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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 May 31, 2013

Your afib questions were answered by Dr. Walid Saliba, Dr. Edward Soltesz, Dr. David Van Wagoner, Dr. Bruce Lindsay, Dr. Mandeep Bhargava, and Dr. Oussama Wazni of the Cleveland Clinic

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 StopAfib.org 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: www.alivecor.com. 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 StopAfib.org 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.


Diagnosis

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 w

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Last Modified July 1, 2013

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