Atrial Defibrillation: A New Treatment for Atrial Fibrillation. How Do We Best Manage These Patients?

Atrial fibrillation (AF) affects over 3.3 million Americans, and 5 million people worldwide. Patients with atrial fibrillation often have associated symptoms such as heart palpitations, fatigue, dizziness, shortness of breath, and/or pressure or discomfort in the chest. It may also cause more serious complications such as syncope, stroke, or heart failure. Atrial fibrillation can interrupt patients work schedules, social functions and other daily activities. A number of treatment options for atrial fibrillation are available, including medical therapy, catheter ablation, surgery, and chemical or electric cardioversion. Electrical cardioversion has long been an established technique for restoring normal sinus rhythm in patients with atrial fibrillation (Lown, Amarasingham, & Neuman, 1962). The cardioversions have traditionally been performed in the hospital under direct physician supervision with the patient sedated. Patients were at the mercy of their physician regarding scheduling the procedure, and the patient had a specified recovery time due to the sedation given. In May 2001, the FDA approved an implantable cardioverter defibrillator (ICD) for treatment of atrial fibrillation for patients in whom antiarrhythmic drugs are ineffective. The company releasing the ICD, Medtronic, Inc., estimates this population represents five percent of the 3.3 million AF patients in the United States. The ICD not only provides treatment for atrial arrhythmias, but also provides treatment for ventricular arrhythmias, as well as rate-responsive dual chamber pacing for the treatment of bradycardia. The pacing attempts to gain control over the arrhythmia by interrupting the pathway of the atrial arrhythmia and uses low-energy pacing, which is usually goes unnoticed by the patient. In cases when ATP is successful, the patient may not even be aware that they have had an arrhythmia, until their device follow-up. Recent studies (Gold, Sulke, Schwartzman, Mehra, & Euler, 2001) have shown pacing therapies successful in terminating 40% of atrial arrhythmias in patients with implantable atrial defibrillators. This may save the patient from an electrical cardioversion which can cause some amount of discomfort or anxiety. If the antitachycardic pacing is unsuccessful in converting the rhythm, the device may be programmed to deliver an automatic or patient activated cardioversion. The patient, along with his doctor, may choose the type of therapy he feels is best for him. If an automatic therapy is desired, the patient may choose the time of day he desires the shock to be given. Unlike a ventricular arrhythmia, which can be life-threatening and needs immediate treatment, the therapy can be given at a time that the patient feels is most convenient for him. Studies have shown that patients do not typically perceive a device shock as painful, but can cause some amount of anxiety. Studies have also shown patients may perceive less anxiety when the shock is delivered during the night while the patient is sleeping. (Benton, Bailin, Johnson, & Hoyt, 2001). However, only the patient and his physician can choose which time is best for him. If a patient wishes, he can opt to perform cardioversion at the time of his choosing utilizing a patient activator. This activator, called the InCheck AT Patient Assistant, is a small, hand-held device the size of a keychain. The activator allows a patient to check their rhythm by pushing a blue query button marked with a ?. This confirms whether a patient is actually in an atrial arrhythmia. If the device confirms the patient is having an arrhythmia, a patient may push a red button marked Z, allowing them to initiate their own out-of-hospital cardioversion. If the patient wishes, he may have both automatic and patient activated shocks available, allowing him the choice of therapy that is convenient to him at the time of his arrhythmia. Having an atrial defibrillator can be accepted as a positive change, providing a feeling of control and relief for the patient with atrial arrhythmias. However, it can also cause feelings of anxiety, depression, or fear. It is important to discuss these issues with the patient, prior to and after their defibrillator implant. At our center, we encourage patients to call the clinic nurse with any questions regarding their device. Patients are also invited to attend a support group for defibrillator patients, giving them the opportunity to talk with others who share their condition. The patients are encouraged to come to the clinic to give themselves their first patient activated shock, if desired. They are asked to sit in a recliner in a quiet environment, with the nurse providing any emotional support necessary. Some patients find comfort in the nurse s presence in the room. Some may wish family members to be with them at the time they activate their cardioversion. If patient activated therapy is desired, patients are asked to develop a plan of action for when their arrhythmia occurs. They are asked to decide ahead of time where they will sit, whom they want present, and how they will perform the cardioversion. We have found this helps to decrease patient anxiety during the actual event, allowing them to feel more control over the situation. Recent studies have concluded that implantable atrial defibrillators are an effective means of treating atrial fibrillation with overall high patient satisfaction (Daoud et al., Gold et al., 2001). Our center has utilized the atrial defibrillator successfully in a number of patients for effective treatment of their atrial arrhythmias.