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Atrial Fibrillation & Other Irregular Heartbeats – Drs. Saliba, Wazni, and Bhargava

Tuesday, December 17, 2013 - Noon

Description

Atrial fibrillation or Afib is the most common heart rhythm abnormality. Over 2 million Americans are affected by AFib and while it is often a mere annoyance, it is responsible for 15% of all strokes. It can also be responsible for life-threatening medical emergencies that result in cardiac arrest and even sudden death. Walid Saliba, MD, Oussama Wazni, MD, Mandeep Bhargava, MD, and Mellanie True Hills from www.stopafib.org answer your questions about atrial fibrillation and other irregular heartbeats.

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Atrial Fibrillation – General Questions

Ed95: (58 yr old male.) I have been out of rhythm for about a year now (under the care of a cardiologist). Does remodeling or any other function of being out of rhythm for x number of days, prevent me from being able to return to NSR in the future (cardioversion, meds, ablation, etc)? Also, is there any new data that might suggest I should shoot for NSR rather than my current state? (I'm not having any real problems being out of rhythm, other than the occasional shortness of breath.) Thanks.

Walid_Saliba,_MD: The longer you are in atrial fibrillation - the harder it is to maintain normal rhythm. But - this usually implies weeks and months and not days. The decision to restore normal rhythm should depend on your symptoms and atrial fibrillation and how good you feel in normal rhythm.

Terence: I'm a 72 male and in excellent health and taking no medication for any condition. I do have a cardiologist diagnosed case of vagally mediated paroxysmal afib (occurs predominantly, but not always, during sleep and spontaneously reverts shortly after waking and two cups of coffee). I take no medication for it. My questions are: 1. I've been charting my afib events for almost four years (frequency, duration, situation at time of event) and find that over the past few years, my afib will nominally occur every 7 - 10 days, often without the presence of any of the well-known triggers. Why does it occur with this regularity? What is biologically happening during that 7-10 day period that concludes with an afib event? 2. To what extent does mild hypohydration act as a trigger of afib. 3. Since childhood I have had a tendency to low blood sugar for which I've been evaluated by an endocrinologist (no diabetes or early onset, possibly sub-clinical). Does this have a role in afib?

Walid_Saliba,_MD: Afib can have many triggers. Some of them are difficult to understand. It is hard to comment on the regularity of your afib but we have seen cases of hypohydration facilitating the onset of atrial fibrillation. I am not aware of low blood sugars specifically triggering atrial fib. But it is not unreasonable to think that it can do it through its effect on the autonomic nervous system.

linda35: We have a circle of friends that we have known for years (we're all in our late 60's). Three of the men are struggling with Atrial Fibrillation (none have had an ablation to date, but all are taking medications with undesirable side effects). It seems that none of the doctors they are consulting are certain what specifically causes AF. Questions: So many people seem to have this problem. Is it on the rise or is it just easier to diagnose; are there any steps one can take to avoid this health problem (diet, exercise, etc.); and, is heavy alcohol use a factor? (All three of these friends with AF have been heavy drinkers for years). Thank you.

Mandeep_Bhargava,_MD: Most often, AF is just a consequence of age related degenerative changes in the left upper chamber of the heart. In some patients, there can be precipitating causes like alcohol, thyroid disease, valve disease, etc. The best chance to reduce risk of AF is to control hypertension and other heart diseases but it can occur in normal hearts too. It surely is easy to diagnose once it happens but there is just more awareness of AF lately because of the availability of so many tools with which one can make a difference in the quality and quantity of life of patients who have AF.

saintrose: I want to know everything that can be done for A-Fib. I have trouble with the medications. I need ideas on life style changes or anything that I might be missing to help my condition.

Walid_Saliba,_MD: If you have trouble with medications and have symptomatic afib, then seriously consider the option of ablation. I would be more than happy to discuss this with you.

RogB: I was on both Flecanide and Sotalol after afib diagnosed 3 years ago, neither kept me out of afib more than a couple of weeks so I decided to try rate control. I am on Warfarin and maintain proper inr level along with 5 mg of Norvasc. When I go into afib, I take 25mg of Atenolol to keep heart rate below 100. Episodes last approx 24 hours and recur about every 10 days about same interval as the meds. I am 71 and otherwise in good health, no underlying heart problems or so I'm told. Maintain proper weight and get regular exercise. Blood profile is excellent. Question- Is rate control an acceptable way of dealing with afib? It's not pleasant but not debilitating and does avoid meds that didn't do much good anyway. In my case do you think an ablation should be pursued? I would rather avoid it if possible.

