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Get in Rhythm. Stay in Rhythm.® Atrial Fibrillation Patient Conference October 30 - November 1, 2020, in Dallas, TX
Get in Rhythm. Stay in Rhythm.® Atrial Fibrillation Patient Conference October 30 - November 1, 2020, in Dallas, TX

Transcript of Afib Chat with Cleveland Clinic Atrial Fibrillation Experts on October 30, 2012

Your afib questions were answered by Dr. Walid Saliba, Dr. Sergio Pinski, and Dr. David Van Wagoner of the Cleveland Clinic

November 12, 2012

  • Here is the transcript of our October 30 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 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. Sergio Pinski and Dr. David Van Wagoner from the Cleveland Clinic and Mellanie True Hills, Founder and CEO of StopAfib.org, answered your questions about atrial fibrillation.

The Atrial Fibrillation Web Chat had to be cancelled as the chat functionality was not working properly and the hosting company was out of the office due to Hurricane Sandy. Those who were registered were invited to submit questions that were answered offline. The transcript appears below.


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 Fibrillation

Katie: Can Afib ever go back to being normal by itself just got diagnosed in physical on EKG by accident cannot feel it on pradaxa and digoxin and hate I'm 73 and read all sorts of things like shorter life and dementia because of it. It scares me doctor not fond of doing procedures.

Dr. Saliba: It is very unlikely that atrial fibrillation would go away by itself. While sometimes, atrial fibrillation can come and go by itself; the usual natural history of the disease is progression to a more persistent form for atrial fibrillation. Because you do not have significant symptoms, it is reasonable to treat you with Pradaxa and controlling your heart rate, however, it is also reasonable to give you a chance at restoring normal sinus rhythm and see how long you are able to maintain normal rhythm. The aggressiveness of the therapy down the road will be dictated by whether you feel better in normal rhythm and how long are you able to maintain it. We do not know if atrial fibrillation really changes longevity and whether putting you back in normal rhythm would change your risk of developing dementia or heart failure. However, early studies are underway to answer these questions.

Diana McNeil: My brother is 49 years old & was diagnosed with Atrial Fibrillation in his early 40's. He has been shocked into a regular rhythm a couple of times & is on medication & anticoagulants. While I had begun to experience heart palpitations approximately 7 years ago, it wasn't until the past few years I began to experience multiple symptoms. Unfortunately, due to other health issues, most symptoms were excused away. It wasn't until about one month ago (when I suffered a serious attack), that I was definitely diagnosed with Atrial Fibrillation. Due to the length of time I had been experiencing an attack (more on than off for 10 days); they were not able to shock my heart into a regular rhythm. I am currently on Diltiazem (60 mgs 4 times a day).

  1. As both my brother & I have been diagnosed with Atrial Fibrillation... what are the chances that this is hereditary in origin?
  2. As I have been living with many symptoms for approximately 2 years & was in an A Fib attack (on and off) for approx 10 days before being diagnosed & treated, what are the chances that the cardiologist will be able to successfully treat me long term?
  3. What are my chances that I can be cured from A Fib?

Thank you for taking the time to read my email & respond.

Dr. Saliba: Atrial fibrillation can be a manifestation and the product of several diseases. Clearly, some atrial fibrillation have genetic predisposition. There have been some genes related to atrial fibrillation, but not all patients with atrial fibrillation have a clear cut genetic etiology for their disease. Furthermore, genetic based therapy does not exist at this point for atrial fibrillation. Treatment of your atrial fibrillation depends on the amount of symptoms you are having and how persistent the atrial fibrillation is. If you have significant symptoms, then despite the duration of the atrial fibrillation, it would be reasonable to attempt to maintain normal rhythm with suppressive medical therapy initially and subsequently, potentially with ablation. We cannot talk about a cure for atrial fibrillation; mainly, because we do not understand the true mechanism of the disease. Therefore, the goal of atrial fibrillation is to minimize, rather than eliminate the occurrence of atrial fibrillation as much as possible to a point that is satisfactory to the patient. The idea is that if you have symptoms related to atrial fibrillation and you have a lot of atrial fibrillation, minimizing the occurrence of atrial fibrillation will minimize your symptoms to an acceptable level. It is still possible to reduce the burden of your atrial fibrillation to the satisfactory level despite the duration of your atrial fibrillation especially if you are still having on an off episodes rather than a persistent form of the disease.

Dr. Van Wagoner: Diana — in response to your first question, when 2 siblings have AF, the odds are quite high that there is a hereditary / genetic component contributing to AF risk. It has been estimated that if one parent has AF, the children have a 1.7x increased risk of AF. If both parents have AF, the children have about a 5x increased risk of AF. Ongoing studies have documented a number of regions that are associated with AF risk (P. T. Ellinor, et al. Meta-analysis identifies six new susceptibility loci for atrial fibrillation. Nat Genet 44 (6):670-675, 2012). While significant progress is being made and it is a long-term goal to use the genetic information to guide personalized care of individual patients, we are not yet there.

Tom K: 75 years old. In June, 2011 had a significant AFib episode. Catheterization showed no obstruction or coronary disease but a very significant myocardial bridge. A pacemaker was installed, taking warfarin and 80 mg sotalol twice a day. The AFib burden until recently has been around 10% with 80 -95 heart rate when in AFib. Over the past few months the AFib episodes started to significantly increase and now I am in AFib essentially all the time, still about the same heart rate. Have compensated cirrhosis that limits the anti-arrhythmic drugs that I can take. What course of action would you recommend? What is the long range impact of being in AFib all the time?

Dr. Pinski: The main priority would be to prevent stroke, in his case with warfarin or another anticoagulant. Second priority - alleviate symptoms that he does not mention. If he is bothered by the atrial fibrillation it may be worthwhile a trial of dofetilide (which is not contraindicated with compensated cirrhosis). If atrial fibrillation becomes permanent despite dofetilide and the ventricular response still fast, one could consider AV nodal ablation down the road, as a pacemaker is already in place.

