Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on May 31, 2013

July 1, 2013

  • Here is the transcript of our May 31 afib community chat where the atrial fibrillation experts at the Cleveland Clinic answered your most pressing questions.
  • Transcript is reprinted with the permission of the Cleveland Clinic.
  • Reading time: Approximately 30–60 minutes

Chat Description:

The most common irregular heart rhythm is called atrial fibrillation (AF or AFib) and involves the two upper chambers (atria) of the heart. Over 2 million Americans are affected by AFib and it is responsible for 15% of all strokes. Treatment options may include medications, lifestyle changes, invasive therapies or surgery. In some cases, no treatment will be necessary.

Dr. Walid Saliba, Dr. Edward Soltesz, Dr. David Van Wagoner, Dr. Bruce Lindsay, Dr. Mandeep Bhargava, and Dr. Oussama Wazni from the Cleveland Clinic Center for Atrial Fibrillation and Mellanie True Hills, Founder and CEO of answered your questions about atrial fibrillation.

The chat transcript appears below.

For more information, see Cleveland Clinic Atrial Fibrillation Center

Chat Transcript:

Please note that the comments below are the opinions of the Cleveland Clinic doctors, and if you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.

Atrial FibrillationGeneral Questions

JAlex123: Can overworking the heart be a cause of Atrial Fibrillation?

David_Van_Wagoner,_PhD: Stress can affect the activity of the nerves that control heart rate and blood pressure, as well as the function of the body’s immune system, leading to increased blood pressure, heart rate and decreased immune defenses. In addition, working in some cases is associated with sitting – if you have a desk job. There is evidence that a sedentary lifestyle – too much sitting – is also not healthy. Fitting regular exercise into your schedule can help to deal with stress and the associated problems.

Retired Dan:Is there a way to monitor at home whether I am in A-fib or not?

David_Van_Wagoner,_PhD: The least expensive way to monitor your rhythm status is to have your doctor or a nurse show you how to check your pulse for regularity. An irregular pulse is typical when you are in AF and is relatively easy to determine. To visualize the ECG, there are now devices that can directly record the ECG for transmission to your doctor, or to see directly. One such device that is smartphone based has recently received FDA approval: Purchase of this accessory (~$200) requires a prescription from your physician. [Note: AliveCor is offering this monitor at a special discount for those in the community — see Get a Discount on the AliveCor Heart Monitor and the Cardiac Designs ECG Check.]

zeegoman: What is the relationship of paroxysmal AF and gastric symptomatology?

David_Van_Wagoner,_PhD: Both the heart and the digestive systems are strongly regulated by the vagus nerve. Stimulation of the vagus nerve is responsible for controlling gastrointestinal motility and can sometimes initiate episodes of AF. Because of this relationship, it is sometimes observed that cold drinks can trigger episodes of AF.

Grampjet:My afib stated 10 years ago. I am male, 61. Episodes have become more frequent. I finally quit smoking almost a year ago, and since then the afib quickly has become a daily occurrence, and more invasive to life style. There is little doubt my quitting has rapidly increase the frequency of it. I believe my afib is stress/anxiety related (30 years in Air Traffic Control (retired)). I almost feel I would be better off smoking, or taking some anti anxiety pill( would rather not), or some other solution….At least with smoking, the episodes were once every two weeks.

My doctor and cardiologist just confirm my afib and tell me to go on blood thinners. No one seems to be targeting the cause of the afib, nor providing a solution (like ablation) Are there questions I should be asking MY doctors, or something I should be saying to/telling them that I want from them?

Like most, I deal with it every day now, life is pretty much done. Thanks This forum has helped me a lot, and I thank you all for it. Rod.

Walid_Saliba,_MD: If you are having frequent episodes of atrial fibrillation with associated symptoms it is very reasonable to consider the possibility of ablation. Unfortunately, not all atrial fib have a clear cut etiology. Please contact us if you need more information. Please call 866-289-6911.

Launell: When in A Fib are there any behavioral, physical, or other actions that the patient can do to minimize the effects of the A Fib episode ? Are there any known factors such as diet, or exercise or lack of exercise that will reduce the time in A Fib? On the same topic, while in A Fib are there any activities, foods, etc that increase the chance of stroke that we as patients should avoid. Thank you very much for your answers.

Walid_Saliba,_MD: I wish we knew – we could recommend them.

pennsylvaniagal: Dr. Saliba: Is it common practice to be seen by a physician’s assistant when being treated for A-Fib?

Walid_Saliba,_MD: The initial evaluation needs to be by a physician. Follow up for anticoagulation and anti-arrhythmics can be done by a knowledgeable PA or NP in collaboration with a physician.

swirlgrey:I had an afib attack 2 years ago. Another, only due to cessation of medication, last January. I am on 225mg Rythmol 2x and doing well. My question: the symptoms I experience without medication which lead to the second afib attack are not called “afib” by any of the cardiologists. I understand the attack itself, the rapid heartbeat, is afib, but the PACs, PVCs, tachycardias and pounding which lead up to it should be called something, Right?? For instance, AFIB SYNDOME. Instead, these symptoms are “brushed away” as if unimportant giving the patient a false sense of security. In general, I believe the cardiology community is not tasking Afib seriously. I’m told it is not life-threatening which is an outright untruth. Why then have I been rushed to an emergency room 3 times? Why then is it a oft-quoted fact that afibbers are 5 times more like to have (and possible die of) a heart attack or stroke?

I never had a single PVC, PAC, tachycardia or arrhythmia or pounding prior to my Afib event. Now I have it all and take Rythmol to control. These are symptoms of afib, call it pre-afib if you like, but they are dangerous and need to be addressed as such. I would also hope the cardiology community would begin to investigate the causes of afib instead of just doling out different medications until they find one that works. In my case, extreme domestic abuse over a 20-year period led to my afib attack. STRESS is well known on the internet among the afib chat rooms as a main cause, yet, when asked, the cardiologists say they have no idea what causes it. I believe this is irresponsible and the cause(s) should be known. If it is stress, then relief of stress should reduce the risk of afib, correct?? Having had it once may not mean you will always have another. Your thought, please. Thank you,

Mandeep Bhargava, M.D.: We respect your thoughts. It is true that in some patients, Afib can worsen the underlying disease and that atrial fibrillation can often be a marker of advanced disease and increase the risk of heart failure and hospitalizations in many patients. However, the causes are multifactorial and not a single reproducible one and in most patients, the single biggest risk factor is age due to which the AFib may continue to progress over time. Treating AFib by drugs or an ablation can have risks of its own and hence, one has to be judicious about using the treatment approaches. In general, short bursts of PACs, PVCs and nonsustained atrial tachycardia may be asymptomatic and are benign and the risks of increasing medications to suppress them all the time may not be worth any additional benefit. In those patients where AFib is leading to heart failure, heart muscle dysfunction and worsening of underlying heart disease, there is proven benefit of suppressing it more aggressively with ablations/drugs and the additional risks are worth the gain. Hence, management has to be individualized for every patient. I apologize for your frustration with the cardiology community regarding the unknowns with atrial fibrillation but we continue to find out more answers to such questions through ongoing research and hope that we have more and more answers with time.

Swirlgrey: I wish you would address my issues below:

Answered below by Mandeep Bhargava, M.D.:

  1. If the PVCS PACS Tachycardia and Pounding that lead to my Afib events aren’t Afib, then what do you cal them?Answer: Just as you did, PACs, PVCs and short runs of non-sustained atrial tachycardia
  2. Can hypoglycemia cause the above mentioned symptoms and lead to Afib?? I have borderline diabetes blood sugar yet fall into low blood sugar attacks immediately if I don’t eat (20years).Answer: It is possible theoretically but fairly unlikely to do so on its own.
  3. Can magnesium supplement help?Answer: Hypomagnesaemia may precipitate AF and needs to be avoided but Mg supplements are not used as targeted therapy for AF per se.
  4. Rythmol is perfect for me, after failing amiodarone (hi TH), metoprolol (too low HR), flecainide (too high HR). No side effects. Will it eventually fail as I’ve been told all anti-arrythmics will eventually?Answer: I am not sure if I would call that failure of AF but we feel that AF is a progressive disease and can outgrow the Rhythmol and become refractory to the drug over a period of time. This period is variable for every patient and cannot be predicted and can only be seen over time.
  5. Can the relief of all stress stop fib attacks?Answer: It may reduce the episodes in patients where it is a documented stressor but is usually not the only cause. Exceptions surely can occur.

SG:I am a 63 yr old female, started having a fib incidents 2.5 yrs ago, paroxysmal lone, converted by “pill in pocket” with diltiazem and flecainide. 14 months ago after an afib incident I had a “tiny” stroke that presented like a TIA, but there was imaging evidence of stroke in right thalamus — completely resolved within hours. Since then I have been taking Pradaxa. A fib incidents have increased to 1x monthly or more. Over the past year I have found that exercise (1 to 4 miles on stationary recumbent bike) is converting the a fib episodes most of the time. I understand this is an indicator that the a fib is vagally-mediated. What does this suggest as far as causal factors, triggers to avoid, treatment regimen, and success of ablation?

Mandeep Bhargava, M.D.: The treatment for the stroke is anticoagulation for which you are taking Dabigatran. Some patients can have vagally mediated AF and some authors believe that vagally mediated AF may have a better response to ablation. Most patients have more AF than what they perceive and hence all episodes may not be vagally mediated. For paroxysmal AF, in general one could expect a success of about 75-80% and the need for that should be guided mainly by symptoms and burden of AF.

SG:What, if any, might be the relationship of a fib to bronchiectasis, asthma and shortness of breath?

Mandeep Bhargava, M.D.: In patients with advanced lung disease when pulmonary hypertension sets in, there can be a relationship. In general, most patients with asthma may not have a significant predisposition for AF.

Adourian:Have had 4 paroxysmal afib episodes over past year that have corrected within a day (2 with medication and 2 without). Trigger is yet unknown. No symptoms other that rapid irregular heartbeat.

  1. Would you recommend additional tests to try to determine the trigger?
  2. Regarding my next episode, how long can I wait to see if it self corrects before increasing my risk of stroke and needing to take more medication than my current daily baby aspirin?
  3. Since I have mild aortic valve stenosis should I be more aggressive in trying to eliminate all episodes in anticipation of future valve replacement surgery or doesn’t it matter as long as they continue to be infrequent, lasting less than a day or two?

Mandeep Bhargava, M.D.:

  1. You should at least get an echo and thyroid function tests.
  2. Your risk of stroke is governed by the number of risk factors you have and should be treated with either Aspirin or other anticoagulants as needed. In general, we do not recommend changing strategies by the duration of AF. The treatment for AF itself is governed by the symptoms and burden of AF.
  3. Usually mild AS should not be additionally impacting the AF or be impacted by it. You treat the AF by the symptom severity and burden.