Mandeep_Bhargava,_MD: Rate control versus an ablation in your situation is unlikely to change your risk of stroke or your lifespan. However, the ablation has the potential to improve your quality of life by reducing or eliminating your atrial fibrillation. You have to see if you are comfortable with the risks of the ablation and if you are, then an ablation is reasonable but not mandatory. Hope this helps.

soolim: Hi, I was diagnosed with AFIB last year, and on Xarelto and Flecainide 50mg 2/day. I am 70 years old. My blood pressure is in control with medicines at around 120/70 except early in the morning. Early in the morning, it is about 10 - 15 % higher. I have no symptoms at all what so ever, and it does not affect my everyday life at all in any way. I am very active enjoying outdoors, and do hiking and golfing quite a lot. I realized that my heart rate is elevated to around 140 when I play golf and sometimes it remains high even after golf game for an hour or two. Also sometimes when I run upstairs, my rate is elevated to around 130 or so.

1) Is this a symptom of AFIB?
2) Can I continue my hiking?- strenuous
3) I plan to go Alps hiking next summer for two(2) weeks-strenuous, continuous hiking. Will I be OK?
4) Catheter ablation is an option for me, or just stay with my current medicines?
Thanks, Soo Lim

Mandeep_Bhargava,_MD: 1. It would be important to know if you have paroxysmal or persistent atrial fibrillation. If your heart rates are fast with exercise, it could be due to sinus tachycardia also if you go in and out of AF but if you are always in AF, then the AF can get faster with exertion. You may need to step up your rate control medications if the latter is the case. 2. Usually it is safe to continue hiking if you have no significant symptoms even if you are in AF, but you would like to control your heart rates because if they are persistently elevated then they can sometimes weaken your heart muscle. 3. You should discuss this with your doctor as it depends on your overall heart status in terms of the blood supply, heart function and valves. If all parameters are controlled, it may be fine. 4. Catheter ablation is surely an option if you have symptoms or difficult to control AF/heart rates or heart muscle dysfunction with drugs. In patients who are asymptomatic, the role of a catheter ablation is less well defined but if you have persistently elevated heart rates or AF related tachycardiomyopathy, it may deserve consideration.

dmburgess: Can stress play a role in atrial fibrillation? I am 55, healthy without heart disease, have good blood pressure, drink very little alcohol, don't use caffeine but have A-Fib. Prior to being diagnosed with A-Fib, after a day of extreme stress, the next day I would have an episode of irregular heart beat and my heart rate would spike up to 180 and nothing would bring it down causing me to go to the ER for emergency care. Thus, being diagnosed with A-Fib. I ask my cardiologist why I have it then...he says I'm just predisposed to having it. I think stress plays a strong part in my A-Fib since that is the only time it happens. What are your thoughts and experiences with stress and A-Fib?

Cleveland Clinic Physician: Stress has effects on heart rate, the activity of autonomic nerves (stimulating the “fight-or-flight” response), and on the immune system. Each of these activities may acutely increase the risk of tachycardia (rapid heart rate) and/or AF. In a human experimental study, mental stress test increased heart rate, blood pressure, and cardiac output. In an experimental animal study, persistent infusion of norepinephrine (the neurotransmitter released in the heart during stress) caused an increase in fibrosis in the heart. Many recent studies have shown that atrial fibrosis can increase the duration of AF episodes. The extent to which the animal studies parallel what happens in patients is unclear, but an overall reading of the literature would suggest that stress can act both as a trigger for AF, and potentially as a pathway that can affect AF persistence. What can you do? Regular moderate aerobic exercise and weight control may help to reduce stress, restore autonomic balance, and decrease the frequency and duration of AF episodes.

dmburgess: Once a healthy person (without any heart disease) is diagnosed with A-Fib, is it possible that your A-Fib will go away?

Cleveland Clinic Physician: This is a complicated question, because the causes of AF vary from person to person. Some AF is associated with lifestyle associated modifiable risk factors such as obesity and hypertension. In such patients, treatment of the risk factors, if addressed early, may help to reduce the burden of AF or prevent its progression. There is a genetic (hereditary) component of AF, with children of a parent with AF having about a 1.5x increased risk of developing AF; the risk is even greater if both parents have a history of AF. It is whether lifestyle changes can prevent the occurrence of AF in this circumstance. Interventional approaches, such as Maze surgery or pulmonary vein isolation, may be effective in isolating the triggers that cause AF in these cases.

dmburgess: Once you have atrial fibrillation, is it possible that atrial fibrillation will go away during one’s lifetime and be taken off their antiarrhythmic drug?