Eleanor: I use an Omron HEM-7901 T blood pressure monitor which allows me to print out graphs of all my readings. At least 50% of the readings show an irregular heartbeat. My doctor says this is nothing to worry about. But I'm wondering if an irregular heartbeat can have some correlation with my afib? Any other information about irregular heartbeats would be appreciated. Thanks.

Dr. Saliba: Irregular heartbeats can result from atrial fibrillation, but also can result from extra beats from the upper or lower chamber of the heart despite the fact that you might be in normal rhythm. The only way to find out the nature of the irregular heart beat is to perform an EKG or monitor that would allow your physician to make the correlation of the irregularity with nature of the abnormality in your heart rhythm. Based on that, specific therapy can be given.

Victor P: I have A-Fib. My condition is as follows: Have enlarged atrium (per echo test) 78yrs old diagnosed with AFRIB 3 yrs ago I had bypass surgery in 1993 with five by passes Now have 6 stents ( mostly in original by-pass grafts) What can be done to correct my A-fib.

Dr. Pinski: We need more information. Is the atrial fibrillation permanent or on- and off? Are you on a blood thinner? Do you have symptoms related to the atrial fibrillation? What is the rate during sinus rhythm and atrial fibrillation? Assuming that something needs to be done to correct your case of atrial fibrillation, a trial of an antiarrhythmic drug, sotalol or dofetilide would be the first to try.

Raymond Sousa In the introduction to the A-fib session tomorrow, Mellanie mentioned "life threatening irregular heart beat" as a medical condition associated with A-fib. This is the first time I have seen a reference of "life threatening" with A-fib medical condition. Can you expound to this reference? Under what conditions is A-fib considered life threatening? I have persistent A-fib and am wondering about the possible connection.

Dr. Saliba: While atrial fibrillation by itself is not life-threatening and its burden is mainly symptomatic, the associated complications that occur with atrial fibrillation might be. Mainly, the risk of stroke carries with it a certain amount of mortality. From that stand point, it has been reported that strokes that result from atrial fibrillation are usually more severe and result in a higher mortality compared to strokes that occur from other etiologies. Therefore, the treatment of atrial fibrillation consists predominately of reducing the symptoms and more importantly of reducing of the risk for embolization and stroke formation.

Dr. Van Wagoner: When discussing “life-threatening” heart rhythms, one usually thinks about ventricular fibrillation (VF), a condition in which function of the ventricle (the main pumping chamber of the heart) deteriorates within minutes, typically leading to death within 15 minutes of persistent VF. While the electrical properties of AF and VF are related, AF is not acutely life-threatening in the same manner as VF. However, AF significantly increases the risk of clot formation and stroke. Stroke can be life threatening or lead to significant disability. In addition, AF can lead to increased ventricular rate and decreased ventricular pump function. Both of these factors increase the risk of developing heart failure. Thus, due to the risks associated with stroke and heart failure, Mellanie is correct to say that AF can be life-threatening, but this is not typically a risk associated with the acute onset of AF.

Chris M: I have several questions

1.  Aside from working at a large heart center, performing a large number of ablations each year and having a "good" success rate, what makes someone a good EP? E.g. good hand eye coordination, inquisitive mind, knowledge of physics, computers, electronics, medical school, residency or specialty training, etc. I have heard other physicians refer to EPs as "spooky" but in a good way.

Dr. Pinski: A good EP is first a good doctor. Second, has the capacity to continuously learn from his or her experience and that of the others. Third, professes realistic optimism. I don’t think that a practicing (i.e. not in research) EP has to be an engineering, computer, or physics genius. You don’t need to know the inner workings of the telephone or the phone company network to be a good conversationalist on the phone.

Chris M: 2. How many ablations a year should a competent EP perform?

Dr. Pinski: There is no strict number. Once an EP is over the learning curve, a huge number of ablations are not required to maintain the skill. If the whole team, including lab staff, anesthesiologists and nurses are stable, 2 or 3 a week should suffice.

Chris M: 3. What is your opinion of the FIRM ablation and why do you hold that opinion?

Dr. Pinski: I do not have personal experience with FIRM ablation and I am eager to see more studies coming out in the future. For now, I am remaining skeptical that it is a “magic bullet”. In my experience and that of others, termination of atrial fibrillation during ablation has not been a predictor of long term success. Furthermore, when patients with recurrent atrial fibrillation undergo second ablation we almost invariably find reconnection of several pulmonary veins. Re-isolation of the veins generally results in long term success. My hopes in atrial fibrillation ablation reside in developing techniques for more reliable and durable pulmonary vein isolation.

Chris M: 4. Is there an outside limit on the number of cardiac ablation procedures performed on one individual? If the answer is "it depends," upon what does any such limit depend? If the amounts of radiation or atrial scarring are factors can you explain why and to what extent they impact the decision on whether or not to perform multiple procedures? What is "atrial mechanical dysfunction" and how does it impact a decision as to whether to perform multiple ablations?

Dr. Pinski: Of course it depends on many factors, such as the clinical impact of atrial fibrillation, age, anatomical substrate, and findings on previous ablations. In my practice, I have had a few patients with 5 total ablations (but not all with me). Generally in those cases, earlier ablations resulted in elimination of atrial fibrillation and the last couple of procedures were aimed at eliminating focal atrial tachycardias.

Chris M: 5. What is dofetilide/tikosyn and how does it impact post ablation care and/or sinus rhythm?

Dr. Pinski: Dofetilide is an antiarrhythmic agent that is safe and effective in the treatment of persistent atrial fibrillation, including patients with structural heart disease. We think it is also useful in controlling some regular atrial tachycardias that can appear early after ablation, although to my knowledge this has not been studied extensively. We use it very often.

Chris M: 6. Is there anything that can be done to alleviate patient anxiety immediately post-ablation when, in the recovery room, a patient is subjected to constant beeping of the heart monitor and can see the posted heart rate? For example it can be stressful as you listen for an inconsistent beep or see ones heart rate increase. It would seem less stressful if the patient could simply relax without all the chaos resulting from hearing and seeing the constant monitoring. Any comments?

Dr. Pinski: Education before ablation and a reassuring recovery room staff should take care of this. It has not been a problem in our experience. Furthermore, because we use general anesthesia, patients often have amnesia for the events immediately after the procedure.

