly in a class by itself. If you are a fan of Dickens, you might say, “It’s the best of times, it’s the worst of times.” So, let me explain that to you.
[00:19] I started using amiodarone early in my career, in the early 1980s, before it was actually an approved drug. There are a whole bunch of us who were investigating it. We were fortunate enough to write some of the early papers on it. But, we were using it back then mainly for life-threatening ventricular arrhythmias, and by the way, to the best of my knowledge, that’s still its indication.
[00:37] Okay, so guidelines clearly tell you you can use this drug, but if you actually look in these package inserts, you’ll probably find out, for the most part, it’ll still say it’s for life-threatening rhythms. So, here’s what you need to know.
[00:49] It’s a drug that’s extremely effective. Often will work where no other drugs work. It’s a drug that has to be handled with care, and not everybody is a candidate for it. So, knowing that some of the major side effects have to do with lung toxicity, liver, and thyroid, but not as high as in the old days when we used larger doses. Don’t go by this 10 percent, and five — all those numbers. I’ve been using this drug for decades, and my numbers aren’t anywhere near that high, but we’re using lower doses than we used to.
[01:20] Every patient should undergo pre-amiodarone testing: a chest x-ray, pulmonary function tests (including what’s called a DLCO, which measures diffusion capacity in the lungs), liver enzymes, and thyroid testing. We do all that as our pre-amiodarone screen. Every now and then you find a person, and you feel bad about it because you know what you have to tell the patient, actually has severe lung disease they didn’t know about, and they’re not a candidate for amio. That’ll be clear, but then the patient, unfortunately, has to deal with this other problem they didn’t know was there. So, once we clear a patient, we will start them on the drug, but we review carefully with everyone, before they start, all the risks and the benefits. And, we don’t use it unless other options aren’t available to us.
[02:08] You could do ablation, but some patients would rather take amio than ablation. That is a patient preference. That’s not my preference. Patients have a right to choose what they want, and if they choose that, then you have to make sure there’s no drug-drug interactions. For example, some statin’s doses, not all — depends on the metabolism of a statin — have to be lowered.
[02:29] So, what occurs is the following. First of all, you do preliminary testing, make sure it’s safe to use.
[02:35] Second of all, you’ve had a discussion with the patient — they know risks and benefits.
[02:39] Third of all, you tell them to stay out of the direct sunlight because you can get really photo-sensitivity with the drug. You have to prepare the patient for all these.
[02:46] Then you look at their drug list, make sure there’s nothing you have to alter. Get them off a certain statin, lower the dose of a statin. If they’re on warfarin, you have to manage through that.
[02:55] And then, you follow them. Everybody, I shouldn’t say everybody, people have different ways of following them. My own way of following patients is every six months to repeat those tests, not the pulmonary function test. Chest x-ray, liver, thyroid function tests, I repeat every six months, and I usually get an amiodarone level. But I get that level often in the three month period. You’d be surprised how variable the level is for the same dose. Remember, it’s not a dose of amio, it’s a level you try to get to. And, if you’ve given someone just a pill a day, but their level’s too high, you cut back on it.
[03:31] So, you have to just manage them over time, and you tell them to let you know if they have any shortness of breath, or a cough. These are early signs of lung problems. And, you’ll find, if you do that, honestly, the drug will be a very safe to use, realizing some people will have problems with it.
[03:49] The concept that no one should get amio is absurd because there are some people that that’s the only drug that works, and who are you to tell them they should be miserable their whole life. You know, it’s a patient choice. It’s a risk-benefit discussion with the doctor and the patient, and patients have a right to make a decision there.
What Do You Need to Know if You’re on Amiodarone?
[00:10] When I’ve been to some of these patient conferences that Mellanie True Hills puts on, that are really terrific, I’ve had the opportunity, and also the sadness at times, to hear what’s going on around the country, because you sit there and you chat with patients that aren’t your patients. And, they tell you right up front, “Here’s what I’m on. Here’s what my doctor’s doing. What do you think Dr. P.?”
[00:33] I’ve had a whole bunch of them who are on amiodarone with absolutely no follow-up. And, I’ll say, “Well, how often does your doctor do follow-up tests?”
[00:41] “What follow-up tests?”
