I read this recent article by New York Times business writer Duff Wilson regarding his mother's difficulties managing atrial fibrillation: the need for anticoagulation, ineffectiveness of cardioversion, the side effects of the antiarrhythmic drugs, and her indecision regarding future drug or device therapies. For now she has decided leave her rhythm alone and (hopefully) stick with just anticoagulation. For some, doing nothing might just be the best option, provided the heart rate is well-controlled.
Our drugs are just not that effective for atrial fibrillation. Any of them. Even the upcoming dronedarone. Certainly some may work better in some patients than others, but once you fail one drug (especially amiodarone), the odds of having long-term success with another drug is limited (dofetilide might be an exception here, but can only be used in patients with normal or near-normal kidney function).
Sometimes, though, I find its helpful to try to determine what causes some one's fatigue. Is it the rapid heart rate, the irregularity of the heart rhythm, or the loss of mechanical synchronization between the atria (top chambers) and the ventricles (bottom chambers) of the heart.
If the patient complains of racing heart rhythms, then using rate control medications like beta blockers or calcium channel blockers may be all that's needed to improve their symptoms.
If the patient complains that the irregularity of the rhythm is what bothers them, then there is a good chance that a pacemaker might improve their symptoms since their rhythm can be regularized after implanting the pacemaker and then ablating the AV node. While this has the downside of rendering someone pacemaker-dependent for their heart to beat, in the older age group, this therapy has been shown to demonstrate marked improvement in symptoms with only the need for ongoing anticoagulation without the potential side effects and toxicities of antiarrhythmic medications. In the older crowd, this might not be such a bad option.
Finally, if the person's primary complaint centers on fatigue, there are two options: (1) do nothing and continue anticoagulation (since fatigue may be a difficult symptom to resolve) or (2) consider catheter ablation of the atrial fibrillation - provided the risks of the procedure are carefully reviewed. In a small subset of patients, octogenarians were thought to be as safely treated with catheter ablation as younger adults. This study was limited, however, by its retrospective design and limited numbers. What has not been shown yet is a mortality advantage to this approach and certainly there are plenty of risks with this procedure.
Finally, the need for follow-up after any one of these therapies is undertaken might vary and influence which therapy to recommend. The take-home message here is that no two patients' needs are alike and sometimes it's tough to always make the "perfect choice."
Anyway, just some thoughts. It'd be interesting to read what others might recommend.