Chris M: 7. Are then any cardiologists or other practitioners who can explain all the various realistic options for someone with afib? E.g. meds, ablation, FIRM ablation, maze, mini-maze, etc. It seems most cardiologists are frustrated with afib because the patients are hard to deal with, meds are not particularly effective and have bad side effects, and don't totally understand the nuances of ablation or surgical options. Where would you find these practitioners?

Dr. Pinski: In general, EP doctors are best suited to guide a patient through the complexities of atrial fibrillation management. There are some outstanding clinical cardiologists that can also do it, but they may be hard to find.

Chris M: 8. From an EP's standpoint with respect to an ablation what is the significance of atrial flutter vs... afib? E.g. is it necessary to do the left chamber of someone who is in flutter?

Dr. Pinski: Currently, We perform isolated cavotricuspid isthmus ablation for atrial flutter much less frequently. Many patients with atrial flutter also have (or will have) atrial fibrillation.

Chris M: 9. Is there anything new on the horizon regarding the treatment of afib? E.g. new techniques, new instruments, new meds.

Dr. Pinski: Atrial fibrillation ablation is a somewhat mature field by now. I expect incremental improvements and not a “revolution” in the next few years.

Chris M: Please convey my gratitude to the physicians who answer these questions. Thank you.

Nick D: We have a few questions-a little background if we may. My father is 81 years of age-within the last year & a half, he has suffered (4) TIA events with one of them causing him to be in a unresponsive state (Encephalopathy?) for (2) days. Both his cardiologist & neurologist are concerned about Atrial Fibrillation as a possible cause. His medications include Plaviix-75 mg, Crestor-5mg, Lisinopril-10 mg,& Amlodipine 2.5 mg. He also has encountered weakness and fatigue the better part of the last (2) years (my own opinion is that he is deconditioned because of a decrease in physical activity over this same two year period).He has been experiencing lightheadedness the last 4 months or so, but that occurs less frequently, if at all, with increasing water intake, more physical activity,& increased salt intake somewhat as well as some common sense practices like getting up slowly from sitting/lying positions. Incidentally, kidney testing, blood testing, etc. are coming in well.

Dad has worn the Holter monitor (with accompanying mobile event recorder) by Cardionet for (28) days-testing revealed no Atrial Fibrillation. Our blood pressure checks at home show Dad's pulse rate within the normal range-50-100 beats/minute.

Doctors are now suggesting that Dad try an implantable loop recorder because the (28) day window may have been insufficient to detect Atrial Fibrillation. Dad has a Right Hip Replacement as of 10/27/2011-we are extremely concerned about infection with his new hardware.

In your opinion, how common is it for A Fib to reveal itself outside of the 28 day window?

What are the other risks associated with this device/procedure i.e. internal bleeding, infection, & so on?

Why should we believe there is A Fib present when testing reveals otherwise?

Many thanks for this very valuable service-we appreciate any help we can receive concerning this matter and we look forward to your response.

Dr. Saliba: Your dad has suffered already for TIA events. While it is very possible that atrial fibrillation might have contributed to these events, one would expect a higher burden of atrial fibrillation that would have been caught on 30 day monitoring. Nevertheless, in view of his age, it is still possible that atrial fibrillation is contributing to his symptoms and if found, the only change in therapy would be the addition of full anticoagulation. An implantable loop recorder is a relatively safe procedure with minimal risk of infection and might prove to be useful in this situation. I have to assure that further workup including carotid ultrasound and imaging of the aortic arch did not show any possible etiologies for your dads TIA events. As you know, while atrial fibrillation is one of the main risks for a stroke in the elderly population (up to 25%), there are other reasons why patients in this age group develop a stroke including the possibility of vascular disease, carotid disease, among others. Your dad is on Plavix. The only difference, the finding of atrial fibrillation would make, would be the institution of full anticoagulation. Therefore, the choice comes down to proceeding with empiric anticoagulation with its associated risk of bleeding –vs.- continuation of further work up to confirm the presence of atrial fibrillation (or not) and accordingly decide on further anticoagulation issues.

Dr. Van Wagoner: While AF is a common and important cause of stroke and TIA, it is not the only cause. Surgery of any type can lead to a temporary increase of inflammatory cells and cytokines that injure blood vessels and increase the risk of clot formation. It is possible that the TIA events are related to inflammatory changes associated with the hip replacement. Given your father’s age, it is also possible that occasional episodes of AF have occurred (and may recur).

Bill O: Several Questions: 1. Are there any identifiable causes of AF? I have paroxysmal AF. I've had 6 episodes that lasted over 1 hour in past 10 years; over 50% were when I was taking steroids for sinus infections. The others occurred last year when I lost 40 lbs. and my BP was low (below 100/60). It seems to me that anything that increases my HR appreciably will trigger an episode. I also have a pacemaker for tachy-brady syndrome.

Dr. Pinski: There are a few direct causes of atrial fibrillation, but many risk factors and potential triggers. All the things you mention could be consider triggers or risk factors. Most patients with pacemakers with sinus node dysfunction have atrial fibrosis that can also predispose of atrial fibrillation.

Dr. Van Wagoner: Inflammation is a primary cause of atrial fibrosis, and this can lead both to sinus node dysfunction and increased risk of AF. While you might expect anti-inflammatory drugs to uniformly reduce the incidence of AF, high dose steroid therapy has been shown to increase risk of AF, probably due to changes in the expression of ion channels that affect atrial electrical activity. Relevant references with links to PubMed are listed below.

M. K. Chung, D. O. Martin, O. Wazni, A. Kanderian, D. Sprecher, C. A. Carnes, J. A. Bauer, P. J. Tchou, M. Niebauer, A. Natale, and D. R. Van Wagoner. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circ. 104:2886-2891, 2001. PubMed

C. S. van der Hooft, J. Heeringa, G. G. Brusselle, A. Hofman, J. C. Witteman, J. H. Kingma, M. C. Sturkenboom, and B. H. Stricker. Corticosteroids and the risk of atrial fibrillation. Arch.Intern.Med. 166 (9):1016-1020, 2006. PubMed

Bill O: 2: If there are identifiable causes, which treatment modality would likely eliminate the episodes?