DY: I have experienced paroxysmal atrial fibrillation for three years. It has been very irregular. At times, it has happened once or twice a week, at other times, once a month or once every couple of months. There have even been stretches without A-fib for three months. To begin with, I thought it might be caused solely by physical or psychological stress. So I tried to modify my activity and lifestyle. But sometimes episodes came on for no apparent reason. Episodes were disabling, especially if I was far from home.

Because I have a very slow normal heart rate (in the 30s), drugs were not an option and the combination of pacemaker and drugs were considered extreme. (I have, of necessity, used a beta blocker eye drop to treat my glaucoma for over three decades, which may have contributed to my low heart rate.)

For this reason, I decided to proceed with catheter ablation. The ablation was done in the early morning of May 23, 2013 at the Peter Munk Cardiac Centre, Toronto General Hospital. I was told that the procedure itself was “classically” successful. Since then, however, I have experienced a worsening of my situation.

The first A-fib episode came about six hours after ablation, with heart rates veering erratically – mostly in the range of 150 to 175. A 25mg of a mild beta blocker may have helped get my heart into sinus rhythm in four hours but my episodes regularly last three to four hours. I was released the following afternoon and, that same evening, I experienced another episode that lasted a couple of hours. The next day, May 25, was the worst I’ve ever experienced, with A-fib lasting most of the day or coming and going all day. Since then, I’ve had a couple of good days but on May 28, I had another episode and was shaky most of the day. Generally, I feel much more sensitive and vulnerable.

I know it is early days and recurrence of A-fib is expected during the healing process but I feel helpless. I have no defense because beta blockers could slow my heart rate to a dangerously low level. Reducing my normal activity drastically does not seem to provide any insurance against episodes either.

Before ablation, I had a very low risk of stroke or heart attack. I am otherwise healthy and have been physically active, with good diet, for many years. Coffee and alcohol have been part of my lifestyle but I have reduced both since being diagnosed. Before preparation for the ablation, I was simply on a low-dose aspirin and 20mg of Atorvastatin. During my post-ablation convalescence, I’m taking Pradaxa (150mg) and Omeprazole (20mg).

  1. What can I do during this healing period to protect myself from and during episodes? Would Xanax, Valium or Ativan be useful?Walid_Saliba,_MD: Unfortunately anti-anxiety medications are less likely to suppress atrial fibrillation.
  2. In a previous online chat, Dr. Van Wagoner, in response to a question about the causal effects of food and drink, said “Vagal nerve activity typically further slows heart rate and is a common trigger for AF.” But “milder stimulation can sometimes terminate or prevent AF.” (my emphasis.) What does this mean? Sipping water or chewing a biscuit?
  3. Because of my slow heart beat, am I going to need a pacemaker eventually despite this or a future ablation?

David_Van_Wagoner,_PhD: Sorry for the confusion! This is comment referred to a recent series of experimental studies described in the attached link. It has not yet been determined how to translate these studies to clinical practice. Efforts are underway to develop different devices (alternative) that can help you do this. You may also find that regular, moderate exercise could have this effect.

superdavestrate:Hello My name is David, I’m 44 and I have been experiencing afib and flutter and have been hospitalized twice this year. They have converted me twice with meds and I am on pradaxa, digoxin and cardizem daily. Lately I have woken up with an irregular heartbeat and it has converted in a couple of hours other times it takes about 15 hours this is destroying my life and going to sleep is getting to be a waiting game… I also suffer from mild anxiety and have been given ativan to use a needed. I have tried lifestyle changes such as no caffeine minimal drinking, foods, etc. it hasn’t really changed anything and most of the time I feel great .I have been studying the ablations and my doctor thinks that I’m a good candidate since I am so active and I work outside, my problem is picking someone to do it and to be honest I want the BEST!!! Up here in the Tallahassee area I am very skeptical with our EP program and have been searching Shands, Jacksonville and Cleveland Clinic Florida and have heard talk of Doctor Pinski and your staff. I have great insurance and need your advice on this matter because I don’t know who to use I am willing to travel to wherever I can get the best results!!! please help thanks David.

Mandeep Bhargava, M.D.: If the symptoms are impacting your quality of life so much, an ablation is reasonable for the same. You could even try antiarrhythmic drugs (AADs) which may suppress your AF but do not cure it. All AADs have some risks which you should discuss with your doctors. Ablations are invasive and also have risks but are potentially curative. Cardizem and Digoxin are not AADs and do not reduce your burden of AF but just control the rates when you are in AF. In case you have normal heart function, digoxin is best avoided. In case you would like to come to the Clinic for an ablation, we would be glad to help as the Clinic AF ablation program is clearly among the leading programs. However, you have to be aware that AF ablations in your case also would have at best a 75-80% chance of success with a single procedure. All the best and we hope you are able to make the best decision for yourself.

Firefighter: Hello and thank you for this opportunity. I had a pulmonary vein isolation done this past March and have several questions.

I’m a 61 year old retired firefighter, 6’2″, 235 lbs, BP 130/65, RHR ~77 now. I am a lifetime weight lifter and walker; overall in good health. Head injury in 1996 (hit by jet ski) and Jan 1998 (head on car collision). Mar 1998 sleep apnea began; CPAP until 2004. Currently no sleep apnea. Diagnosed with paralyzed vocal cord. Infrequent episodes of racing heart in the middle of the night a few times a year from about 2003 until Dec 2008, when a 15 hour episode started after bending over to pick up a dog. Decided to go to the ER in the morning but a shower stopped the irregular heart beat. Went to cardiologist and started Toprol. Small episodes followed until April 2009 when azithromycin sent me into a 30 hour episode and official afib diagnosis; added 225mg Rhythmol pill in the pocket to the Toprol. Also added 1mg Clonozapam at night. Had multiple afibs of short duration and 2-3 episodes per year lasting up to 24 hours until Oct 12, when I went into afib for one and a half months straight mitigated by daily doses of Rhythmol but not stopping.

Ablation decision was made. Cat scan showed “atherosclerotic changes …in the aorta”. Is this heart disease? Calcium score is 28 – is this related to the atherosclerotic changes? EP said Rhythmol is too dangerous with heart disease and had to stop. Nov 26, 2012 started Tikosyn. Ablation was March 12, 2013. Afterwards put on 500mcg Tikosyn, Coumadin, and 25 mg Toprol. Symptom free until May 1, then intermittent skipped beats and palpitations for 30 seconds over one week then tapered off to 1/wk. Stopped all meds but clonozapam May 29, as per doc’s post surgical orders. I feel on the edge but pretty steady. I also take an 81mg aspirin, 300mg krill oil and 2000 mg vitamin D every day.

  1. What can I expect if the ablation worked? If I continue to have skips and palpitations, does this mean it failed? How will I know if I need another ablation?
  2. Why do some doctors put you on Coumadin before and after ablation and some don’t?
  3. Why can’t I take Rhythmol? What would happen? Since the ablation my RHR has gone from 50s/60s to 70s/80s. Is this OK?
  4. I don’t want to take Toprol since I believe it slows my brain down. Can I use Tikosyn or Rhythmol as a pill in the pocket and drop the Toprol?
  5. How much damage is done by the x-rays during ablation? Is it safe to be exposed to that much radiation if subsequent ablations are needed?
  6. I’m concerned the ablation only takes care of the end result of an undiagnosed problem. Is there any progress in understanding the mechanism? Could my head injuries have contributed to my afib?
  7. What is Renal Artery denervation?
  8. Any news or new opinions on the FIRM process?

Thank you very much for your time.

David_Van_Wagoner,_PhD: Your list of questions suggests that it may be helpful to you spend some more time talking with your cardiologist. However, I will address a few of these: 1) AF recurrence during the first 3 months after an ablation does not mean that the procedure has failed, as there is a role for inflammatory changes that frequently lead to transient episodes of AF following ablation. After the inflammation has subsided, it will be more evident to you and your cardiologist if the initial procedure was successful, or if you require a repeat treatment (not uncommon). 2) In general, the decision to use Coumadin or other anticoagulants is based on the assessment of your risk for stroke. Different doctors may use different diagnostic tools and reach somewhat different conclusions; 3) Rhythmol increases risk of serious ventricular arrhythmia in patients with ischemic heart disease; the aortic atherosclerosis suggests that you may be at risk for this, thus Rhythmol is not advised. 7) Please see other answers about renal artery denervation.

HLJ333:Can you please discuss connection between A Fib and sleep apnea?

David_Van_Wagoner,_PhD: Sleep apnea leads to transient episodes of low oxygen in the blood stream (hypoxia) and changes in pressure inside the body. Hypoxic episode send a signal to the brain to increase blood pressure. Frequent episodes of sleep apnea promote high blood pressure, coronary artery disease and heart failure. This link (freely available) describes some of the major links between sleep apnea and AF. It has been estimated that one third to one half of patients with AF suffer from sleep apnea.

CR:WHAT IS THE CONNECTION BETWEEN ATRIAL FIBRILLATION AND THE VAGUS NERVE and even the Thoracic spine. What specific research has been done on this relationship. PLEASE ANSWER on the online chat. I can not get any positive info from my cardiologist always typing continually during appointments and is miles away from answering my questions.

David_Van_Wagoner,_PhD: The autonomic nervous system regulates heart rate and blood pressure, as well as digestion, blood flow and many other physiologic responses. The autonomic nervous system involves a balance between nerves that increase heart rate and blood pressure (sympathetic), and nerves that slow heart rate and blood pressure (parasympathetic). The vagus nerve is the primary nerve of the parasympathetic nervous system. It is responsible for slowing heart rate and controlling digestion. The balance of activity of the sympathetic and parasympathetic nerves is important and has an impact on the development of electrical activity that initiates AF. The balance of autonomic nerve activity is disturbed by sleep apnea, hypertension, heart failure, and stress, leading to increased risk of AF in these conditions. The vagus nerve is a bit like Goldilocks — you don’t want too much activity, or too little! In patients with too little vagal activity (especially with heart failure), several experimental studies have shown beneficial effects of stimulating the vagus nerve directly, indirectly by baroreflex stimulation, or by stimulating the nerves in the spine.

Grampjet:61, Male. Paroxysmal AFIB for 10 years,. Incidents increasing in frequency and length. Usually every couple of days lasting several hours.

Questions answered by Mandeep Bhargava, M.D.