Cleveland Clinic Physician: This is a tricky question, as AF is a sporadic rhythm. In general, monitoring studies are used to assess the frequency and burden of AF. In patients that have undergone ablation procedures, antiarrhythmic medications are sometimes withdrawn if there is no evidence of AF 3 months after a procedure has been performed. Similarly, if the burden of AF is very low, your cardiologist might suggest termination of antiarrhythmic medications. Stroke is a primary concern; as many episodes of AF cannot be perceived, it is important to try to prevent AF and maintain anticoagulation in patients with significant risk of stroke. This is something that needs to be addressed on an individual basis with your cardiologist.


Atrial Fibrillation with other Medical Conditions

katee: My 86 year old father has a qualitative platelet disorder, has been on a fentanyl patch (placed over his heart) for two years for orthopedic pain, takes atenolol and baby aspirin daily, and was recently diagnosed with Afib via a pre-op EKG. The platelet disorder classifies him as a "bleeder"; however, outpatient procedures (kyphoplasties, epidurals) have been successful with the use of DDAVP. He has much vitality and was considering lumbar laminectomies, but now concerned primarily with the afib and what treatment options would be advisable given his bleeding issues. He has developed a cough of two months' duration which is worse if he lies on his right side. He is post two CABGs and has a "tortuous" aorta. Any advice would be much appreciated, thank you.

Walid_Saliba,_MD: This is a complex clinical picture and would warrant a medical evaluation in the office. It is hard to make any suggestions without full clinical picture availability. We would be happy to see him.

CCAN: I have AFIB, but also have a deficiency of my clotting factors 8 and 12, so I can't take blood thinners. What treatment would you suggest and what are my risks of a stroke if I can't take blood thinners?

Walid_Saliba,_MD: The risk of stroke is obviously lower - never the less if you have a high CHADS score there is always the possibility of left atrial appendage occlusive device (when available) which would eliminate the need for chronic anticoagulation.

mrs. Z: My husband has A-Fib which lead to his stroke in March 2007. In the last 6 months or so, he has shortness of breath, seems to have difficulty breathing "normally'. It doesn't happen all the time but very often. His primary doctor believes that the A-fib lead to shortness of breath which lead to Congestive heart failure. Are they related? if so, what can be done about it?

Walid_Saliba,_MD: It is possible that he may be having atrial fibrillation with fast heart rate that is causing his shortness of breath. Afib and congestive heart failure are very closely linked together - afib worsens heart failure and heart failure aggravates afib and both cause shortness of breath and need to be treated.

mysticmac: I was diagnosed with Bradycardia in Oct., had pacemaker put in end of Oct., 2 weeks later had pericardial tamponade and had to have chest tube for four days. During that time, I got A Fib and was given medicine to lower HR. Was not given any meds after I went home for pericarditis or A Fib. Two weeks later had to go to ER with same chest pain and was in hospital for five days. No surgery this time but had another A Fib incident along with the pericarditis. I am now on Naprosin for pericarditis and digoxin, lopressor, xarelto for bp and HR and protonix for stomach protection. Question: did pericarditis cause A Fib or does the A Fib go hand in hand with the Bradycardia??

Oussama_Wazni,_MD: If you never had afib prior to this incident, then most likely the afib was related to the irritation caused by pericarditis. Hopefully as the pericarditis is treated, the afib will resolve.

terryd: Is there any correlation between excessive coughing and atrial fibrillation? My husband was recently diagnosed with fast AF. No cause found, CRP was normal. He is asthmatic and for months has been c/o excessive mucus production which he believes is from an inhaled dental part two yrs ago!! Unlikely? Our cardiologist believes the mucus is a result of the AF, however his lungs sound clear for much of the day. Just before needing to cough they are full of rattles and crackles. He was coughing so violently I feared he could get atelectasis. He tends to cough in private so I don't think the doctors were fully aware of this or how bad his lungs sound at times. He has a chest CT scheduled for Dec 30. He has slipped back into AF twice since coming home both after episodes of coughing. His AF is controlled with amiodarone which also concerns me because of the lung implications. Is it possible that the coughing could stimulate his vagal nerve? Should I be pushing for more respiratory tests?

Walid_Saliba,_MD: Pulmonary problems facilitate the occurrence of atrial fibrillation. Amiodarone can cause lung injury and this needs to be evaluated. If your husband has significant problems with afib and pulmonary issues amiodarone may not be the best medication for him. The results of the chest CT will hopefully be revealing.