Dr. Pinski: In the absence of a direct single cause, prevention of atrial fibrillation is based on management of upstream risk factors (high blood pressure, sleep apnea, etc) and elimination of triggers (such as alcohol). When these measures do not suffice, one resorts to an antiarrhythmic agent or ablation.

Bill O: 3. The newer anticoagulants seem to cause hematomas from simple bumps against something. How can these drugs be better managed?

Dr. Pinski: The newer anticoagulants (dabigatran, rivaroxaban) have demonstrated in controlled studies to be safe and have a risk of serious life-threatening bleeding equal or lower than warfarin or aspirin.

Bill O: 4. Studies show that by taking anticoagulants reduces one's risk of stroke to about 1%, taking aspirin reduces stroke risk to about 4%, but the risk of hemorrhagic stroke is about 2.5% by taking the anticoagulants. Are the relative risks worth taking anticoagulants over ASA?

Dr. Pinski: In patients with atrial fibrillation at risk of stroke, anticoagulants are clearly superior to aspirin and should be prescribed.

Bill O: 5. During every episode of AF recently, I've taken a 10mg diazepam and the episodes subsided within a short time period, always before I could get to the cardiologist's office or hospital for cardioversion. How does this medication work, if it is the critical med, to correct AF?

Dr. Pinski: Many studies have shown that 90% of episodes of acute atrial fibrillation terminate within 24 hours with a placebo (i.e., an inert drug). In your case, Valium may help you to reduce the anxiety until the episode terminates on itself. If you really want to know, you could conduct an n-of -1 blinded randomized study. You would need the cooperation of your physician and pharmacist to produce a placebo that looks identical to your diazepam and to generate a random allocation schedule. After you have had many episodes treated with diazepam or placebo you could un-blind the results and conclude if diazepam speeded up conversion. I doubt this is worth the effort.

Dr. Van Wagoner: AF and other arrhythmias can be triggered by sympathetic nerve activity. Diazepam has been shown to improve heart rate variability and reduce sympathetic nerve activity. T. Ikeda, M. Doi, K. Morita, and K. Ikeda. Effects of midazolam and diazepam as premedication on heart rate variability in surgical patients. Br.J Anaesth. 73 (4):479-483, 1994. PubMed

Bill O: Thank you very much for offering this valuable service. If any answers to my questions have clinical research citations, I will appreciate that reference.

Robert M: My question re Afib is that I have had afib for 25 years. Is there any treatment at this point that might get me back to normal?

Dr. Saliba: If you have had atrial fibrillation persistently for 25 years, then it is less likely that suppressive medical therapy or ablation or even surgery, would lead to any long term maintenance of normal rhythm. If on the other hand, you have had on and off atrial fibrillation and you are still experiencing that same pattern, it is then possible to administer such therapy. Obviously, the indication to proceed with any therapy would be the burden of the atrial fibrillation in terms of how much symptoms is it causing you and how much limitation to your daily activity that you are having from this arrhythmia. Otherwise, provided that you have good rate control and adequately anticoagulated, if you are asymptomatic, then there is no need to proceed with any further therapy. Obviously, there other factors that come into play such as your age and the presence of any associated cardiac disease which would influence the aggressiveness of the therapy at this point.

jimm: how is irregular heartbeat differentiated from AFIB? THANK YOU

Dr. Pinksi: An ECG at the time of the abnormality is necessary to diagnose atrial fibrillation and differentiate it from other cases of an irregular heartbeat such as atrial or ventricular premature contractions.

Melinda F: I am female, 68, Lone Afib, had 1st ablation July 11, scheduled 2nd ablation Nov 12th, on Pradaxa 150 mg 2x/day since June; added Sotalol 80 mg 2x/day after 1st ablation. Digestive discomfort. Since 1st procedure, in and out of rhythm (day or two either way); Recently, mostly out. Several questions:

  1. Does Afib "spread"?
  2. A Cleveland Clinic transcript said Afib affected by exercise, eating, drinking, hiccupping, etc. Is it also positional? Once "cured", will these still provoke Afib episodes?
  3. Day of surgery: no food or drink after midnight. Pradaxa & Sotalol due that A.M. Take couple mouthfuls plain yogurt to prevent the heartburn? Nexium? What can I do?
  4. Why is it ok for me to swallow the glop for the trans - esophageal Echo so close to surgery?
  5. If out of rhythm mostly constantly prior to 2nd ablation Nov 12th, need cardioversion?
  6. What about Renal Artery Denervation?

Dr. Saliba: Atrial fibrillation is a progressive disease. The usual natural history is more episodes of atrial fibrillation until it becomes persistent. Sometimes we have seen recurrence of atrial fibrillation several years after a successful ablation. The aim of an ablation is to try to minimize the occurrence of atrial fibrillation and give you long periods of normal sinus rhythm. It is difficult to say that we are actually curing atrial fibrillation per se. On the day of your surgery, you should not take any food or drink after midnight. Physicians differ in whether they want you to take Pradaxa and/or Sotalol the morning of the procedure and that would depend on your physician performing the ablation. I would definitely not eat any plain yogurt the morning of the procedure. While your doctors might ask you to swallow the TEE, it is not the swallowing process that is the problem at the time of the surgery, but we do not like to perform the procedure on a full stomach as you might experience some regurgitation with aspiration in your lungs of the content of your stomach. Your doctor will perform a cardioversion at the time of the ablation if the ablation is not able to restore normal rhythm. Therefore, a separate cardioversion is not needed.

Your question regarding renal artery denervation is interesting. There are no true studies at this point in time looking at concomitant renal denervation in conjunction with ablation, but I am sure over the next couple of years, such studies will be emerging.

Dr. Van Wagoner: The vagus nerve is part of the autonomic nervous system that is responsible for controlling breathing, digestion, and slowing heart rate. Holding your breath (or swallowing, eating, etc.) can all increase vagal nerve activity and sometimes can provoke AF episodes. Ablation procedures often decrease the influence of autonomic nerve activity on the atria, and would likely decrease – but probably not eliminate – the effects of these nerves.