  • Why is it now that when I lay down on my right or left side in bed at night, it wants to start into AFIB almost immediately? Answer: Surely a strange correlation which we have very rarely seen with some tachycardias but hard to explain.
  • It seems when I even think about my AFIB, it starts to flutter and beat irregularly then start an episode….is this anticipation anxiety?Answer: Very possible, you have to try and stop worrying about it to treat it on more objective terms. You are probably becoming very sensitive to every skipped beat or short run that you may have.
  • Does the fact that I am acutely aware of every initiation of an episode (when afib starts and stops) mean that this is somehow a stronger ‘version’ or better or worse than those that do not know when they are in afib or not?Answer: Not really, you either have AF or do not have it. There is nothing like easy or difficult AF or good or bad AF or weak or strong AF. The symptoms and extent of hemodynamic impact it causes in an individual patient can definitely be very variable.

Adele:Hello, When my husband was put in assisted living, I began to have AF on occasion. As he got worse so did the AF. Went to doctor and I am on a channel blocker and aspirin. No other problems with my heart. Now my husband passed away and the AF is reduced considerably. This amazes me. Do you think they will go away now that the stress has ended? TY

David_Van_Wagoner,_PhD: Stress leads to increased sympathetic nerve activity that can trigger AF, so it is possible that the frequency of your AF episodes will decrease with a reduction in stress.

Kimberly1102: I was diagnosed with A-Fib 2/2013 so still learning. Is it normal to have chest pain with A-Fib and how do I know if I need to go to the ER? I can feel the flutter, sometimes pretty bad, along with the pain and pressure. Thank you.

Mandeep Bhargava, M.D.: You should consult your doctor to make sure that the pain is not due to ischemia and not causing any dangerous impact on the heart in terms of causing cell necrosis or enzyme leak. Most often it does not.

Realton:Is there any progress in discovering the underlying causes of AFib that may lead to a total cure (or preventative measures)?

David_Van_Wagoner,_PhD: Yes, there are many studies underway, including here at the Cleveland Clinic. A summary of what is and is not known, and a reasonably current summary of ongoing research directions focused at understanding mechanisms and leading to prevention can be found here. There is a strong hereditary component to risk of developing AF. Recent genetic studies have documented a number of regions in the genome that are associated with risk of AF.

Chuckarc: My mom has been diagnosed with Sjogrens disease. Can this cause afib and shortness of breathe?

Mandeep Bhargava, M.D.: Most often if patients have Sjogrens disease and AF, it may be coexistence rather than a direct cause and effect relationship. You may want to have her evaluated for pulmonary causes of shortness of breath if she has Sjogrens as it may often be associated with other rheumatologic illnesses.

Emerald: My doctor says I most likely have vagus nerve induced afib. Are there any other items besides cold drinks that might trigger afib? I would like to take as much responsibility for my condition as possible, such as avoiding triggers. Any other specific triggers to avoid?

Mandeep Bhargava, M.D.: Some people feel that fatty and cheesy meals like Pizzas may trigger that. All this is not very well proven. We generally ask patients to avoid only those things that they are very convinced has a clear relationship in there situation but often these are co-incidental and when patients have more episodes over a period of time, they realize that the triggers are very random.

Adourian: Regarding possible causes of paroxsymal afib. Of my 4 episodes over the last year, each lasting less than 24 hours, in 2 cases I went to the emergency room for treatment. Each time my potassium levels were around 3.6 (not out of range but low). Over the past 15 years of blood work, my potassium levels have always been above 5. Could the low potassium be a potential trigger or could it just be the effect of afib?

David_Van_Wagoner,_PhD: This is difficult to assess. Potassium levels affect blood pressure and the excitability of the heart. Low potassium may have some adverse effect on blood pressure and AF, but it is likely not the only factor contributing to the onset of AF. There is certainly no harm associated with increasing your dietary intake of potassium (from bananas, fruits and vegetables), and there is some evidence of benefit.

Disup: After 4 cardio/v and 2 ablations over past 6 yrs, I have been in flutter for past 8 months. What are the long term effects to staying in aflutter with minimum problems to my lifestyle? I am 72 pulse daily in 90 feel generally good fairly active taking warfarin, lovastatin, and vytorin.

Mandeep Bhargava, M.D.: If your rates are well controlled, LV function is normal and your symptoms are minimal, the impact may not be much other than your symptoms. However, if the rates are not controlled, persistent atrial flutter can cause progressive weakening of LV function in some patients.

WebQuest:Can extrasystoles originating within a ventricle travel back into the Atria and trigger Afib? If so! Would ablating the atria hotspot(s) get rid of the afib, with the continuing presence of ventricle extrasystoles? Or would the ventricle area triggering the extrasystoles have to be ablated first (if it can be done) to solve the afib without an atria ablation.

I have been hooked to several cardiac recorder events. None has been able to pin point if my Afib originated from the Atria or from a PVC traveling back into the Atria causing it to go haywire. I was told by that this was very rare. But if this is my case how can this be determined and then corrected?

Mandeep Bhargava, M.D.: In general, PVCs do not trigger the AF. If the AF is to be ablated, we concentrate our efforts in ablating for the triggers in the pulmonary veins and the left atrium and not on the PVCs.

Treatment: General Treatment Questions

Hoagie0013:Hello doctors, I was first diagnosed with afib in 2000. have had 2 ablations. I still get weird heart rates every 6 or 7 days in-between. first I will get a rate around 120 bpm for around 30 to forty min. or sometimes all day then all of a sudden the rate seems to slow to around 49 bpm or even slower when I get to moving around after standing and walking. this could last all day then the heart rate seems to slowly start to try and correct itself one beat at a time. it starts as beat, beat . then b,b,b. then b,b,b,b,and continues until it gets back to normal which can take all day. I am scheduled for 3rd ablation 6/18/13 do you think this will help.

Walid_Saliba,_MD: We need more information in regards to the nature of your arrhythmia as well as the two prior ablations. But – an EP study will be able to determine the nature of your arrhythmia problem and ablation can potentially correct that.

Barlee:I am a 68-year-old female who was diagnosed with A-Fib immediately following a modification of the AV node for SVTs in 2004. A few days later I was informed that I had paroxysmal AF and began 60mg of Betapace 2Xday that was eventually increased to 180mg 2Xday. My episodes were a few a month. In 2010 I discontinued Betapace because my episodes were increasing, and I began Multaq 500mg 2Xday, with Cardizem 60mg as my “pill in the pocket.” I also take ToprolXL 25mg with lunch, as well as 81mg of aspirin. For the last few years I have been experiencing about 3-4 episodes a week, always in the evening, and lasting anywhere from 4-8 hours. Emotional stress, mild exercise, and a heavy meal are often triggers. A recent echo stress test showed no evidence of inducible ischemia. I am reluctant to have an ablation because my EP informed me that isolation of all trigger points may not be possible, and that a second or even third ablation may be attempted to achieve possible success. Until a few weeks ago, I had believed that my stroke risk was low, which was based on the CHADS guidelines used in the US. I have none of the following: CHF, hypertension, diabetes (but I am prediabetic), previous stroke, and I am younger than 75. However, a STOP AFIB email apprised me of the newer CHADS European guidelines, which classify me as high risk based on gender and age. I have GERD, am prone to nosebleeds, and have a family history of ulcers. Please help. If I were your patient, would you prescribe oral anticoagulation such as Coumadin or Pradaxa? Is there any medicine or combination other than Multaq that would likely provide better rhythm and rate control? Would you advise a different “pill in the pocket”?

Finally, if my present symptoms are no worse, my husband and I are considering a 3-4 week vacation to New Mexico in the fall. In your opinion, would an altitude range of from 3500 to 7200 feet, and the resultant decreased oxygen and the physiological changes in adrenalin levels increase my risk for AF or lengthen the episodes? All my life I have lived in NY close to sea level. Thank you in advance for your concern and answering my questions.

Walid_Saliba,_MD: We would recommend afib ablation to alleviate your symptoms and the potential to go off anticoagulation if successful. In the meantime, altitude may precipitate atrial fibrillation but there should not be any reason to withhold your trip.

Josephine:How long must one take Coumadin before it is safe to “shock” the heart in attempt to reach a sinus rhythm? And 2) Must one have been on an anticoagulant for a period of time before a catheter ablation for A.F.?

Mandeep Bhargava, M.D.: At least 3-4 weeks prior to the cardioversion and make sure the levels are therapeutic during this time. We usually check weekly INRs for preceding 3-4 weeks. And 2) Must one have been on an anticoagulant for a period of time before a catheter ablation for A.F.? We usually prefer at least 4-6 weeks. If not possible, we may do a trans-esophageal echo prior to the ablation or cardioversion.

Az1435t:I have had two ablations approximately 18 months apart (RF and cryo+RF) for afib/flutter. A year after the second ablation I was training for a marathon and was diagnosed with CPVT at CC (documented on Holter monitor) and subsequently received an ICD and started 25 mg atenolol daily (weight is ~110lbs, height 5″10″). About 2 months later I started having a significant increase in PVCs and then I was told the afib returned and was given 0.25 mg of digoxin daily. Since then (~3 months) the afib incidents are significantly reduced, however I am extremely tired after exercising and can nap for several hours. My question is 1) atenolol makes me tired (I was on 12.5 mg previously and it affected me the same way after the second ablation), can the dose be reduced or even stopped? and 2) is the digoxin aggravating this tired feeling? I have a hard time getting pulse above 120 bpm without feeling winded. Am I a candidate for another ablation (or maze procedure) to control the afib and eliminate some of these meds that I feel really impact my lifestyle? I have had the ICD for ~7 months with no further VT incidents, but have significantly reduced exercise regimen.

Edward Soltesz, M.D.: You would certainly be a good candidate for a totally thoracoscopic Maze procedure along with left atrial appendage exclusion.

Pgfischer: Hi Drs. Saliba, Soltesz, and Van Wagoner – I’m 41 years old and was diagnosed with a-fib six years ago. My 44-year-old sister was just diagnosed this year. Our dad died of a heart attack at age 41. We’re not sure if he had any history of a-fib. Because of my dad’s fate, I’ve seen a preventive cardiologist for several years and follow a strict diet that keeps my weight and my cholesterol down. I’m 5’11” and 175 pounds, so obesity has not played a factor in my a-fib.

I’m currently taking 225mg of Propafenone in the morning and 325mg in the evening, though my doctor and I just discussed upping the morning dosage to 325mg. He also is about to start me on 12.5mg of Toprol per day. I have Hemophilia B, Factor IX deficiency, which provides me with a natural defense against a stroke, from what I understand.

Despite the medicine, I experience daily episodes of a-fib, usually in the late afternoon or evening, and usually anywhere from 5 minutes to 3 hours long. The more fatigued I am, the more likely and more prolonged the episodes seem to be. The current game plan my doctor and I have is to keep taking medication until my quality of life tips the scales in favor of a corrective procedure, which will of course have to be weighed against the risks due to hemophilia.