KenPM: Hi, I have Hypertrophic Cardiomyopathy. Is AF more common when you have this condition? I was diagnosed with HCM in 2010. I have a fitted ICD. I've started to experience AF recently this year, started in Aug, - five episodes so far, last one at the end of October. Interestingly I’ve only had the episodes in the middle of the night (they wake me up) and only on weekends. Since July to now I've lost 30 pounds through minimizing starch & sugar in my diet. I've been seeing my cardiologist regularly through this period and he's switched me from Atenolol to Metoprolol (150mg). They also did an electrolyte test. Showed normal. I started taking Magnesium & Potassium supplements since late October, and again haven't had an episode since Oct. 28. My EP thinks that it will come back and ultimately I'll need to get an ablation procedure done. Does any of this make sense to you? Can significant weight loss and a change of diet precipitate AF? Is HCM a factor?

Walid_Saliba,_MD: Atrial fibrillation does occur in patients with HCM. Usually weight loss and cardiac conditioning might reduce the episodes of atrial fibrillation but does not eliminate it . I agree with your electrophysiologist that you are likely to develop recurrence of atrial fibrillation and will require aggressive therapy as atrial fibrillation is not well tolerated in patients with HCM.


Atrial Flutter

grammarhodes: I've had a mini-maze for a-fib and four ablations for SVT's. My current heart rate is about 90 bpm. Rather than schedule more cardioversions (I've had at least seven) and ablations to reduce my rate to normal (which is about 52 for me), my EP thinks I should just try to live with it. I can tolerate this rate since it is usually steady, but wondered if 90 +/- is a "safe" rate to maintain. I take a beta blocker and blood pressure medication as well as blood thinner. Also, can PAC's or PVC's trigger flutter and SVT's? Which drugs work on those types of problems?

Walid_Saliba,_MD: It appears that you are in atrial flutter following so many ablations and maze. PACs can trigger atrial flutter. While 90 bpm is ok to maintain, it would be better to control the heart rate more aggressively with medications or the possibility of another ablation - depending on what was done during the last one or two procedures.


Symptoms

Savannah: When I am in A Fib what determines when I should , #1 contact my physician. #2 call 911. I am 85 yrs .old and live alone..A Fib usually occurs at night. I usually "fib" at bedtime. My treatment has been to take an extra metoprolol and go to sleep..if the discomfort isn't too severe. Thanks...J.H. (retired nurse.)

Walid_Saliba,_MD: I would call 911 based on severity of symptoms. If only palpitations and you are used to it - then no need for it. But if you have associated chest pain, shortness of breath or dizziness then you need to be evaluated. Taking metoprolol as you are doing is ok.

mridder: I had my diseased, bicuspid aortic valve replaced with a bio-prosthetic bovine valve on November 7, 2012 at Cleveland Clinic main campus hospital. I completed a full 12-week cardiac rehab program and my recovery has been progressing quite well. Just recently at about the one-year anniversary of my surgery I started noticing more frequent and discernible palpitations and irregular heartbeats. I exercise regularly wearing a heart rate monitor and I'm noticing spikes and drop offs with these irregular beats in the trace that I have on my treadmill screen. What criteria should I use to differentiate between a serious arrhythmia in these irregular beats versus something more benign? I just want to be sure that I'm exercising properly and not harming my recovery in any way.

Walid_Saliba,_MD: The best thing for you to have a holter monitor at the time of your exercise to document the nature of your arrhythmia and treat it accordingly.

alanher: Is there a way for me to know if an irregular heartbeat I am experiencing is due to Afib or is simply harmless without going to my doctor?

Walid_Saliba,_MD: You will need to have an ambulatory monitor to document the nature of your palpitations. That requires going to a doctor.

rosed: On 11/12/13 I had my aortic valve replaced. At my last office visit I was told I have an "extra" heartbeat. It seems to only bother me in the evening when I actually feel the extra beat and it makes me have a little cough. I was put on Metoprolol 50mg twice a day instead of only once in the morning. I am told in time this will go away once my body is used to the valve. Is this anything to be concerned about? And about how long will it last? Thank you.

Walid_Saliba,_MD: I don't think that there is a concern about it. However, if it bothers you a lot , then monitoring should be done to evaluate the nature of this extra beat and there are medications that can be given to suppress it. And, if very frequent, ablation can be considered as well.

BillieKeaffaber45: My father had atrial fibrillation on his death certificate and I have had tachycardia spells in past, I normally have bradycardia spells and had a pacemaker placed. I have left ventricle non compaction cardiomyopathy could I be prone to atrial fibrillation as well. Been dizzy and having few issues but doctors don't know what causing the stuff.