BandBH: My grandmother had heart surgery for some sort of arrhythmia about 50 years ago (not at the clinic) and died because the doctors could not help her to regain her heart rhythm on the table while she was under anesthetic and she began to fibrillate. I know little else about her condition, but here is my question. My 18 year old, otherwise healthy daughter has recently been diagnosed with hyperactive thyroid and has a t3 of 1.89. She is scheduled for surgery in December and her local endocrinologist is not concerned about anesthesia at her current thyroid level. I am wondering if my grandmother might have had an undiagnosed thyroid condition that may have caused a thyroid storm or weakened her heart. Would you have concerns about operating on a patient with this level of hyperactivity? She has noticed some palpitations and shortness of breath at times when walking up hills (she is normal weight and has history of normal to active routines).

Dr. Saliba: We do not have enough information to answer this question in an accurate fashion. However, ventricular fibrillation, rather than atrial fibrillation is most probably the reason of your grandmother’s problem when she was under anesthesia. In regard to your daughter, the anesthesiologists are usually well aware of the problems that are associated with hyperthyroid states and you might want to ask them these questions specifically. It is less likely that there is any relation between your grandmother’s fibrillation problem and the condition of your daughter undergoing surgery.

Dr. Van Wagoner: Thyroid disease is associated with increased risk of AF, and it is relatively easy to treat thyroid problems with medication, radiation treatment or surgery. A thyroid condition is not a significant deterrent to surgery, and addressing this condition will likely have significant benefits, potentially including a reduction in palpitations and decreased risk of AF. Many aspects of surgical technology, care and monitoring have improved over the past 50 years.


Paroxysmal Atrial Fibrillation

John CA: Why do many medical experts say that once you have experienced an afib episode, even one diagnosed as a lone paroxysmal one, that chances are you will have another? I just experienced such an episode with the probable trigger being hypokalemia. I was hoping that keeping my potassium at a healthy level, reducing my salt consumption and avoiding dehydration would keep me from having another. If I do this am I still prone to experience another and if so what is it about afib that causes that exposure?

Dr. Pinski: As a rule of thumb, I believe that “only “50% of people with a single episode of atrial fibrillation, especially with a clear identifiable trigger develop recurrent episodes over the next few years. So, yes, you have a higher risk than somebody your age who did not have atrial fibrillation but you should not be doing anything different from what you are doing at this time.

Tom E: Why take meds for Afib that occurs random; 2-4 times a month?

Dr. Saliba: Treatment of atrial fibrillation consists of treatment of the symptoms as well as treatment to reduce risk of strokes. If you have short episodes of atrial fibrillation occurring 2 times a month and not causing any significant symptoms and if your risk of stroke is relatively low based on other clinical parameters, then you will not need to take any medications. However, if your risk of stroke is high, then you need to be on medication to reduce such risk. Medication to treat atrial fibrillation per se is indicated for patients who are symptomatic from atrial fibrillation. This is predominately a symptomatic treatment. Furthermore, if you have fast heart rate associated with your atrial fibrillation, usually you should be on medication to slow down your heart rate as this might lead to some potential problems if persistent down the road. All things considered, the aggressiveness of the therapy of atrial fibrillation, whether with medication or ablation, depends on the burden of this arrhythmia in terms of its symptoms, occurrence and frequency in a typical individual.

liesel: I have had 7 A-Fib episodes in two years. It always happens during rest. Pulse raced from a resting of 50 to between 120-180; takes from 2 -6 hrs. to revert to sinus rhythm. I take Plavix, 81 mg Aspirin, 25 mg Metoprolol succrete ER, Crestor 10 mg. Heart history: MI, 2 bare metal stents in LAD, 1 DES stent first marginal. I do have moderate mitral valve prolapse. During these A-Fib episodes I chew 1-2 whole Aspirin, take 1-2 Xanax, 1 Metoprolol (but the faster acting tartrate). Question: Is there anything else I could be doing to shorten the episodes? I am 73 years old. I exercise daily and live and eat very healthy.

Dr. Pinski: At some point of time, one has to decide if the frequency and severity of the episodes of atrial fibrillation warrant a trial of an antiarrhythmic agent or ablation (It does not appear to be your case at this time). Also one has to estimate the individual risk of stroke from atrial fibrillation. I do not have all the data to calculate your risk score, but if it is high enough it may be sensible to put you on an anticoagulant and stop the Plavix (depending how long you have had the DES stent in). Because of coronary artery disease, you are not a good candidate for a pill in the pocket approach with propafenone or flecainide to try to speed up conversion. Chewing 1-2 aspirins during the episode may do more harm than good.

David H: I am 57, and have an AF attack about once/month. It lasts 6-16 hrs, but goes, when I can fall asleep. This has happened for the last year with the exception of a 4 month AF free period. If I can tolerate the symptoms, why would I need an ablation or to take anti-arrhythmic meds, if the risk of fibrosis is supposed to be very low in episodes lasting less than 24 hrs? At present I use Bystolic to lower the heart rate and rest. Would an ablation greatly reduce the risk of AF later in life? After what period of time in AF does the heart become damaged? Thank you.

Dr. Saliba: The aggressiveness of the therapy for atrial fibrillation depends on how frustrated you are with the occurrence of this arrhythmia in terms of its frequency and its associated symptoms. Therefore, the treatment of atrial fibrillation with antiarrhythmic medication or ablation is to reduce significantly the frequency of occurrence of these episodes. It is not known whether treatment of atrial fibrillation with such therapy would reduce the progression of the disease and the data about the occurrence of fibrosis is also not very definite. There are a lot of unknowns about this disease, especially its long term implications as compared to patients in normal rhythm. The bottom line is that if you are frustrated with the symptoms, then you are more likely to seek treatment with antiarrhythmic medications and if these fail, then proceed with an ablation. If on the other hand, you can tolerate these symptoms and you are satisfied with frequency of these episodes, you can just continue the treatment with medication to slow down your heart rate when you go into atrial fibrillation. Atrial fibrillation is a progressive disease and it is expected that you will have more frequent episodes and longer episodes with time. The rate of progression of this disease is variable in different individuals. There is early data to suggest that earlier treatment of atrial fibrillation with suppression with an ablation might reduce the risk or delay the progression of the atrial fibrillation down the road. However, larger studies are currently underway to answer this question.