Many thanks for your time.

Questions answered by Mandeep Bhargava, M.D.

  • By delaying a procedure, am I weakening my heart and running a greater risk of premature death (even if that means dying at 85 instead of 90, should I be so lucky). This is an emotional issue for me, having lost my day when I was 4 years old, because I have a 4-year-old son of my own and a baby on the way.Answer: The answer to this question is currently not very clear and a large trial called the CABANA trial is trying to answer the question whether doing an ablation earlier impacts survival. However, if your quality of life is being impacted so much by the AF, it is reasonable to consider either an alternative antiarrhythmic drug or an ablation. However, you should consult a hematologist to guide you regarding the anticoagulation as you would have to be on anticoagulation for the ablation.
  • What are the risks of heart failure due to a-fib if I maintain an otherwise healthy lifestyle?Answer: Some patients can have heart muscle dysfunction and heart failure due to atrial fibrillation regardless of a health lifestyle. In those patients, we like to be more aggressive with the use of ablations and antiarrhythmic drugs.
  • Am I at a greater risk of suffering from dementia or cognitive decline due to a-fib? If so, is that something that is more likely to occur at a younger age given how young I was when I first developed a-fib? Answer: There is some data to point in this direction but again not enough data to show the reverse i.e. that treating AF earlier reduces the risk of dementia. Sorry, there is borderline and weak data on this aspect but the hypothesis is a concern.

tonypohl:Hello Dr’s: I’m trying to decide between continuing drug therapy or trying an ablation. I’m 53 years old, and in very good health. Eight years ago I had episodes of palpitations, racing heart, etc. and at least one confirmed episode of aFib. These episodes seemed to be triggered by stress (worrying about my health), caffeine, adrenaline and a hurried lifestyle. Tests, 8 years ago and also currently (blood, echocardiogram, nuclear scan, etc.) showed that I have a strong heart and no heart disease. With the help of a Metoprolol (25-50 mg daily), symptoms disappeared after a few months and essentially went away for 7 years. About 1 year ago the palpitations came back (maybe a couple times a week). Metoprolol (25-50 mg daily) seemed to help. About 6 weeks ago–after a period of doubling my exercise routine—I experienced about 8 episodes of afib or a-flutter (with one confirmed case of a-flutter) in a two-week period. My cardiologist put me on Metoprolol 50mg and Flecainide 100mg daily. That didn’t seem to help. He increased the Flecainide to 200mg daily. After a few days, this dosage seemed to help. For the last 3+ weeks I’ve been on Metoprolol 100mg and Flecainide 200mg daily and have had no a-fib/a-flutter episodes. I’m not sure if I should continue the drug therapy with the hope of possibly reducing/discontinuing in the future, or do an ablation and try and knock it out? I really don’t want to do drugs for 30 years (maybe I wouldn’t have too) but I also don’t want to rush into an ablation. Comments or insight is appreciated!

Oussama Wazni, M.D.: Ablation is reserved for when medications are ineffective or not tolerated. So as long as the medical regimen is effective there is no need to pursue ablation as ablation is not 100% effective and may be associated with complications.

Louryann11: I have atrial tach which by one test is activated 3 mm bundle of hiss. is there a way to fix this? A second doctor said the tests were not complete and could very well be activated initially in a safer area. Relating to my primary question, here is the second doctor’s opinion:

  • Unfortunately Dr. Porter did not map from the left ventricular outflow tract or aortic root, or the mitral valve annulus from the left side, to ensure that the tachycardia did not arise from one of these areas, further from the His. I have never found an atrial tachycardia that we could not safely ablate before. You could be the first, but I am willing to give it a try.

Is this accurate in your opinion?

Oussama Wazni, M.D.: I agree that this atrial tachycardia may be approached from the systemic (left side) of the heart.

Jplas3:If you have afib and CAD and have responded to cardioversion and been maintained by sotalol for over 3 years and then it has been discovered that you have LVH but you do not have high blood pressure

Questions answered by Oussama Wazni, M.D.

  • Should you be taken off sotalol and put on amiodarone?Answer: This depends on the degree for LVH. Sotalol is not recommended when there is substantial LVH >1.4cm.
  • Would you consider ablation for a patient with cardiac amyloidosis and afib?Answer: Not generally.
  • Is amiodarone more likely to cause LBBB than sotalol?Answer: No.
  • Cardioversion is almost guaranteed to return a heart to normal sinus rhythm, if only for a short while. Will cardioversion also correct LBBB?Answer: No.

Jojo51:Do you have any knowledge, either by experience or review of clinical studies, of stem cells being used in the treatment of atrial fibrillation? In correspondence to that, what would the difference be between using adult stem cells from the person himself, compared to cord blood stem cells derived from a close relative?

Oussama Wazni, M.D.: I am not aware of such studies.

MB: I have had A FIB since 2007. I have a heart ablation and a pace maker installed. It is in the av and sv node. I am also on Xarelto. I was told by my doctor that I am in AFIB 67-75% of the time now. Do to the AFIB I have had 5 strokes. I am happy to say that I have recovered very well from them. MY last stoke was in January of 2012 after I had to go off my blood thinner prior to a colonoscopy. I have tried very many medications for the AFIB, but nothing has helped. When I went to see my electrocardiologist this week he told me “there is nothing more I can do for you”. I am very scared and don’t know what that means. I have started going to the gym 3 days a week for a low impact workout. I feel good except when I am in AFIB. I refuse to believe what he is saying. Please help me, I don’t know what to do. I am a 64 year female.

Oussama Wazni, M.D.: When medications fail AF ablation may be warranted and may help in your situation. Also given that you have had recurrent stroke you may be a candidate for left atrial appendage occlusion to prevent stroke in the future.

Pyre:Hi from “down under”. I’m 59yo fit male. Diagnosed first time AF 1st May 2013. Taking flecainide, Digoxin and Warfarin. Underwent echocardiogram, CT head and chest x-ray; all clear. I’m worried that something may have been missed as I never feel ‘normal’. Experiencing a strained, pulling sensation under my sternum area particularly bending forward. Very bad day yesterday all day with heavy weight feeling in chest (throbbing) and breathlessness. Now 3 weeks chemical therapy. Are there some other exploratory methods apart from what I’ve already undergone? Thank you – concerned!

Oussama Wazni, M.D.: If you are still in atrial fibrillation then DC cardioversion is warranted. This will alleviate your symptoms. If AF is recurrent after the cardioversion then another antiarrhythmic medication or ablation may be considered.


ESTHERLEON: Doctor Saliba, thanks for your answer, but I would like to know about the symptoms I have at this time, irregular heart beat, I can feel the sounds of them in my head. I try to rest when I am feeling this problem, but they don’t stop. It happens when I’m eating too fast or too much, and when I am facing some problems, yesterday I was exercising with an exercise bike and after that I started to feel that hard and irregular heart beat with a strange feeling in my chest. Now in the morning, it is gone. Do you think I am having some kind of problems with my heart?

Walid_Saliba,_MD: You would probably need a monitor to evaluate any arrhythmias that coincide with your current symptoms. We would be happy to evaluate you.

Barlee: I am not sure if my shortness of breath is coming from my paroxysmal AFib or CAD. How accurate is my recent echo stress test which indicated that I do not have CAD?

Oussama Wazni, M.D.: Stress echo reliability depends on the experience of the interpreter of the study and has a sensitivity of about 80%.

Atrial Fibrillation Treatment: Medications

bboyle:Over the past 2-3 years I have had 4 AFib events, each lasting approximately 12-15 hours. I am on Pradaxa twice daily for this. I am very sensitive to my body signs and can fell the AFib attack beginning immediately, and I can detect the minute that it stops. I went to the ER for the first 3 events. Following the 3rd event I was put on Sotalol which enabled me to wait out the 4th AFib event at home. This last event happened 8 months ago and was the mildest of them all. Following the last event, I read that vitamin D may prevent AFib attacks, so I began taking 2000 units of vitamin D daily. Since doing this, it seems that I have avoided an attack for a longer period of time than in the past. My questions are a.) With attacks this infrequently, do I need to stay on a daily dosage of Pradaxa to prevent blood clots? Can I take something as soon as I detect an attack beginning? and b.) Do you feel that vitamin D is helping me to prevent the attacks? Thank you very much for this very helpful chat opportunity.

David_Van_Wagoner,_PhD: A) You should discuss the need for Pradaxa with your cardiologist. B) A study of a large US population did not found evidence for a link between vitamin D levels in blood and the development of AF; this suggests that vitamin D deficiency does not promote the development of AF. Smaller studies comparing AF patients with matched control groups have shown that the AF patients had lower levels of vitamin D than the control. As there is some evidence for benefit of vitamin D with respect to cardiovascular health, if your vitamin D levels are low, taking a supplement is not likely to increase risk of AF and may be helpful. There is not solid evidence to support this at present.

LJean:I had a cardioversion a couple of weeks ago. It didn’t last only a day or so. Now I have to make a decision to pursue an Ablation or just stay on blood thinners and beta blockers. I’m not sure what, xarelto and metoprolol will do to my overall health over a long period of time. I am a 64 year old female. Could you give me some insight as to what I should do? Also if the cardioversion didn’t work will that affect the outcome of an ablation.

Walid_Saliba,_MD: The treatment of afib is based on symptoms – if you are having symptoms in atrial fibrillation, then it would be recommended you attempt more aggressive therapy to maintain normal rhythm.

JimVE: Can blood thinners stronger than 81 mg aspirin cause retinal bleeding our fluid loss in my remaining good eye being treated with Lucentis for wet AMD? If so, which might be safer: Plavix with aspirin, or rivaroxaban 20 mg? I am 81,otherwise in very good health, and am asymptomatic and paroxsmal in terms of my afib. Frankly I’d just as soon continue on my 81 mg aspirin as I’ve done for a year now. I will not be near a computer on the day this chat is scheduled. Any chance of the answer being e-mailed?! THANK YOU!

Walid_Saliba,_MD: Blood thinners can cause retinal bleeding. I would suggest you consult your ophthalmologist regarding your specific questions.

Aquarius: Should all A Fib patients be on an anti-coagulant!

Walid_Saliba,_MD: No – only If you have high risk factors for stroke.

Yless1:I have heard of the “Pill in the Pocket” approach to treating A-fib but never heard what that pill is and who would benefit from this approach. Can you tell me what medication is used in this management technique.

Walid_Saliba,_MD: Usually it is flecainaide or propafanone and it is used in patients who have relatively infrequent episodes of atrial fibrillation.