[00:42] “Well, does he do a chest x-ray?”
[00:43] “No. Why should he?”
[00:45] Look, if you’re the patient, and someone put you on amiodarone, make sure you know you’re supposed to have follow-up tests. That’s all I can tell you. If somebody did it, and didn’t have follow-up tests, go seek another doctor, frankly. That means that person either doesn’t understand or forgot to tell you.
[01:06] The point is, you need your follow-up tests. It’s just not the way you handle the drug.
When Do You Combine Rate and Rhythm Control Medications?
[00:10] Often, you need more than one type of therapy for a particular patient.
[00:14] Let’s say, you’ve chosen a rhythm control, so your primary objective is to maintain sinus rhythm. But, you live in a realistic world for the patient that that’s probably not going to happen 100% of the time. So, you want to be sure when they go into atrial fibrillation, that they’re not putting themselves at risk because their heart’s too fast or too slow. So, they’re typically going to be on a drug for rhythm control and a drug for rate control. And, what you have to do is make sure you don’t pile on, so you have to look at the drug you selected. For example, if you chose dofetilide, it has very little effect to slow the rate. So, there you might want to be sure you’ve got a good rate-controlling drug with it if the person has recurrences. Otherwise, they’ll come in with 130, 140-beat-a-minute afib.
[01:04] On the other hand, if you have a drug like sotalol that has beta-blocking effects plus primary antiarrhythmic effects, you’ve already got a beta blocker on board. You may not want to add more beta blockers or calcium channel blockers to that patient because if they go into afib, they may go at a really slow rate and get into trouble.
[01:23] So, you’ve got to balance the two out, and you have to figure which drug you’re on and how do the two drugs interact. Obviously, you want to avoid any kind of drug-drug interaction, but that’s not usually a major problem with the classes of drugs we’re talking about. Now, they can interact with some of the blood thinners, for sure, and other drugs, but that’s not usually a major thing.
[01:45] So, it’s usually, you’re already on a drug that slows the rate.
[01:49] And, I’ll tell you, pharmacists are forever a pain in my you-know-what because I’ll put a patient on a drug like flecainide with verapamil. Okay? Which is fine. And, I’ll get a call from the pharmacist — I’m using two drugs I shouldn’t use together because of some, I don’t know, computer program they have. You have to have some blocking of a drug. So, I can tell them, “Fine, I’ll switch to this one,” but they’re not happy. And, I’ll tell him after that, “Please read my textbook, or just fill my prescription.”
Which Rhythm Control Medications Have Beta-Blocking Properties?
[00:10] You need to know, with some antiarrhythmics, which drugs also have what’s called antisympathetic effects. They’re not all traditional beta blockers, but it doesn’t really matter how. They are antisympathetic.
[00:21] So, for example, amiodarone can really have a major beta-blocking-like effect. It’s not classic beta blocker, but it’s antisympathetic.
[00:31] Sotalol clearly has a major beta blocker in it.
[00:35] There is some AV node blocking ability to a drug, dronedarone. It’s not dramatic; it’s not as potent as the other two I’ve mentioned.
[00:43] And, surprisingly, propafenone. Propafenone does have beta-blocking effects. And, in fact, there is a genetic abnormality in some people who can’t break the drug down. And, one of the classic things that we want our trainees to know is, if you start somebody on propafenone, and they call up because their heart rate’s really slow, or they’re wheezing, you can be pretty sure that they’re not metabolizing the drug properly because the metabolized component does not have a dramatic beta-blocking effect. So, it depends on what kind of metabolizer you are. But, you’ve got to remember, it does have some beta blocker activity. So, if you’re supposed to avoid a beta blocker, let’s say you have some really significant asthma, then you don’t want to be using propafenone. At least, I wouldn’t. You might get away with it, but you should avoid drugs that could exacerbate their underlying lung problem.
[01:36] And, I always ask those things, “Do you have wheezing components?” before I start any of these drugs because there are alternatives that don’t have problems with the lungs. And, you should select those drugs instead.
What Can You Do When Insurance Companies Refuse to Pay?