Walid_Saliba,_MD: Yes - you can be prone for atrial fibrillation. Interrogation of the pacemaker is the best way to find out if you have been having any arrhythmias. We would be happy to evaluate you.

thursty: I have been suffering a-fib "events" for four+ yrs. They occur at least once a week and sometimes more frequently. I am currently under care and taking metoprolol and rythmol. I also take a baby aspirin two times daily. This treatment has not reduced my occurrences at all and I am concerned I may be just coasting along and not being aggressively treated and may be advancing from paroxysmal to persistent stages without any attempt to "cure". Should I be asking for 2nd opinions and pursue more treatment options or am I most likely to be receiving the most effective remedy for my symptoms? The episodes are debilitating and as a business owner they render me unable to perform, negatively impacting my business and general life experience. Thank you.

Walid_Saliba,_MD: If you are not satisfied with the current medical regimen and your afib is not acceptably suppressed, there are definitely other options such as other medications or an ablation, which I would consider strongly. We are happy to evaluate you.

bryanro: I would like to ask about Cortisol, but first some background. I am 67 and was diagnosed with lone paroxysmal AF (no P wave but echocardiogram indicated sound mechanics, with CHADS score of 1) in August this year, but now it is persistent. My heart rate is still the same average as when I was in sinus rhythm (60 - I am fairly fit, jogging and golf). It is regularly irregular (!) varying consistently from 0.25 to 2.5 s per beat, with an average of 1s. I wake up every day around 6 am after usually a good sleep, but if I wake up a little earlier and happen to be lying on my left side I can feel my pulse in the left carotid artery and it seems quite regular for about 30 min - is this an effect of Cortisol peaking to wake you up or is it something else - what is going on? The rest of the time I am in AF. I am not on any medication.

Mandeep_Bhargava,_MD: I do not think that cortisol would be playing any role. I think you need to be sure about the diagnosis of AF versus some other things like PACs, bigeminy or 2 for 1 phenomenon as you say your heart rate is "regularly" irregular. In AF, most often it is "irregularly" irregular. Confirm with a specialist. If your heart rates are stable and you have no symptoms, you may not need any aggressive therapy.

georgelowy: I am an 87 year old male suffering from paroxysmal A-Fib for the past 13 years. I have a St. Jude pacemaker. I am getting fibrillations every two- three weeks on the average. They last anywhere from a few minutes to eight hours. When I have fibrillation I feel weak and depressed, but not incapacitated. My question is if I should go on medication, have an ablation or do nothing, as I have been doing till now.

Oussama_Wazni,_MD: Treatment of afib is targeted at improvement in quality of life. So the answer to the question really depends on how affected you feel with your afib. If you feel that you need a treatment, then anti-arrhythmic drugs would be the first line of treatment.

Multa: Since I have occasional atrial flutters due to my Rheumatic Heart Disease, I was told to check my pulse after they occur and, if it is regular, not to worry. I'm not sure what I would notice if it were irregular. How obvious would the irregularity be?

Oussama_Wazni,_MD: This is a very crude method of checking your rhythm. A better approach would be to consider periodic long term monitoring with a 21 to 30 day ambulatory cardiac monitor.


Low Heart Rate - Bradycardia

Yobeth1: Hi, I was diagnosed with afib in June 2013. I'm a 50 year old healthy female with no risk factors (no DM, no hypertension, no Tia). I take 150 mg of Toprol per day plus 100 mg of Flecainide. My heart rate is always in the 50s. Is there any dangers/concerns keeping my heart rate this low? Also, what is your opinion of ablation for newly diagnosed patients that only have afib occasionally (paroxysmal; a few times a year) and not persistent afib? Thank you.

Walid_Saliba,_MD: Heart rate at 50 is ok as long as you are feeling well. Ablation is a consideration if you have increasing episodes despite flecainide therapy.

Serge: My diagnosis by very reputable electrophysiologists is paroxysmal Afib and sinus bradycardia. I have had one complex ablation – baseline sinus bradycardia with circumferential PV isolation and AF ablation. There were no complications but the results were unequivocally negative. I am scheduled for my second complex ablation in a couple of months. Can my normal low and lowering heart rate (currently averaging 38 beats) be the cause of my AF? If so, I am concerned that another ablation will not stop the A-fibbing. What research has been done on the connection between a very low ‘normal’ heart rate and AF?

Walid_Saliba,_MD: There is no correlation necessarily established between low heart rate and atrial fibrillation. We will need more information to better answer your question for example what medications you are taking.


