How AFib is treated
AFib treatment has two jobs: protect you from stroke and control your heart. Most people start with the simplest steps and move on only if they need to.
From Dr. Kenny Civello, cardiologist and electrophysiologist
The first is protecting you from stroke. The second is controlling your heart, either by slowing it down or by keeping it in a normal rhythm. These are separate decisions. A treatment that fixes your rhythm does not by itself remove your stroke risk.
Stroke protection
Based on your stroke risk, not on how often you feel AFib. Many people need a blood thinner.
Rate control
Keeps your heart from beating too fast while it stays in AFib. Most people feel much better.
Rhythm control
Brings your heart back to a normal rhythm and helps keep it there.
Why treating the causes comes first
Extra weight, alcohol, high blood pressure, sleep apnea, and too little exercise all drive AFib. Treating them makes every other treatment on this page work better and last longer. See the AFib risk guide.
Stroke protection
AFib makes a stroke about five times more likely. Clots can form in a small pouch of the upper heart when it does not squeeze normally.
Your stroke risk score
We add up points for age, sex, high blood pressure, diabetes, heart failure, blood vessel disease, and any past stroke. The score tells us whether a blood thinner will help you more than it could harm you.
Blood thinners
Most people take apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa). Warfarin is still used for some people, such as those with a mechanical heart valve.
Aspirin is not enough
Aspirin does not protect well against AFib strokes, and it still raises bleeding risk. It is not a substitute for a blood thinner.
If you cannot take a blood thinner
A small device can close off the pouch where clots form. It is placed through a vein, like an ablation. It is an option for people who cannot stay on a blood thinner long term.
The treatment steps
Most people start near the top and move down only if they need to. Some people skip ahead, and that is expected.
1. Lifestyle and risk factors
- Lose weight if you carry extra.
- Cut back on alcohol or stop.
- Treat blood pressure and sleep apnea.
- Build up to regular exercise.
Why
These changes reduce how often AFib happens and how long it lasts. The national guideline recommends them for everyone with AFib, alongside any other treatment. Details are in the AFib risk guide.
2. Medicines
- Rate control: metoprolol, diltiazem, or digoxin slow the heart.
- Rhythm control: flecainide, propafenone, sotalol, dofetilide, dronedarone, or amiodarone help hold a normal rhythm.
Why
Rate control medicines do not stop AFib. They keep the heart from racing, which eases symptoms and protects the heart muscle. Rhythm medicines work on the electrical signals that start AFib. Each one fits certain hearts better than others, so we choose based on your heart and other medicines.
3. Cardioversion
- A brief, timed shock while you are asleep, or a medicine.
- It usually takes minutes and you go home the same day.
- It resets the rhythm. It does not stop AFib from coming back.
Why
If AFib has lasted more than 48 hours, a clot may have formed. You take a blood thinner for at least 3 weeks before, or we check for clots with an ultrasound from inside the throat. You keep taking it for at least 4 weeks after.
4. Ablation
- A catheter treats the spots that start AFib.
- Options include cryoablation, radiofrequency ablation, and pulsed field ablation.
- For some people it is a first choice, not a last resort.
Why
Ablation works better than medicines at keeping a normal rhythm for many people. The national guideline now supports it as a first treatment for some patients, especially when AFib comes and goes. See Getting ready for your ablation.
5. Surgery
- For AFib that has not responded to other treatment.
- At Our Lady of the Lake we perform both the Convergent procedure and the Cox Maze procedure.
- Sometimes done during another heart surgery.
Why
The Convergent procedure combines surgery on the outside of the heart with catheter ablation on the inside. The Cox Maze procedure creates a pattern of scar lines during open heart surgery. Both are for AFib that has lasted a long time or has come back after other treatment.
When the rate cannot be controlled
- A pacemaker is placed first.
- Then the connection between the upper and lower heart is ablated.
- The pacemaker sets a steady heart rate from then on.
Why
This is for people whose heart rate stays too fast despite medicines, and who are not good candidates for rhythm control. AFib continues in the upper chambers, so stroke protection is still needed.
Rate control or rhythm control?
There is no single right answer. We decide together.
Rhythm control often fits when
You have symptoms, AFib is new, you are younger, or AFib is weakening your heart. Newer research shows that treating the rhythm early, within about a year of diagnosis, can help some people avoid stroke and heart problems.
Rate control often fits when
You feel well once your heart rate is slowed, AFib has been present a long time, or rhythm treatments carry more risk than benefit for you.
Either way
Stroke protection is decided on its own, and risk factor treatment helps every plan.
Plans change
AFib often changes over the years. A plan that works now may change later, and that is normal.
Questions to bring to your visit
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Common questions
Will I have AFib forever?
For many people AFib tends to come back or progress over time, especially if risk factors are not treated. Treating those risk factors and treating the rhythm early can slow that, and some people stop having AFib.
If my rhythm is fixed, can I stop my blood thinner?
Not on your own. The need for a blood thinner depends on your stroke risk score, not on whether you feel AFib. We review it with you over time.
Is ablation a cure?
Many people stay free of AFib for years after an ablation. Some need a second procedure. Treating weight, alcohol, blood pressure, and sleep apnea makes success more likely.
Do I have to take rhythm medicines for life?
Not always. Some people take them for a while, some only after a procedure, and some switch to ablation instead.
Can my watch help with treatment?
It can. Recordings help us see whether treatment is working. See the watch alert guide.
More on atrial fibrillation
Lowering your AFib riskGetting ready for your ablationMy watch says I have AFibThis page is general education for my patients. It does not replace advice from your own doctor. Do not start, stop, or change a medicine without talking with us.
Based on: Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation. 2024.