Dr. Van Wagoner: As we age, our ability to respond to injury becomes weaker, and the heart responds in a similar manner. There are significant person-to-person variations in the rate of change in AF duration and episode frequency. In general, it is better for you to be at a healthy weight, have well controlled blood pressure, eat well and exercise regularly. It is not always possible to detect episodes of AF. The use of anticoagulants (including aspirin) is meant as a preventive measure to decrease the risk of clot formation during extended episodes of AF. In experimental studies, a significant increase in atrial fibrosis can be detected within a few days of persistent AF.

Dave S: I have infrequent episodes of Afib (once every 2 months or so) where my heart beat suddenly jumps to 180-200 beats per minute. I also have an aortic root aneurism of 4.6cm. I take 75 mg of metoprolol daily. My question is do these episodes of Afib pose a danger to my aneurism?

Dr. Pinski: I do not have sure answer. Common sense tells me that one should at least try to reduce the fast rate during the attacks of atrial fibrillation. Please consult with your physician. Maybe you could achieve this by taking some extra short acting beta-blocker at the onset of the episode.

Don R: Hi, I had signed up for the on-line AFIB chat for tomorrow that was cancelled. Following is my question:
What is the success rate for a first time ablation for a person who has periodic AFIB attacks with no underlying valve conditions? How does that improve after a second ablation?

Dr. Saliba: The success rate of an ablation procedure for paroxysmal atrial fibrillation, with otherwise no valve condition, is between 75-85%. This can improve up to 90% with a redo ablation. However, there are other clinical features that need to be taken into consideration while making this assessment, including the size of the left atrium, the function of the left ventricle and the presence of other associated problems such as hypertension or diabetes. All these fine tune the success rate of this procedure.

Barry W: I have infrequent bouts of afib maybe once a week for half an hour sometimes twice. its always when I am resting or may have eaten or had a couple of glasses of red wine (I am a moderate drinker) my afib has been going on about a year or so recognized. you just feel something isn’t right, check your pulse and there it is. I did have a bout which lasted half a day in April this year and had to go to hospital for observation, they stopped it with a beta blocker and it didn’t re occur for several weeks, it showed up clearly on the ecg. my doctor tells me not to worry and is reluctant to put me on a 48 hour monitor. I am 66 years of age quite fit and healthy otherwise, on smoker and a bottle of wine over 7 days at most. I was diagnosed Celiac 6 months ago. Should I be concerned and push my doctor for a deeper diagnosis such as a heart scan or exercise ecg. Thanks

Dr. Pinski: I would not be surprised if you had more atrial fibrillation than what you actually experience. This could be documented with a longer term monitor. All patients with atrial fibrillation should have some baseline cardiac evaluation, including at least an echocardiogram.

David AE: I am a 73 year old male that suffered a heart attack two years ago. A stent was put in and no surgery took place. The doctors say I have no damage to my heart and I am not restricted from any activity. I am on Metropolol, a time release Diltiazem, Losartan & Doxazosin for blood pressure and heart. Typical BP is 125/70 with a heart rate of 56. Since the heart attack I have issues with A-Fibs about twice a month. Heart rate will go to 70-80+- and is irregular. To control the A fibs the Diltiazem is suppose to help and does somewhat. I would like to know what triggers these A Fibs such as food or drink and what can I do when I get them to stop it? There is no specific or typical time when they come on. Thank You

Dr. Saliba: Unfortunately, most atrial fibrillation do not have a specific and identifiable trigger. As you mentioned, these occur with no specific or typical time. This is one of the frustrations that occur with this specific problem. If atrial fibrillation is occurring quite frequently, then suppressive medications with antiarrhythmic drugs or even consideration for ablation might be reasonable in your situation.

Dr. Van Wagoner: Age is one of the strongest risk factors for AF – and a very difficult one to modify! Things that you can do are: 1) continue to control your blood pressure, 2) eat well to maintain a healthy weight, and 3) exercise regularly. Population studies suggest that individual foods and beverages do not have very strong effects as triggers of AF. However, it is wise to avoid excessive alcohol consumption.


Atrial Fibrillation and Valve Disease

Dennis R: I'm a 64 year old male who had rheumatic fever 50 years ago. The first time I was aware was when my heart went into afib back in 2006. It is controlled with medications. My mitral valve is most affected and I am bordering on severe with few symptoms. Progression of the disease has been mercifully slow. No surgery has been scheduled. My question is if someone with a bad mitral or someone even just diagnosed with rheumatic fever why don't we do the valve repair or replacement surgery before a fib and enlargement of the heart occurs? My situation in 2006 nearly killed me and it seems like things will just get worse from here. In view of all that I've been through this seems like a dangerous way to go when it might be inevitable that further damage will occur if nothing is done. Thank you.

Dr. Saliba: Timing of mitral valve surgery is a complex issue and depends on the severity of the problem associated with symptoms and heart function. Surgery has some risks involved and obviously, one cannot take these risks unless fully justifiable. Furthermore, doing surgery early might require you to have another operation down the road as these valves have finite lifespan. Obviously, the presence of atrial fibrillation adds significant symptoms to a patient who has valve disease and might be an indication to advance the timing of the surgery accordingly. This is usually left to the combined expertise of the electrophysiologist and the cardiologist and the surgeon discussing this together with the patient and coming to a final conclusion.

Dr. Van Wagoner: Rheumatic disease is a common cause of mitral valve dysfunction, and this is a significant risk factor for AF. If you have recurrent episodes of AF, it may be worth having a second opinion from a cardiac surgeon to discuss mitral valve repair and concomitant Maze surgery to decrease AF risk.

Ray L: Atrial Fibrillation Chat Question: Received diagnosis for Afib being caused by moderate-severe mitral valve regurgitation. Blood pressure and heart rate average 120/80 with irregular heart beat and no other Afib symptoms such as palpitations and racing heart rate while taking Diltiazem medication. Echocardiogram results show left ventricle systolic diameter 35 mm, Ejection Fraction 64%, left atria diameter 41 mm, pulmonary pressure 24 mmHg and no evidence of left ventricle hypertrophy. Is mitral valve repair surgery necessary at current time? When is mitral valve surgery recommended for my condition?