Sharon45: When is enough? I have been going in A-fib every 12 to 15 days. Then went longer just one time. The sotalol has ceased to be very effective after one year and I do not want on another anti-arrhythmic. Is it time for ablation?

David_Van_Wagoner,_PhD: It seems that your frustration is there and it is time for an ablation since you have failed antiarrhythmic drug therapy.

Retired Dan: Are there medicines now that work better with fewer side-effects than Amiodarone, which I have been taking for 15 years?

Walid_Saliba,_MD: There are other medicines such as tikosyn which require a 4 day hospitalization for initiation; but it does not have better efficacy necessarily.

jplas3:Can amiodarone cause left bundle branch block? What about sotalol? Is there a higher incidence if a patient is taking either of these medications?

If a patient has been maintained in normal sinus rhythm by sotalol for 3 years without failure, what would be reasons for discontinue sotalol and switch to amiodarone?

The flow chart on page 165 of Heart Rhythm, Vol 9, No 1, January 2011 indicates that, if you have CAD, but not hypertension, sotalol would be your first choice. It appears that substantial LVH only comes under consideration if you have hypertension. In that case, amiodarone is recommended. Is this a correct reading of the chart? If it is, why would a patient who has been maintained in rhythm for 3 years on sotalol be switched to amiodarone simply because of having LVH but without hypertension? How are any of these questions affected if the patient has LVH caused by TTR wild type cardiac amyloidosis?

Walid_Saliba,_MD: Antiarrhythmics can cause LBBB on the EKG. The main reason to discontinue sotalol is prolongation of QT interval or development of conduction system disease, but not necessarily LVH by echo.

Breakaleg:If one has Atrial Flutter and Atrial Fibrillation and prefers not to undergo a progressive procedure, what are the risks of using a combination Tikosyn or Sotalol with a type 1c medication? Are there harmful side effects using this combination of drugs and what are the percentages of success? What are the specific benefits and percentages of success with this combination?

A doctor has recommended Tikosyn with a 1c medication, I don’t understand what the 1c medication is and how the combination would work and why don’t doctors typically use this procedure?

Walid_Saliba,_MD: We have used these combinations at the clinic with a success rate around 50% at one year suppression of atrial fibrillation. However, this should be done in a very closely monitored setting because of the potential side effects. 1c is flecainide or rhythmol.

3skipabeat3:I am 63, male, in general good health and physically very fit, 5’8″ 158#s, diagnosed with AF in 2009. Flecainide completely controlled my palpitations. I was also started on Metoprolol 50mg 1/day resulting in good blood pressure control. Stress test in Dec. 2012 suggested ischemia, angiogram then confirmed 40% midvessel stenosis in circumflex and RCA arteries. Was switched to Multaq which has failed to control my palpitations. (I was also put on Crestor 10mg 1/day). I experience fairly strong palpitations daily, sometimes for a few minutes, often for hours which is unacceptable to me.

  1. Since Multaq has failed, is there another medication to try?
  2. Can I stop taking Multaq now, and if so, cold turkey or gradually?
  3. Can I continue my rigorous exercise program in the absence of an effective AF medication?
  4. If ablation is the appropriate next step, how soon after can a patient resume exercise?

Walid_Saliba,_MD: There are other medications available such as sotolal and tikosyn which would require hospitalization. Yes – you can stop taking multaq cold turkey – but make sure this is done in conjunction with your doctor’s recommendation.

You have to be careful about exercising during atrial fib as this can result in a fast heart rate that can be very symptomatic. Following an ablation (which I think is the right next step for you) you can resume exercise in a week).

Emerald: I developed afib about 10 years ago and have a total of about 8 brief episodes. I have had successful cardioversion twice. My interventional cardiologist has ordered EKGs, sleep apnea study, two-week cardio monitoring, echocardiogram and stress test. All are normal except my stress test indicates inadequate conditioning. I am also overweight. I take 50 mg metoprolol and 50 mg flecainide twice daily. 3 of the episodes have been in the last six months, each converted at home with the pill-in-pocket approach, by taking an extra 200 to 250mg of flecainide at onset for a total of 300 to 350mg on those days only. Conversion occurs within one to three hours. My doctor does not think I need to be on anti coagulants because I have no other risk factors. He has me on 2 baby aspirin a day. Does this seem overall like a reasonable treatment plan? I have read that aspirin is on its way out, that possibly “it does more harm than good.” Would your recommendations for me differ?

Walid_Saliba,_MD: This treatment regimen seems very reasonable. However, I would be careful about the potential for asymptomatic/silent atrial fibrillation that still increases your potential risk for stroke.

ATSunny:I’ve been reading on the StopAfib site that women are at a higher risk for stroke. It mentions being on a blood thinner like coumadin instead of just aspirin. Does this mean everyone? I have afib occasionally (every couple of months) and it lasts anywhere from minutes to a few hours. I don’t have any other symptoms with it. I am 67, not overweight, no other heart disease, hbp under control, and B+ blood type. My cardiologist has not mentioned blood thinners and I only take 325mg aspirin once a day. Under the latest thinking, should I be on a blood thinner?

Walid_Saliba,_MD: At this point in time and based on US guidelines, aspirin is acceptable. By European guidelines you would require blood thinner. I would suggest you bring this up with your cardiologist.

Ralphgschmitt: I’m a 68-year-old male, 6′ 1″ tall, 215 lbs, in good health. I exercise vigorously 6 days/wk. I had two ablation procedures in 2012 (latest on 11/6). After the 2nd ablation, I was still experiencing some arrhythmia (diagnosed as “flutter”). After flecainide was added as a prescription on 1/3/13 (50 mg, 2/day), my arrhythmia started to subside in April/May. I’m now in NSR with a consistent resting blood pressure of 124/72 and a resting heart rate 60 bpm. Will I need to continue flecainide indefinitely or may I be able to discontinue it?

Walid_Saliba,_MD: It would not be unreasonable to try to discontinue the meds at one year following the procedure. If the arrhythmia recurs then you will need to restart the medication.

Senga:Have racing heart episodes once or twice a month lasting sometimes up to 5 hours. (198 BPM) Leave me exhausted and weak. Cut out all caffeine. Doctor put me on metopropol tartrate 25mg as needed and a daily 400 mg magnesium oxide. See no difference. Catheterization and stress test showed no abnormality. What more can I do?

David_Van_Wagoner,_PhD: You should seek a referral to a cardiac electrophysiologist to diagnose the source of your rapid heart rate. It may be treatable with an ablation procedure.

Mountainman:I am a 59 year old active male who is in above average condition for my age group. I have had PACs for approximately 10 years. About 5 years ago I noticed that my heart beat became irregular. My doctor confirmed that it was atrial fibrillation and I began taking regular strength aspirin. The A Fib got worse over the next couple of years affecting my ability to exercise and my quality of life in general. My cardiologist tried to regulate my heart rate with three different drugs with no success. In August 2009, I had a TIA that lasted about 20 seconds. I did not suffer any permanent damage. At that time I was told to start taking Coumadin. The only other medication that I take is Simvastatin.

In October 2010 a had a very successful catheter ablation. Immediately after the procedure and since then I have not had any recurrence of A Fib (I can immediately feel when my heart beat is different such as when I have a PAC).The doctor who performed the ablation tells me that I should continue to be on Coumadin because I had a TIA. However ever since I started taking Coumadin my migraines have become much more frequent (6-8 times per month) and severe to the point that I had to take Sumatriptan(which also increases stroke risk) to relieve the pain. After discussion with my GP I stopped taking Coumadin in early April. Since that time I am sleeping much better and I have only had one migraine in the last month.

I am 99.99% sure that my AFIB is no longer present because I can feel any change in heart beat. On this basis I am comfortable with no longer being on Coumadin. Based on this information can you comment on my decision to stop taking the Coumadin. Thank You.

David_Van_Wagoner,_PhD: There is evidence to suggest that one’s ability to detect AF is decreased following an ablation procedure. Having suffered a TIA, you don’t want to have a full-blown stroke. There are several alternative anticoagulant drugs available now (Pradaxa, Xarelto, etc.) that are more effective than aspirin and less onerous (and fewer side effects) than Coumadin. I suggest discussing these options with your cardiologist or cardiac electrophysiologist.

dublinafib: Hello Doctors my name is Bob. I am a 64 year old male currently in AFIB. I have had a few EKG tests over the years; all were ‘normal’ and I have no cardio problem history except high blood pressure. My height is 6’4” and I weigh 260. (20-30 lbs. overweight). I have no history of stroke, heart failure, or diabetes and my kidney function is normal (Creatinine of 1.3).

On February 6, 2013, I had cataract surgery on my left eye. The surgery went well and the pre and post op process was normal.

On February 13, 2013, I had cataract surgery on my right eye. Without going into great detail, the pre-op process for this surgery was rushed and maybe understaffed. In any case I was completely under before leaving the pre-op area and woke up after surgery with the anesthesiologist saying I had a heart problem. My family doctor was contacted and I was able to see her late the next day.

I was told I was in AFIB and my medication was changed from Lisinopril 40mg + Simvastatin 20mg once per day to Metoprolol 25mg (2Xdaily) + Simvastatin 20mg (1X) + Aspirin 325mg (1X).

Following this change and a brief introduction to the issues of AFIB, I had: (1) a Treadmill myoview stress test in February during which I exercised for 7 METS, maximum heart rate of 139 and there were no abnormalities on imaging with an EF of 60% ; (2) an echocardiogram which showed normal function with an EF of 65%, no valve abnormalities, and moderate enlargement of the left atrium (4.9 cm); and (3) a 24 hour Holter test which showed resting heart rate in the mid-70s and exercise rate at 140 bpm. This work was completed in March of 2013.

I have had no symptoms since being on metoprolol except for the first couple of weeks (intermittent woozy periods but not fully dizzy).

I am aware that atrial fibrillation is associated with an increased risk of stroke and can lead to other problems over time. I have had 2 visits with my local cardiologist and we have discussed electrical conversion as well as other procedures. His current recommendation is to stay the course of current medications unless other symptoms develop. Last visit was mid-May, 2013.

Question 1. Should I be on an anticoagulant now? Are there other tests that should be done first?

Question 2. How important is it that I have a normal heart rhythm? Should I seek to get a normal heart rhythm? What should I try first?