Premature Ventricular Contractions (PVCs)

kit: In 2008, diagnosis of AF; every drug except tikosyn tried. In 2011, a cardiac tamponade suffered during a failed ablation procedure, followed by a long period of recurring pericarditis. 2012, after multiple severe events of AF with rapid ventricular response amiodarone administered. Maintenance dose of 100 mg. The amiodarone seemed to hold the AF in check. In June, dose reduced to 50 mg. but increased breakthroughs occurred. Event monitor showed persistent PVC’s and some PAC’s, no AF. The episodes cause me to get extremely dizzy (quality of life issue). In July, my cardiologist moved away. A subsequent doctor (EP) said not to worry about PVC’s, wanted me OFF “nasty” amio. and tried beta blockers (HR too low), then Multaq 400 mg/day. The PVC’s (“skipped beats”) continue to plague me. EP gave me two choices: back to 100 mg. Amiodarone or 400 mg. Multaq b.i.d. My question. Why do I need “nasty” drugs if PVC’s are "harmless?" What would you advise? I am 74 and want the best option to enjoy life!

Walid_Saliba,_MD: If you have frequent pvcs then the possibility of ablation of pvcs can be considered in order to avoid taking amiodarone. On the other hand if amiodarone is suppressing your arrhythmia, it would be ok to continue it provided you have regular follow up to look for potential side effects. If pvcs are symptomatic I would consider an ablation.

victoria1102: Hello Dr. Wazni, my question is in regards to PVC's and long lasting heart palpitation like sensations along with a paused gap until the next beat. I'm a 36 year old healthy female, I don't get them often but when I do it seems like I can feel and am extra sensitive to the fluttery flip flop sensation that I have been experiencing. I had several EKG's done and a treadmill test in which were both normal. Yet when I experience these sensations, they will last throughout the day. My cardiologist and GP says I have nothing to be concerned about and that PVC's are common. Is this something I should be concerned about and possibly need further testing such as a heart scan or an echocardiogram? It's a scary feeling and I just want to get a second opinion. Any feedback is appreciated.

Oussama_Wazni,_MD: You should at least get an echo-cardiogram to start with. If this is normal, then I agree that you should not be too concerned about the PVCs. However, if these PVCs affect your quality of life, whereby they interfere with what you like to do, then suppression of these PVCs may be warranted to improve your quality of life. This may be performed by decreasing your caffeine intake if you feel caffeine may be a contributing factor. Treatment would be targeted to improve your quality of life. If you feel that you can tolerate the PVCs, no treatment is necessary. However, if these are truly bothersome, the PVCs may be suppressed by medication or preferably abolished by an ablation.

Alex2: Is there a surgery that corrects PVCs?

Mandeep_Bhargava,_MD: Yes, we could do a catheter ablation for PVCs.


Ventricular Tachycardia

kahuna8: Recent diagnosis of Polymorphic Ventricular Tachycardia. How does this fit in with past diagnosis - severe aortic valve stenosis - .9 valve area, gradient 52, Ejection Fraction 74%. Age 77, male, in age adjusted excellent health. Bottom line - does the PVT modify the projected AV replacement in 6 to 18 months and/or TAVR eligibility vs. AVR open heart. Thank you. HWH

Walid_Saliba,_MD: The etiology or reason for PMVT needs to be investigated (medications; CAD; ischemia, etc). It should not modify your projected aortic valve management but a decision should be made whether you have a defibrillator placed if no clear cut reversible reason is found.


Postural Orthostatic Tachycardia (POTS)

rachelep: I wore an event monitor for oen month which recorded numerous daily episodes of tachycardia, bradycardia, and arrhythmias. I also have POTS. My cardiologist said my case is beyond his scope of treatment and recommended going to the Clinic for evaluation/treatment. Does this combination of symptoms represent a significant health risk and who would you recommend I see at the Clinic. Thank you!

Walid_Saliba,_MD: I would suggest you see Dr. Jaeger for further evaluation of POTS. He is wonderful and most experienced.


Supra Ventricular Tachycardia (SVT)

jswig: I am an 18 year old female college student with SVT. I have been to two different emergency rooms this year six months apart when the tachycardia did not subside on its own. HR 260 the first time and 235 the second time. Both ER's have told me I need ablation. I am concerned about this procedure damaging the heart and having to have it repeated and damaging the heart further. What is the success rate of patients that only need it performed once versus repeated procedures. And what is the percentage rate of patients that end up with a pacemaker for this problem. I am in good health with no other health problems.