Dr. Pinski: Timing of mitral valve repair is a delicate issue, and depends in part of the extent of local surgical expertise. My colleagues here who are experts in valvular heart disease consider atrial fibrillation as a factor that makes them recommend surgery sooner rather than later.

Fit4life: I presently am experiencing persistent/permanent A-fib that has been precipitated by aortic stenosis that is presently classified as “severe”. I was first diagnosed with aortic stenosis in June, 2010. The A-fib could have been present prior to that but I have no way of knowing as it was asymptomatic and still is to a large degree. I am scheduled to have aortic valve replacement surgery in Feb 2013. The cardiothoracic surgeons I have consulted have told me the best chance of returning me to sinus rhythm is to perform a “maze” procedure at the time of AVR. Given the nature of my A-fib, do you agree that the “maze” procedure would be my best option, and if so, what do you think the probability of success would be (success is defined as returning to sinus rhythm).

Dr. Van Wagoner: Aortic stenosis increases the workload of the heart. As you are already scheduled to aortic valve replacement/repair, addition of the Maze procedure may help both to decrease the AF frequency (burden), and to decrease the risk of stroke (by removal or occlusion of the left atrial appendage, where clots that cause stroke often form). You do not provide enough information about your age, condition, etc. to speculate about the likelihood of maintaining sinus rhythm.


Medications

Andrew P: What are the latest, most effective treatment medications? Thanks.

Dr. Saliba: The most commonly used antiarrhythmic medications for atrial fibrillation include Tikosyn and Amiodarone. Unfortunately, all antiarrhythmic medications do have potential side effects and some of them require admission to the hospital for initiation. The most recent medication, Dronedarone (Multaq), is also an option, but is less effective than other medications. There are other medications that are effective, but are used in patients without any evidence of underlying heart disease. These medications include Flecainide or Rythmol.

Betty: I am 84 years old. I had open heart surgery March 2009 and a pace maker in Oct 2009. My warfarin levels are relatively stable, but I have tried various beta blockers over the years that have caused numerous harsh side effects. In 2011, I started Digoxin with my Verapamil. My first Digoxin test was a few weeks ago. My physician wants to increase the dosage of both my Digoxin and my Verapamil. I'm very concerned about increasing the dosages when the only side effect I have had this year is low energy. I really don't want to increase the dosages, but if I have to, I want to make sure of toxicity levels. Will the Digoxin test toxicity levels; and if yes, what would be the appropriate scheduling of testing - monthly, bi-annually...? Any guidance is greatly appreciated.

Dr. Pinski: Digoxin and verapamil are at times used to control the ventricular response in patients with atrial fibrillation. The chances of digoxin intoxication depend in a part on the kidney function. I am personally not a big fan of this combination nor a common user of digoxin levels to guide therapy. In patients with a pre-existent pacemaker, AV nodal ablation is often useful.

Jeannette I: Are some of the side effects using Multaq -- weight gain and thinning hair? How do you know if no treatment is necessary?

Dr. Saliba: Multaq side effects include predominately some gastrointestinal symptoms, but less likely weight gain. I am not aware of thinning hair being a side effect of Multaq, but can be a side effect of Coumadin if you are on such therapy. The treatment of atrial fibrillation is mainly driven by symptoms as well as associated disease. Based on your specific situation, your doctor can determine if medications are reasonable or not.

ccafib: My cardiologist recommended Multaq, with the "standard" dosage of 400 mg, twice daily. This made me feel extremely weak and my (resting) pulse rate, normally 60 BPM, dropped to around 42 BPM. The cardiologist cut the dosage in half and this seems to work. Have there been studies on lower-dosages of Multaq?

Dr. Saliba: I am not aware of any effectiveness studies that were done with ½ dose of Multaq. However, remember that treatment of atrial fibrillation is based on symptoms and if this appears to work in your situation, with a lower dose of Multaq, then that would be acceptable for the time being.

EdL: (57 year old male.) I've been taking Multaq since October 2009. I'm aware there are potential side effects / issues with this drug. My cardiologist checks my EKG every 3 months and bloodwork every 6 months or so. So far I have shown no side effects from the drug. Are the potential problems with Multaq such that "if I haven't experienced a problem by now, I should be okay?" Also, would you consider the use of Multaq effective, if the patient goes out of rhythm every 3 - 5 weeks for approximately 12-24 hours?

Dr. Saliba: The main concern with Multaq is in patients who have symptomatic congestive heart failure. Otherwise, it is a relatively safe drug. Multaq is not one of the most effective medications for atrial fibrillation in our experience. The evaluation of the effectiveness of the therapy depends on your satisfaction with the recurrence pattern of atrial fibrillation. If the current pattern is acceptable, then continuation of such therapy is reasonable. If on the other hand you are seeking a better control from the symptomatic stand point, then a trial of a different medication or consideration of an ablation might be a more reasonable option. You can discuss this with your physician.

Harold S: I developed atrial fibrillation about 2 years ago during knee replacement surgery. I take warfarin to thin my blood and Multaq to maintain my heart rhythm. I have never had any symptoms of atrial fibrillation it only shows up on an EKG. I take two 400mg multaq daily. This is quite expensive. What would be the risk to cut back to one multaq daily or none at all? Also is there a less expensive product that I could take?

Dr. Pinski: There are several generic antiarrhythmic agents that could be cheaper than Multaq. In general, Multaq is not considered a drug of first choice. If your only episode of atrial fibrillation occurred 2 years ago in the setting of surgery, it may be reasonable to stop the antiarrhythmic agent and see what happens.

John C: My question for you is, Thyroid pills (Levothyroxine 50 mcg tablets & having Atrial Fibrillation a bad combination? I'm now taking 50 mcg tablets of Levothyroxine (Thyroid) medication. I am also diagnosed with Atrial Fibrillation. Is there a problem with this?