Question 3. Can a process be structured at a specialty center like the Cleveland Clinic to go thru AFIB correction procedures or must it be done closer to home. (I live in NH)

I have led an active, outdoor life, including hiking, swimming, bike riding (racing at one time) and would like to continue that lifestyle as much as age permits. Thank you. Bob

David_Van_Wagoner,_PhD: These are good questions. With a history of AF and left atrial enlargement, you do have an increased risk of stroke, and a treatment other than aspirin may be more effective in stroke prevention. An endocardial or surgical ablation procedure may help to restore sinus rhythm. You should seek a consultation with an expert in these areas. There is nothing to preclude you from seeking a consult outside of your home area. As you suggest, your ability to exercise vigorously would likely be enhanced by an intervention that restores sinus rhythm. Careful efforts to lose weight and control your blood pressure are also warranted.

Trey:42 year old male with paroxysmal AF for 8 years. Currently taking 150mg flecainide twice a day and 1 81mg aspirin once a day. I’ve noticed getting tired more often so have prompted my EP for a longer time period event monitor(King of Hearts AF). I am strongly considering an ablation/ 5 box minimaze procedure(my dad had two ablations with no success but has been AF free for six months after his 5 box minimaze).

  1. What else should I consider?
  2. If recommend an ablation, what type and please recommend most qualified physician, preferably in the N Texas area?

Thanks in advance for your help.

Edward Soltesz MD: Either catheter-based ablation or a totally thoracoscopic Maze with left atrial appendage exclusion would be reasonable options for you.

David_Van_Wagoner,_PhD: Your case is rather typical for lone AF, and documents the heritability of AF risk and the progression of AF symptoms. Based on your age and symptoms, it would make sense to consider an ablation procedure, as persistent AF increases the risk of heart failure and stroke if the flecainide (or other antiarrhythmic drug) is not controlling your heart rate and atrial rhythm. With respect to finding an expert referral, you may find this tool from the Heart Rhythm Society website to be useful.

WN: I was diagnosed with Afib about 2 yrs ago. Currently on Tikosyn 500mg bid and Metoprolol XR 25 mg. I am usually quite stable, with AF episodes every 3-4 months, lasting 15 min to 2 hrs. Most recently I’ve experienced episodes almost every morning between 7:00-8:30 AM, lasting 30 min – 2 hrs. This has been going on for about 2 weeks. I have three questions.

Questions answered by Oussama Wazni, M.D.

  • Any reason why I would suddenly have increased AF? Is the Tikosyn not working as well any longer? Answer: You are experiencing the natural history of AF which becomes more frequent, persistent and resistant to antiarrhythmic medications with time.
  • I am extremely tired about 60-90 min after taking the morning dose of metoprolol XR and Tikosyn. Could this be from these meds? Would it help to take the Metoprolol XR at night instead of the AM. Answer: You are right this is most likely a side effect of metoprolol which you may take at night and experience less fatigue.
  • I am in need of arthroscopic knee surgery, but am fearful of going into Afib during/following surgery. Does surgery increase AF? I’m treated with Tikosyn and Metoprolol. Can I take it the day of surgery?Answer: Any surgery may increase the risk of AF. You may take both medications on the day of surgery to minimize this risk.

Bremsh:I take flecainide 150 mg bid and Toprol 25 mg od and still having breakthrough episodes of AF. I do not wish to have an ablation at this time but would rather try another AAD.

Questions answered by Oussama Wazni, M.D.

  • Would sotolol be my next step or tikosyn? Answer: Both Sotalol or Tikosyn are reasonable choices in the absence of contraindications.
  • With the new anticoagulants, anti-inflammatory drugs cannot be taken. What does one do for low back pain which is intermittent?Answer: You may take acetaminophen (Tylenol).
  • You mentioned on a previous chat that Valium improves heart rate variability and reduces sympathetic nerve activity. Would valium be a good drug to take if my AF is triggered by a stressful situation?Answer: It may help.

Waterdoc: I have been taking the drug Multaq for 3 years to control A-fib caused by aortic stenosis. I am almost 72 and very active, and the calcification has not changed during that time based on annual echo-cardiograms. Last month we changed to Flecainide because I was experiencing severe itching over much of my body. My heart rate is higher now and I have more energy, but I just had a short A-fib episode for the first time in many months? My question is, when you have a patient with A-fib caused by aortic stenosis, which treatment regimen do you prefer and why? The only other drug that I am taking is lisinopril to control blood pressure. Before being switched to it 4 years ago, I was taking a beta-blocker and had never had an A-fib episode. Is it possible that a beta blocker alone could do both jobs?

Edward Soltesz MD: I would recommend very careful evaluation of your aortic stenosis because it may actually be much worse than you think. Typically, patients are not recommended for aortic valve replacement surgery until they develop symptoms. These symptoms can be very subtle. Additionally, atrial fibrillation could certainly be caused by the aortic stenosis.

Maggie261: My mother is just turned 80 years young and taking Sotalol for a-fibs. Whenever she’s on it I know because she forgets everything and keeps asking the same things over. When it wears off, she’s back to normal. It has kept the a-fib episodes down a little, but its having this adverse effect on her memory and personality. Is there another drug that maybe other patients that had these kind of adverse effects from Sotalol have safely transitioned to.

Oussama Wazni, M.D.: If the Sotalol is not effective then given side effects I suggest its discontinuation. With advanced age antiarrhythmic medications become more hazardous. So if her symptoms are related to high rates then better rate control with a calcium channel blocker may be more helpful.

Nancybanks: Have been on coumadin therapy for atrial fib since age 58. I am now 84 and still have some episodes of atrial fib which have been documented on EKG but I have a fairly good quality of life. Do have macular degeneration and on maintenance lucentis. The bruises on my arms are hideous along with fragile skin. I am also on 81 mg of ASA daily . Would a switch to xarelto improve the skin appearance or should I just cover up my arms? Other drugs are digoxin lisinopril , vitamins for eye, metoprolol, verapamil, statin (pravastatin), benadryl 25 at hs.

Oussama Wazni, M.D.: Switching to Xarelto may put you at less risk for bleeding provided there are no contraindications. If there are no clear indications for aspirin it may be stopped.

Misslottie:I only had afib event a few times over the span of maybe 3 years and now it is controlled with Cardizem and have not had event in over a year and I have a structurally sound heart. Do I have to take anything more than aspirin daily for blood thinner?

Oussama Wazni, M.D.: No.

BigE:I recently had a catheter ablation for a fib but was asked to continue on Tikosyn to get better results. I am not experiencing any a fib but would like to stop taking Tikosyn because of drug interactions (especially SSRI’S). What is the downside to stopping Tikosyn?

Bruce D. Lindsay, M.D.: Patients are prone to atrial fibrillation early after ablation. Inflammation from the ablation may be a factor. Another reason is that the longer patients are in atrial fibrillation, there are changes that occur at a cellular level that beget more atrial fibrillation. Treatment with an antiarrhythmic medication such as Tikosyn helps stabilize the atria until healing occurs. It generally is discontinued 2-3 months after the ablation.

Passport:What is your opinion on Xerelto? I am on Xerelto for a fib and facing knee surgery, also have ascending aortic aneurysm I need a way to measure the knee pain vs the risk of going of Xerelto for knee surgery. Please rate the other new blood thinners. Thanks.

Bruce D. Lindsay, M.D.: No matter what anticoagulant you use (warfarin, Xarelto, or the others) you will need to come off them for surgery. The advantage of Xarelto is that when you start taking it after surgery it is effective almost immediately. We know that Xarelto compares favorably to warfarin. There are no studies directly comparing Xarelto with the other new drugs. My impression is that they are equivalent. The only concern I have is your aortic aneurysm. Depending on how large it is, urgent surgery would not be possible with the new drugs. That is the one advantage of warfarin because it can be reversed. The other option is to undergo implantation of a left atrial appendage closure device, which eliminates the need for anticoagulation.

Witter123: Is amiodarone the first drug of choice for afib? How long does a person stay on this before having to change to another antiarrhythmic med? Thanks.

Bruce D. Lindsay, M.D.: Amiodarone generally is not the first drug of choice, but sometimes there are reasons why other drugs cannot be used. The length of time that amiodarone can be used safely varies a great deal. Some patients are treated successfully for years, but your physician would need to follow you carefully for any signs of toxicity. You might be a candidate for treatment with another drug or an ablation procedure if you would rather not take amiodarone.

LucyJ: What is the roll with beta blockers and fibrillation? I know there is a trial going on with bb’s and those that have PAH, can you expand on that? Would a high heart rate be a cause for fibrillation (upper 90’s)?Is there a difference between fibrillation and heart palpations?

Bruce D. Lindsay, M.D.: Abbreviations can lead to confusion. You would need to define PAH before I could answer that question.

Beta blockers rarely prevent atrial fibrillation, but they are very useful in helping to control the rate. The goal is to keep the resting rate in the range of 60-90 and the rate with exertion <120 beats per minute, Nonetheless, we do not require rigid adherence to these numbers. Atrial fibrillation is one of several causes of palpitations.

Maggie261: Hi everyone. My mom is on Sotalol for A-fibs. She started about a year ago. At that time, her memory was very sharp. I noticed every time she took the medication she couldn’t remember anything at all, and it was only when she was on the medication. Then when it wore off she would be back to her old self. Now, a year later on Sotalol her memory is worse than it ever was. I checked out Sotalol and saw that in the drug info. for it memory loss is considered a rare adverse reaction. I am wondering if anyone else had this problem with the drug, and also is there another one that maybe other people have used without this side effect?

Bruce D. Lindsay, M.D.: It is not unusual for patients to have fatigue or impaired concentration with sotalol. The memory problem you describe is rare but possible. If your mother has memory problems that may be caused by sotalol, she should speak to her physician about an alternative medication that might not cause this problem.

Atrial Fibrillation Treatment: Ablation

yless1:Does Cleveland Clinic use the new 3D Spin Rotational Angiography equipment?

Walid_Saliba,_MD: We have it. But – we rarely use it for our afib ablation procedures.

Realtom: I started with an ablation for atrial flutter (2 times) and then had an ablation (left side) for a-fib. Now it looks like we will be doing the other side. Is this unusual for have 3 ablations? Can I expect to have more?

Walid_Saliba,_MD: The afib ablation is done on the left side. It seems that you do need a redo ablation for afib if you are still experiencing recurrences.

Queenie:I have persistent a-fib. I am fearful of ablation even though I am told it could help. The “could” is the clincher. I do not feel the irregularity . My worst symptom is shortness of breath when walking. I have actually stopped many previously enjoyable activities because I know I will get out of breath. Could you give me some encouragement?

David_Van_Wagoner,_PhD: Ablation is often effective, but sometimes requires repeat procedures. The frequency and duration of AF episodes is typically reduced by ablation even when there are occasional recurrent episodes. As AF is often the cause of shortness of breath, there will be many more times during which you are AF-free and more able to participate in the activities that you enjoy.