Walid_Saliba,_MD: Depending on the nature of the SVT ablation is recommended - the risk of ending up with a pacemaker is minimal. The risk of fast heart rate and associated problems is probably more. Take care of it soon.

jswig: Also, How do you feel about calcium channel blockers as therapy for SVT for an 18 year old vs. beta blockers for chronic therapy?

Walid_Saliba,_MD: Both are good. Beta blocker might work better but with more side effects for a young person.


Medications

beanjaker: I have a history of AF along with my mother and two sisters. I have also had an aortic valve replaced. My AF first started before my heart surgery, and of course afterwards. I have had a cardioversion which helped for awhile. Now I am on Flecainide 100mg BID. I have not had AF since, but from what I have read, this drug is dangerous. What is your opinion?

Walid_Saliba,_MD: As long as you don't have any coronary disease or heart pump dysfunction it is ok to be on flecainide at the current dose. However, you need to have regular follow-up to confirm the continuous safety.

hardric: Thanks for making this forum available. I am a 56 year old male. I was diagnosed with Afib in November 2007 after being admitted to the Intensive Care Unit at the hospital, and was placed on prescribed medication after release. Since then i was admitted at Intensive Care Unit only once in 2012 where my heart rhythm was normalized. The meds that i am on are Diltiazem 120mg(once daily) and Carvedilol 12.5mg(twice daily). My questions are (1) Do these medication have an effect on my sexuality and (2) Is there any possibility that the meds could either be decreased or discontinued in the further. I am concern as my wife is asking questions.

Mandeep_Bhargava,_MD: It is possible that beta blockers like Carvedilol can affect sexuality and you could talk to your doctor about just keeping you on Diltiazem alone and that may help. If needed, you could take some alternative medications for your hypertension if you have that. You have a fairly low burden of AF and are not really on any risky "Antiarrhythmic Drugs" right now and the current drugs you are one are just drugs which reduce your symptoms if you have AF but do not really reduce your risk of having the next episode of AF.

VirginiaAnn: I am a 62-year-old woman with severe osteoporosis who is considering the range of meds to help with this condition--among them HRTs and Evista--both of which have side effects of Afib, strokes, etc. Is it possible to reduce the possibility of Afib as a side effect to such meds, such as diet/nutrition, drugs (LMWH?)? Thank you.

Walid_Saliba,_MD: We do not usually recommend any prophylactic drugs to reduce the risk of AF as the overall risks are not worth the benefit. The best would be to eat healthy and take care of your blood pressure, sugar, etc.

xdwl: Hi, I am a 55 yrs female with obstructive hypertrophic cardiomyopathy. I successfully had surgical septal myectomy 15 months ago. I have been taking Metoprolol Succinate 47.5mg/day for six months now. Recent holter showed my lowest heart rate was 40 bpm (happened in the afternoon while I did not feel any uncomfortable) and the average hear rate was 48 bpm, sinus rhythm. I would like to ask, can I continue Metoprolol Succinate 47.5mg/day? What is the lowest heart rate for reducing the dosage? Thank you!

Oussama_Wazni,_MD: The decision to decrease the metoprolol will depend on your symptoms (fatigue, dizziness, shortness of breath with exertion, etc.) and not on your heart rate. Also, at times, the blood pressure may drop with the metoprolol which may lead to decreasing the dose. If you feel that you experience fatigue with exertion, then your doctor may want to consider decreasing the dose, otherwise, there is no compelling reason to do that.

freespirit10: I am 61-year-old woman. Had ablation on Nov. 26 after Tikosyn and sotalol failed. Have enlarged atrial size w/left ventricular hypertrophy w/o significant cardiomyopathy or valvular disease. Three arrhythmias found: atrial tachycardia w/cycle length of 508 millisecs; second atrial tachycardia of 300 ms w/2:1 conduction; and third w/300 ms w/different activation pattern in coronary sinus and 2:1 conduction. These interchanged spontaneously during procedure w/very similar surface P waves. Ventricular rates similar. Ablation w/in coronary sinus and base of the coronary sinus did not terminate arrhythmias. I had drain tube for pericardial effusion and ECG showed basal posterior hypokinesis close to coronary sinus site of ablation. Being treated w/sotalol (80mg 2x day), metoprolol (75 mg 2x day), digoxin (25 mg daily), warfarin and lisinopril (20 mg 2x day). My doctor advised of a possible AV node ablation or amiodarone which I prefer to not use. Do you have other ideas?

Mandeep_Bhargava,_MD: The choices that your doctor has given are reasonable. The only other one would be to consider a redo ablation but surely looks like a tough situation as you have multiple arrhythmias. If the ablation needs to be done close to the coronary sinus, the risks are a little higher but can often be done with caution in experience hands.

