How to treat bicuspid valve problems with atrial fibrillation?
One medical question recently put to the Patient team via twitter was: "I have just found out I have Bicuspid Valve Problems with AF. What are the best ways to treat this or cope with it?" Here is my response…
How the heart works
All the exits to the four chambers or your heart, which direct blood around the body, are guarded by valves . These are cleverly designed to allow blood to flow freely in one direction but prevent it from leaking back the way it came. If a valve becomes stiff, limiting the flow of blood forwards, it's called 'stenosis'. If it becomes floppy and leaky, it's described as 'regurgitation'. Either of these increases the work the heart has to do in order to pump blood round your system, putting it under strain.
The aortic valve lies between the exit of the left ventricle - the most powerful chamber in your heart - and the main artery of the body, called the aorta. This valve usually has 3 flaps, but some people are born with a bicuspid aortic valve. It certainly needs regular monitoring with a non-invasive scan called an echocardiogram. A bicuspid aortic valve makes you prone to aortic valve disease as you get older. You can reduce this risk by keeping your blood pressure, cholesterol and weight under control, exercising regularly and avoiding smoking. However, there may come a time where you need surgery.
Key facts about atrial fibrillation (AF) - and some common treatments
AF is the commonest abnormal heart rhythm in the UK , with nearly 50,000 people in the UK diagnosed with it every year. It gets more common as you get older - about one in 200 people in their 50s have AF, compared with one in 10 over-80s.
To some extent, the best way to treat AF depends on your symptoms. Many people don't get symptoms from their AF, and their abnormal rhythm is picked up when they have their pulse checked for another reason (such as a blood pressure check). However, other people suffer palpitations (with a completely irregular and often rapid pulse), shortness of breath, angina-type chest pains and dizziness. AF can also make you prone to heart failure, where fluid can't be pumped efficiently enough round your circulation and builds up in your ankles or lungs.
In the past, these symptoms were often treated with 'rhythm control' - using medicines or electric shock treatment to get your heart back into a regular rhythm. In recent years it has become much more common to control the rate rather than the rhythm of your heart. There are several reasons for this change - rate control is just as effective as rhythm control in preventing symptoms and serious complications; rhythm control often doesn't work in the long term, with your heart going back into AF; and side effects of rhythm control drugs can be serious.
The usual medication used for rate control is called a beta blocker. These medicines used to be used widely to control high blood pressure, as are some other options called calcium channel blockers. A medicine called digoxin is also sometimes recommended, although this isn't used for blood pressure lowering. All these medicines slow down your heart by affecting the electrical impulses your heart generates many times each minute
But even if you don't have any symptoms, AF greatly increases your risk of a stroke - in fact, someone with AF is five times more likely to suffer a stroke than someone who doesn't have it. This is why, with a very few exceptions, everyone with AF should be treated with anticoagulants.
There are several of these blood-thinning medicines available. The most commonly prescribed is warfarin, which has been used for over 50 years to great effect. It reduces the risk of stroke by almost two thirds, although it does need regular dosage adjustments and monitoring with blood tests.
The alternatives to warfarin are called the 'DOACs' (direct oral anticoagulants). They include dabigatran, rivaroxaban, apixaban and edoxaban. They are as effective as warfarin and carry similar or slightly lower risks of bleeding. They can be particularly useful for people whose level of blood thinning is hard to get right on warfarin.
Even as recently as a couple of decades ago, the hugely increased risk of stroke associated with AF was underestimated by doctors. It's estimated that as many as one in five strokes in the UK is due to AF, and if everyone with AF was treated with anticoagulants, we could prevent 10,000 strokes a year in the UK. Now that's a statistic worth bearing in mind.