DannyInKaty:Good afternoon everyone, I’m a 61 year old Caucasian male with persistent AF & a history of heart disease since age 44 (stent in right coronary artery). Though I first experienced AF In 2005 which occurred after drinking a very cold beverage, I received a successful cardioversion after 3 days in the hospital. I noticed some flutters and the occasional skipped beats after that, until having surgery to repair an ascending aortic aneurysm in March of 2009. I had several bouts of AF shortly after my operation, but in all cases rhythm returned to normal with medication. For the next 2 years I did experience some short periods (1-2 days) of AF, but symptoms corrected on their own without medication, once even converted while running in a 5K race. Now I have been in persistent AF since March 2012, only coming out after cardioversion this past Nov. and it only lasted for a week when a drank another cold glass of water.

Because I have an enlarged left atrium, Dr. says I’m not a candidate of the FIRM ablation at this time. Another EP here in the Houston area, recommences an ablation procedure be performed at a major heart institute because of the aneurysm repair. Therefore my questions to you are:

  1. Are there major associated risks with the aneurysm repair other that those commonly affiliated with an ablation?
  2. I prefer to use the most reliable/advanced ablation technique currently available using the 3D technology. Your thoughts please on the type of procedure and any other method you would recommend, preferably not MASE.
  3. After reading several articles on PV cryoablation and consulting with another EP in the Houston Medical Center , I assume that you are still not in favor of this as the preferred procedure to correct my AF?
  4. Is the longer I’m in persistent AF without correction leading to Longstanding Persistent AF and if so, what kind of time period would I be looking at?
  5. What kind of lifestyle can I resume after a successful ablation (and recovery period)? I enjoy the out-of-doors; i.e., running, biking, etc.

Thank you very much, in advance, for your responses and I look forward to the webcast tomorrow.

Walid_Saliba,_MD: 1) the risks are relatively the same; 2) the ablation procedure would be center specific; better technology does not necessarily mean better outcome. Success is related to procedural techniques that are specific to that center; 3) if you have persistent afib it is less likely that cryoablation alone would be successful; 4) not sure of question; 5) if the ablation is successful, you can resume your regular activities within a couple weeks, however, the success of your ablation needs to be taken in context to the size of your LA as this usually reduces such success.

Drshivangi: What is the ideal time interval between 1st and 2nd Cath ablation in Afib patients who had earlier procedure once before and still persist to have Afib symptoms?

Walid_Saliba,_MD: We would recommend at least 4 – 6 months in between procedures.

Drshivangi: I have had one Cath Ablation and now on Tikosyn 125 mg BID. Continue to have Afib episodes at least twice a week and PVCs. What is the next line of treatment ?

Walid_Saliba,_MD: A redo ablation or surgical maze procedure would be the next line of treatment. we would be happy to evaluate you at Cleveland Clinic.

jamesnz: I am now nearly 77 years of age and I have had occurrences of AF since the age of 60 . I bruise very easily and almost bleed some times from just slight bumps to my skin. I have refused so far to take coagulants because of this and worry about the possibility of internal hemorrhaging. What should I do as even aspirin acerbates my bruising ? My cardiologist here in New Zealand does not recommend the ablation procedure because of my age only. As I am reasonably fit otherwise do you think the new procedure of FIRM or the Freezing technique would be permissible in my case ?

I have been free of AF for the last 8 weeks which was rare for me but it has now come back again. I am totally reactive against all antiarrhythmic drugs and barely tolerate for the last 5 years 5mg. of Propranalol 3 – 4 times daily. Too much and I develop ectopic beats which can trigger AF, not enough and I will get AF. Sorry for my rambling but I would dearly like your opinions. James From New Zealand.

Bruce D. Lindsay, M.D.: The guidelines for treatment of atrial fibrillation recommend that patients should undergo ablation procedures to alleviate symptoms, but not to eliminate the need for anticoagulation. The reason is that recurrence rates for atrial fibrillation remain significant after ablation, so the decision to discontinue anticoagulants should be undertaken very cautiously. Another option would be the left atrial appendage closure device which plugs the left atrial appendage and eliminates the long term need for anticoagulation. I am not certain whether this technology is available in New Zealand.

Breakaleg: The Cryoballoon is in its second or third generation and not without impunity. Why is this procedure considered less invasive and who at Cleveland Clinic performs this procedure and why not all the Electrophysiologists?

Bruce D. Lindsay, M.D.: The strongest advocate of the Cryoballoon is the manufacturer. It is by no means less invasive. In fact, the sheath required to insert the Cryoballoon is much larger, which increases certain risks. It is indicated for paroxysmal atrial fibrillation, but not for more advanced persistent atrial fibrillation. There is no evidence that it is more effective than ablation with radiofrequency energy, nor is it safer. Some of the claims about safety have not proven true. Some physicians have adapted it because it makes the procedure easier for them, while others feel the opposite. Several physicians within our group have used the Cryoballoon system and are experienced with it. We are still tracking the long term outcomes before we decide whether it has any advantages. The only indisputable fact is that the Cryoballoon costs more and is associated with higher risk of injury to the phrenic nerve, which controls the diaphragm. Phrenic nerve injuries usually heal within a month or two.

Dr. Mark Niebauer is the member of our group who has the most experience with the Cryoballoon at Cleveland Clinic.

3girls: I am scheduled to have a cryo ablation in the near future.

  • Is this my best choice to stop this problem of a fib?
  • Is an ablation typically a 6 hour procedure?

Bruce D. Lindsay, M.D.: Ablation of atrial fibrillation usually takes about 4-6 hours. The use of the cryoballoon for ablation of atrial fibrillation is largely a matter of physician preference. There is no objective evidence that it is safer or more effective than radiofrequency energy ablation.

DeltaDawn23: Any comments on the new FIRM ablation procedure and the CONFIRM and PRECISE trials?

Bruce D. Lindsay, M.D.: Preliminary results are promising, but further multicenter trials are needed to decide how effective this technology will prove to be.

Atrial Fibrillation Treatment: Surgery – Maze

DeltaDawn23: I am a 67 year old female with Afib, which after 7 years became persistent. I have had 5 cardioversions in 2 years. Norpace CR has kept me in normal sinus rhythm for nearly 2 years, then after 2 cardioversions in December 2012, needed to be increased — I am now taking 150 mg. twice daily for a total of 300 mg. I tried Rhythmol and could not tolerate it.

The Norpace has side effects that are affecting my quality of life. My odds do not seem good with a standard PVI ablation: 50-60%. My regular ep has suggested a mini-maze. I am reluctant to have a larger surgery. Do you have any advice in regard to the 2 procedures?

Do you have any comments on the new FIRM ablation that is being offered?

I suffer from type 2 diabetes and obstructive sleep apnea, both well controlled. I have no significant blockages and my overall health is good. Thank you for this opportunity to submit questions.

Edward_Soltesz,_MD: We are now performing totally thoracoscopic Maze procedures with left atrial appendage occlusions with excellent results. In patients with long-standing persistent atrial fibrillation, the long-term results are excellent, with >90% of patients in sinus rhythm at 12 months without antiarrhythmic drugs. There is no incision, only three small port holes in each side of the chest cavity.

Grammarhodes:I have had a minimally invasive maze operation and 2 ablations. How common is it to develop a-flutter and SVTs following these procedures? If the tachycardia returns, how many more times can they be ablated and what other options are available for me?

Edward_Soltesz,_MD: a-flutter after a mini maze occurs less than 5% of the time but we are usually able to perform a catheter based ablation 6 months to a year after.

Walid_Saliba,_MD: We have performed up to 4 or 5 times after maze procedure.

Horstman:I was just reading the transcript of the Oct. 2012 Chat on AFib. One comment really caught my attention. Please discuss the status of the new device currently being implanted in the left atrial appendage that may lessen the occurrence of stroke in individuals with persistent AFib. Thanks for your response!

Edward_Soltesz,_MD: We can now place a small soft clip on the left atrial appendage on the beating heart using a small camera through two tiny stab incisions in the left chest. Long-term data on this procedure is still forthcoming but should prove to be good at stroke reduction.

Jstrap: I am 70 yo male. valve repair 1998 (Dr Cosgrove) without Maze. Paroxsymal afib since 2010. Present meds coumadin, multaq 400 bid, toprol 50 bid, pacemaker needed after rf ablation for atrial flutter 2011 when developed pulse of 30. Pacemaker printout shows afib/flutter of 280-300 bpm 30% of time but no Sx, pulse 65-70, refused amiodarone. despite no symptoms cardiologists suggests ablation possibly FIRMablation since things will get progressively worse. Thank you for your advice.

Bruce D. Lindsay, M.D.: The main reason to perform an ablation is to alleviate symptoms. If you do not have any symptoms, ablation may not be necessary. While it is true that atrial fibrillation may progress, many patients tolerate it well and do not require ablation. It is difficult for me to make this assessment complete review of your records. The preliminary results of the FIRM trial are promising, but it is premature to advocate this approach. Further trials are planned to assess the long term efficacy of the FIRM approach.

A’amina: Could you still do the totally thoracoscopic Maze procedure if someone has had a his-bundle ablation and has a pacemaker?

Edward Soltesz MD: Yes. A totally thoracoscopic Maze is usually possible for most patients unless they have had prior open heart surgery.

Left Atrial Appendage Procedure

SCOTTSDALE:The risks associated with A-FIB “ablation” and the other techniques seem to be about the same as those of the “Lariat” procedure. Since the Lariat procedure greatly reduces the chances of Blood clot, why is it not a better option than only reducing A-FIB and still using blood thinners, especially for those patients not able to use blood thinners?

Walid_Saliba,_MD: The Lariat procedure addresses the risk of stroke but does not address the occurrence of atrial fibrillation. Because pts with atrial fibrillation do not go away with Lariat procedure.

Horstmann:Thanks for letting me know of your technical difficulties… I just logged on and thought I was experiencing “Groundhog Day” over and over 🙂 In case my question I submitted last evening did not go through, I hope you don’t mind if I repeat it: Read the Oct.2012 AFib transcript last evening and was intrigued by the new device CC is using, an implant in the left atrial appendage for individuals with persistent AFib. What is the status of this device? Has it been approved by the FDA yet, and do you accept patients for the clinical trials of this device? Thanks!

Bruce D. Lindsay, M.D.: The Watchman device, which occludes the left atrial appendage, has been through extensive trials and appears to be as effective as warfarin for stroke prevention. The trial has been extended and we are performing insertion of the Watchman at Cleveland Clinic. The FDA is still reviewing the data and has not made a decision about approval. You could contact Dr. Walid Saliba or Dr. Oussama Wazni in the Electrophysiology Section at Cleveland Clinic if you want to be considered for this approach. They are the physicians in our group who are leading this effort.