Dr. Saliba: Atrial fibrillation is one of the exacerbating and predisposing factors for atrial fibrillation. Your doctor should check the adequacy of your thyroid treatment with blood tests. While over replacement of thyroid hormone can exacerbate atrial fibrillation, your thyroid pills should keep your thyroid status at normal levels. If that is the case, then your atrial fibrillation should be treated as a separate entity and no necessarily linked to your thyroid problem.

Richard J: I am being treated with Sotalol for Paroxysmal Atrial Fibrillation for the last two years. I have seen two different Electrophysiologists, one recommends having an ablation and the other recommends staying on the Sotalol until it no longer works. What is the current standard of treatment.

Dr. Pinski: The decision about ablation is personal and based on many things included patient preferences and physician expertise. In general, if a medicine is controlling atrial fibrillation without any side effects, most physicians would agree in postponing ablation.

Pearl S: I have atrial fibrillation and have been given the choice of ablation or Tikosyn therapy. Can you give me your recommendation on these two choices. Thank you.

Dr. Saliba: The choice between Tikosyn therapy ablation depends on how many drugs have you tried before, how symptomatic you are with your atrial fibrillation, and whether you have any underlying associated heart disease. It is not unreasonable to try Tikosyn and if that is effective in suppressing your atrial fibrillation, to continue on such therapy (as long as it is deemed). Ablation would then be considered if you failed medical therapy with Tikosyn. Some patients opt to proceed with ablation as a first line therapy, which is currently becoming an acceptable option. These two treatment modalities have different risk profiles and effectiveness and usually, these have to be discussed between the patient and the physician. In our practice, we tend to give a trial of medical therapy before proceeding with an ablation.

Sandra O: Thank you, My question is, “What are the best hypertension meds to take with atrial fibrillation?” My cardiologist told me Norvasc sometimes puts in an extra heartbeat and when I stopped them, it seemed to lessen the afib. I stopped them before he told me about the Norvasc because the symptoms were less. Part B of the question is, “If you still have high b/p with 50 mg of Toprol XL and 10 mg of Ramipril/day, what else is good to take to lessen b/P but not contribute to afib?” Thank you.

Dr. Pinski: Guidelines suggest that a diuretic such as chorthalidone or spironolactone should be added at this time.

Dr. Van Wagoner: Research suggests that spironolactone may also be helpful to decrease the fibrosis that often accompanies the development of AF.

CarolA: Metoprolol 25 mg taken when I get afib, brings my rate to 100 average for the next 10 hrs. Is this a safe rate for this length of time? I start out at 150 and drop down within half hr. of taking Metoprolol. I have been diagnosed with afib for a yr and half....in what ways does it get worse as time passes? thank you for helping me with my questions.

Dr. Saliba: It is reasonable to take Metoprolol on an as needed basis when you develop atrial fibrillation. However, if you are experiencing frequent episodes of atrial fibrillation, you might want to consider suppressive antiarrhythmic medication to reduce the frequency of the episodes. Usually, the episodes become more frequent with time, but the rate of progression differ among patients. The more frustrated you are with the occurrence of atrial fibrillation, the more likely you are to upgrade to the next level therapy.

Gladys T: I’m 79 years and have high blood pressure, which my primary doctor has under control. I was officially diagnosed with AFIB about 3 years ago, although I think I had it longer. The cardiologist I was working with at the time immediately put me on coumadin (warfarin). When I experienced excessive bruising while traveling and because we traveled so much and I would have difficulty monitoring it, he took me off. At the time I was only experiencing two episodes a year. My present cardiologist has me on a new routine to substitute for the warfarin and I’ve been going through several medicine changes trying to find something that works for me and doesn’t leave me constantly dizzy and tired. I’ve been experiencing light-headedness, tiredness, and on the last change, a fainting spell while exercising. Also the AFIB incidents are becoming more frequent. I started out with Atenolol 25 MG’s twice a day, Lisinopril 5 MG, citalopram 20MG and baby aspirin. Along the way these medicines were changed and my next to last prescriptions consisted of atenolol chlorthal 50, citalopram, and amiodarone hcl 200MG, It was this combination, probably the amiodarone, that dropped my pulse so low that I fainted while exercising. As of two weeks ago I’m on hydrochlorothiazide 25MG, Citalopram hbr 20, and baby aspirin. I’m feeling like I’m getting back to normal, but I’m concerned about how these medicines will control my blood pressure and the number of AFIB incidents in the future. I notice my blood pressure slowly rising. Before all the latest changes it averaged about 120/60/over 60. It’s crept up to 140/60/60. But truthfully, I would rather have AFIB for a few days than the constant dizziness I was experiencing daily with the Amiodorone. Would you have any comments, suggestions for me? I’m anxious to receive your advice.

Dr. Pinski: You appear to be at higher risk for stroke from atrial fibrillation and should be on a blood thinner if not contraindicated. Aspirin is not protective. Many antiarrhythmic drugs used to treat atrial fibrillation (especially amiodarone) result in bradycardia (a slow heart rhythm). At times, it is necessary to install a pacemaker to allow safe treatment with an antiarrhythmic agent.

John CZ: Doctor, After many years of AFIB it suddenly stopped. This coincided with the time I started taking Calcium with D. Is this just a coincidence? Thank you for your reply.

Dr. Pinski: Difficult to answer. I know of no controlled studies of calcium/vitamin D for atrial fibrillation. Time will tell if this is a coincidence. For now, I recommend 1000 to 2000 units of vitamin D (without calcium) to everybody, especially if levels are on the low side or not exposed to the sun.


Medications: Blood Thinners

Carol A: I am getting closer and closer to 75, I take Pradaxa. What is the possibility of a blood thinner to be more effective and safer for those of us 75 with afib?

Dr. Saliba: Pradaxa is a good alternative to Coumadin for patients who need anticoagulation for stroke prevention in the setting of atrial fibrillation. When compared to Coumadin, it is slightly more effective for stroke prevention with similar bleeding side effects compared to Coumadin.

RangerJoe: Had single bypass 1996. Have high BP is managed. Had Atrial Fib 2001.Converted in hospital using meds. Taking 325 Aspirin since, ZOCOR, Jestril. Had another episode of atria

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Last Modified November 12, 2012

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