[00:10] One of the sad things, without getting too political about our healthcare system, is the fact that doctors and patients don’t always have the last say in what’s the best therapy for a patient. It is not uncommon that I’ll make a decision what’s best for that patient, in a discussion we’ve had on a particular drug, only to have an insurance company say no. I don’t think insurance companies have the right to do that, frankly, but I don’t make the rules, right? And, you get into those situations.
[00:41] So, if there’s a legitimate alternative, that’s the road I usually take. And, maybe drug A and B were close, and they wouldn’t pay for A, they’ll pay for B. Fine.
[00:50] But, if they needed A, and there really isn’t a good alternative, and sometimes, that’s a drug called dofetilide, in our area at least, where insurance companies, for whatever their reason, it’s not on their plan. Or, they won’t pay for it, or the patient has to pay a huge amount of additional money. And, that may be, in that patient, really the drug I want them on. Then, then, the war starts, okay?
[01:09] Then, we have to call the insurance companies. Sometimes, they listen; sometimes, they don’t care, you know, uh; but, we try. We try our best.
[01:18] If nothing works, I guess a patient can change companies, maybe? Or, just have to pay for it.
[01:27] So, we do our best to make sure that patients get what we think is best for them, and what they’ve chosen, as far as their choice. But, you know, a doctor can only go so far. We can’t force an insurance company to pay your bills. We just can’t. So, we can do the best we can, but we don’t always win. But, we do try.
How Should We Manage Medications When Multiple Doctors are Involved?
[00:09] A major problem for patients is multiple doctors and multiple drugs, and the doctor who prescribes a new drug not bothering to look at what drugs the patients are on.
[00:22] If you’re the patient, and you’re on a drug that might interact in a very negative way with a different drug, it is not your job to know which drugs to watch out for. You can’t possibly know that. I can’t either without a program I keep on my phone.
[00:39] All my patients get the following messages from me when I put them on a drug that has those properties. I tell them, “You never allow a new drug, over the counter (sometimes, over the counter drugs can do it) or prescription, to be taken by you without either calling our office first or checking with the pharmacists because, I will tell you, the other doctor who’s prescribing something, you can bet they haven’t looked at your drug list.”
[01:05] I’m just telling you, from years of experience, they haven’t gone down and said, “Oh, look at it this! You’re on sotalol, atorvastatin, and clopidogrel. Oh, well, let me go look up the drug-drug….”
[01:17] They say, “You know what? You came here. You’re nervous. Take this drug.” Or, “You came here, and oh, you have a sore throat. Let me put you on an antibiotic.”
[01:25] Really? What if that antibiotic prolongs your QT interval, and you’re already on dofetilide, and it’s a contraindication, and you go into a life-threatening rhythm? Seriously?
[01:36] You need to know that. You need to remember that. Do not depend on every doctor doing that. You need to take charge of that.
Should Afib Patients Know About Ion Channels?
[00:10] When I have my initial discussion with patients in my office, I walk through the three pillars of care: rate control, rhythm control, and anticoagulation.
[00:21] When we get to the part about drugs, just in a general discussion, not uncommonly, a patient may say to me, “Well, how does that drug work, Dr P.?”
[00:31] And, it’s a moment where you have to make a decision in how your day’s going, quite frankly, because honestly, if the person has no knowledge of cardiac electrophysiology, try to explain to them the following: “This is an IKr-blocker that affects the action potentials in the atrium and the ventricle, and under certain conditions, you could get a life-threatening rhythm, and it interacts this way with certain other drugs, and you have to be aware of that.”
[00:55] Or, try explaining amiodarone that affects calcium channels. It’s got anti-sympathetic effects, it affects sodium channels.
[01:03] I mean, if I will turn to a patient at that point and say, “I don’t mind discussing this with you if you have a background, if you have a biology background, I’ll be happy to do it. But, otherwise, it’s not even worth going into because you’d have to know an enormous amount of information to make it understandable. I’ll be happy to give you a source where you can go read about it, but we’re not going to spend all of your valuable time today on that because there are other issues.”
[01:28] Sometimes, patients are okay with that; other times, they’re not. But, I’m sorry. To be frank with patients, my role is not to describe the electrophysiology of the heart. My goal, with you, is to help you understand your disease, the treatment options, and help you get to what’s best for you. That’s my goal.
[01:47] This is really arcane stuff. It’s hard to understand, even for cardiologists.
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