Fran: How many Lariat Procedures has the Cleveland Clinic done?

Walid_Saliba,_MD: None so far. There is no scientific evidence at this time that exclusion of the left atrial appendage using the lariat system does indeed reduce the risk of stroke. Alternatively there is enough evidence (and we are currently part of a study) that occlusion of the left atrial appendage with a simpler procedure using the Watchman device does reduce the stroke and long term mortality in patients with atrial fibrillation when compared with taking Coumadin. However, we are certified in the lariat procedure which is ideal for patients who are unable to take Coumadin and plan to perform more of these procedures in the future.


Jplas3: I have cardiac TTR wild type amyloidosis that has resulted in the ventricular wall being about 20. Originally it caused afib which was corrected by cardioversion and now controlled by amiodarone. Recently I have developed left bundle branch block and have been told that I am a candidate for a biventricular pacemaker. My question is: Will the pacemaker extend my life or does it only serve to make me feel better? I am 79 and my only symptom is tiredness with minimum effort. Thanks.

Walid_Saliba,_MD: The main role of the pacemaker is to provide symptom relief.

Sinus Node Dysfunction

briand:I am 43 year old male and I recently was ablated successfully for persistent Afib. I now have sinus node dysfunction that will probably require a pacemaker. Does Afib cause sinus node dysfunction and will sinus node dysfunction cause my Afib to reoccur? My cardiologist also wants to repair an atrial septal defect with a catheter. Will repairing the ASD prevent future ablations if there is a re-occurrence of Afib in the future? I have read that an ASD can sometimes cause Afib, but I have also read that the closure of an ASD can also lead to Afib.

Walid_Saliba,_MD: Afib can cause sinus node dysfunction. Sinus node function can improve after successful ablation. Repairing an ASD does not necessarily prevent future ablation. We have had ample experience with this. If an ASD is left untreated, if large, it can lead to enlargement of the atria and precipitate atrial fibrillation occurrence.


misslottie:With occasional AFIB and no other heart problems, can you safely exercise if you are taking a drug like Cardizem ?

David_Van_Wagoner,_PhD: Yes, AF does not preclude exercise. You should discuss the need for anticoagulation with your cardiologist.

Cmiller05: Personal back ground: I am 60 years old, diagnosed with A-Fib in December 2010. Hindsight being 20-20, I had symptoms for 2 years before diagnosis. Started as paroxysmal A-fib and has progressed to persistent A-fib. Currently have a Holter Monitor again, so my doctor can verify that I have persistent A-fib. Current drugs are Multaq, Pradaxa, Livalo, Zetia, Lovaza and just added Bystolic to help slow my heart down when I workout. (see Questions below). I guess I can be considered asymptomatic except when I exercise. My preferred exercise is swimming. I was able to train at a competitive level until about 2 years ago and have steadily decreased my training level about 40%.

Questions: Will I have to continue to decrease my training level the longer I am affected by A-fib? Side effects of training to hard are numbness just in my legs, or both legs and arms, (very distributing at when both arms and legs go numb), rapid heart rate for hours after a workout, and just not feeling correct after a hard workout. If I decide on having an ablation procedure could I go back to the very high level of training I was doing before I slowed down? I added dry land training (weight lifting) and for now I have no side effects from this type of exercise, but will that also change if my A-fib continues to get worse?

Walid_Saliba,_MD: Your exercise would decrease probably due to secondary deconditioning. Following an ablation, if successful, you should be able to resume your previous training regimen.

Stevedon41: Was a jogger with hypertension for 40 yrs. Out of nowhere has 1st a-fib on Sept. 08. Had cardio version for normal rhythm Had approx. 3 more episodes over the following 2 years ( all returned to normal on their own after a few hours. Am considered paroxysmal . Had an ablation at the Clinic in July 11. Have had no issues since !!!!! Consider the ablation a success. I walk hard but am afraid to jog ( 72 years old in good health ). Miss jogging but is it worth it ?? Afraid I might induce an a-fib episode. What tests would I need if I seriously wanted to start jogging again. Thank you.

Walid_Saliba,_MD: Go back to jogging.

Socal20: I am a 69 year old female with a very high level of physical fitness, no CHAD, negatives other than sex and age (but have mitral valve prolapse) and experiencing no symptoms whatsoever from my afib. My LVEF is 70%. My resting heart rate is between 50 and 60 (but can get as low as 40) but I’m concerned about going to higher rates with vigorous exercise. By spinning, I usually go to 150 to 160 bpm when standing but back off when I see brief, short jumps, to 180. On Sundays we do a fast climbing hike where my rate goes to 170 to 175. I am never exhausted by these activities and heart rate recovers very quickly. Am I placing myself in danger when I go to higher heart rates with these (and other) activities? I take only a baby aspirin as I have strong resistance on going to coumadin. Our diet is very heavy on greens which would make controlling the level while traveling very difficult.

David_Van_Wagoner,_PhD: Mitral valve prolapse increases the pressure in the left atrium and is a significant risk factor left atrial enlargement and development of AF. It sounds as though you have a high level of fitness, but your age and mitral valve disease are significant issues. There are newer anticoagulants that you may wish to discuss with your cardiologist that are less onerous than Coumadin but more effective than aspirin.

Afibprison:Good question, I always felt my previous highly competitive running in college caused my afib – too much stretching of the Atria. I am unable to exercise at all, otherwise I go directly into afib. So I am worried about my lack of activity.

David_Van_Wagoner,_PhD: AF does not preclude exercise. If you are out of shape, you may seek a gentle exercise regimen to slowly begin to get back into a higher level of fitness. Make sure that you discuss anticoagulant issues with your cardiologist. An endocardial or surgical ablation may help to prevent AF and enable you to pursue a more aggressive exercise regimen.

Az1435t: I read several article and heard some conversations about afib occurring in marathoners or people who tend to exercise more than “normal”…..can you comment? I have been a runner or speed walker for 40 years, and in the past 5 years have been diagnosed with a fib/flutter and ablated 3 times.

David_Van_Wagoner,_PhD: You do not state your age. The incidence of AF is strongly age-related, going up steeply after age 65. As you suggest, there is some evidence for increased risk of AF in marathon runners. This may be due to changes in atrial size, structure (fibrosis) and nerve activity. In general, regular exercise is beneficial for cardiac health. However, in non-elite athletes, there is some risk of cardiac injury during events such as marathons. Current studies are underway to evaluate this in greater detail.

Treatment at Cleveland Clinic

chaz1315: I’m a 55 year old male. Have been stented 8 times from age 39 to 54. The last stents done in January this year (kissing balloon) to clean two blockages resulted in a thrombosis three days later causing two heart attacks severe leaving me with an EF of 15%. I underwent emergency bypass surgery January 22nd with a single cabg. I then was instructed to wear a portable zoll life vest to see if my EF would increase. During that time I have been cardioverted three times with afib 220-240 bpm. Lucky I guess I was wearing the vest. Lat week I underwent surgery for a single lead pacemaker defibrillator. My EF right now is about 30% and my cardiologist seems to think I may not climb any higher. I am in cardiac rehab (prior to pacemaker) and tolerating moderate exercise pretty well. I have a lot of PVC’s and short bursts of Afib which makes me nervous. I want to explore my options and I may want to come to your Medical Center.

Walid_Saliba,_MD: We would be more than happy to evaluate you. Please contact our nurse line for more information: or you can reach Cardiology Appointments directly at 800-223-2273, extension 46697.

Josephine:Must I have a consultation before scheduling a procedure? If I choose to have one of the clinic physicians “shock” my heart and the rhythm does not change, can you do a procedure within the next day or two or is there a waiting period?

Bruce D. Lindsay, M.D.: You should meet with a cardiac electrophysiologist before undergoing a procedure so that we have a detailed understanding of your problems and can make the right decision. For those who live at a distance, one option is to send appropriate records for us to review. If it appears that you may be a candidate for a procedure, you could come for a visit and potentially undergo the procedure the next day if indicated.

Hoagie0013: I have had 2 ablations since 2001. The afib is much better than 2001 but I still get episode frequently. I am scheduled to have a third ablation ala this month. I have confidence in my ep but maybe a new set of eyes could see my problem better. if I came to Cleveland clinic to be examined how would I go about it, and how long would I have to stay for whatever procedure you think I should get if any. Also can you give me name of good EP in Philadelphia, New York or New Jersey area.

Dr. Edward Soltesz: With two failed ablations, you may wish to consider a totally thoracoscopic Maze procedure.

NicDze:Questions: Of the 1200 heart oblations done at Cleveland Clinic in Cleveland how many were pulmonary vein oblations? How many had one of the risks come to fruition? How many had a:

  • Stroke
  • Heart attack
  • Needed emergency heart surgery
  • A leaking blood vessel
  • Nerve damage that caused paralysis of the diaphragm
  • Pericarditis
  • Cardiac tamponade
  • Atrio-esophageal fistula
  • Death

I have persistent AFib and will probably need at least two or three oblations. I have BCBS Federal Employee health insurance so it does not matter where I have the oblation performed. Since three trips to Ohio can get expensive; please also provide me the above statistics for Cleveland Clinic in Weston Florida?

Bruce D. Lindsay, M.D.: On the main campus in Cleveland, we performed about 1500 ablation procedures in 2012 and about 810 were for atrial fibrillation. Over the past 5 years we have performed more than 4000 ablation procedures for atrial fibrillation. There have been 3 strokes. No patients required emergency surgery. There were no deaths, heart attacks or atrio-esophageal fistulas. The incidence of cardiac tamponade is about 1-2%, which is related to perforation (puncture) of the wall of the left atrium. These were all treated successfully by draining the blood with a needle and did not require surgery. I do not have data pertaining to the incidence of pericarditis, but estimate less than 1%. I am not certain what you mean by a leaking blood vessel. You may be referring to hematomas at the femoral insertion site, which is less than 1% in our experience. We find that use of ultrasound to gain access to the veins has reduced the incidence of hematomas. The risk of phrenic nerve injury causing paralysis depends on whether the ablation is performed with radiofrequency energy (0 in the past 4000 cases) or the cryoablation balloon, which carries a risk of 5-10%. In those cases, the injury usually resolves within a month. I have no data for Weston.


If you need more information, contact us or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.

Mellanie_True_Hills: On behalf of the afib patient community, I’d like to thank all the doctors during the chat and after: Dr. Saliba, Dr. Soltesz, Dr. Van Wagoner, Dr. Lindsay, Dr. Wazni and Dr. Bhargava for answering our questions. See: for more information.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Please note that the comments above are the opinions of the Cleveland Clinic doctors, and if you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.

Reprinted with the permission of the Cleveland Clinic.

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