Rainbow77: I have several questions: I take 25mg Atenolol each pm. My heart rate is 50-60. What is the safe way for me to get off this beta blocker? Will Omega3 500mg work as well for blood thinning as asprin or Eliquis? When taking a blood thinner can I safely take vitamin K2 with D3 and calcium?

Walid_Saliba,_MD: It depends on the reason why you take atenolol. It is a low dose and should be removed under medical supervision depending on the initial indication. Omega 3 does not take the place of anticoagulants. Vitamin K antagonizes warfarin. It is ok to take vitamin D with the other medications.

hitchadmirer: Had catheter ablation for AFib in Spring 2009 with Warfarin and Sotolol. Removed from both within a year of being in sinus rhythm. Was recently rediagnosed with AFib, given Warfarin, then put an Tikosyn (while observed in hospital). Now being recommended to go through another catheter ablation with same surgeon. Any comments and/or recommendations?

Mandeep_Bhargava,_MD: If you are maintaining sinus rhythm on tikosyn, you could continue on that. If you wish to avoid medication or are not responding/tolerating it, then another ablation would be a reasonable choice. The operator choice is completely yours.

kayike: I am a 79 year old male had an heart attack and triple bypass surgery 22 years (1991) ago. Diagnosed with AFIB a year ago. The AFIB symptoms appear only when I exercise and go away soon after. Had a stress test to see if there are other problems, no problems. Electrophysiologist prescribed Eliquis 5 mg twice a day in lieu of the aspirin I was taking in addition I am taking Toprol 100 mg, Losartan/HCTZ 100-25 and Pravachol 80 mg. Should I get medication to control the rhythm ? Is there a medication that can control the onset of the AFIB when I exercise. It does not happen all the time but when it does it happens after some 25 minutes on the treadmill. Thank you . Ziv

Walid_Saliba,_MD: If the episodes are not frequent it is ok to continue what you are doing however, if these episodes become frequent or bothersome, there are suppressive antiarrhythmic medications that can be tried . Keep in mind that medications have also potential side effects.


Medications – Blood Thinners

joek: Currently, I am taking Xarelto 20 mg. for A-Fib. The recent advertisements for Eliquis seem to indicate that the risk of stroke and bleeding is less than coumadin and Xarelto. At this point I am trying to determine whether to switch from Xarelto to Eliquis if the risk reduction is significant.

Walid_Saliba,_MD: If you are doing well on xarelto there is no compelling evidence to switch medications.

joek: I am currently taking Xarelto 20mg. for A-Fib. I am finding it very difficult to get an update on the status of clinical trials for an anti-dote. Has there been any progress to find ways to deal with excessive bleeding due to a trauma event.

Walid_Saliba,_MD: Yes - there are a couple of antidote (concentrates of clotting factors) being investigated in Europe.

dynabal: My mom is 81 and has afib about two to three times a week. Sometimes it will last 24 hours and then she will go back in rhythm. She is on Toprol XL and Losartin. Her average blood pressure when not in afib is 138/72 with pulse in the 60's. She is on Coumadin and her INR is 2.8. My concern is stroke prevention. How does the type of afib she has increase her stroke risk and what can we do to decrease that risk? How can we reduce the risk of Alzheimer's due to afib?

Oussama_Wazni,_MD: The best course of action is to continue Coumadin and maintain a therapeutic INR.

Xomue: I had an ablation (which seems to have gotten rid of my a-fib) and I don't take a blood thinner, not even aspirin. What is the latest thinking in this area of post-ablation blood thinner use?

Oussama_Wazni,_MD: The decision to continue on anticoagulants depends on at least two factors. The first is the recurrent afib or not. The second, the CHADS2 score. If you truly have no recurrent afib, and your CHADS2 score is zero, then no anti-thrombotic agents are needed. In addition, even if there is a recurrence of afib and your CHADS2 score is zero, no anti-thrombotic agents are needed either. The dilemma is when the CHADS2 score is one or more and we are uncertain about the recurrence of afib. In this situation, our practice has been to recommend an oral anticoagulant.

socal20: My wife is not taking medications other than one baby aspirin for her AFIB as we hope that the mild nature of her symptoms means that she is under much less risk for a blood clot but would like to hear your opinion. She is 69 years old, very highly physically fit, takes no other medications, has no symptoms whatsoever from the AFIB, but does have a very mild form of mitral valve prolapse. Under normal activities, her pulse rate while in AFIB is in the range of 60 to 80 and with exertion in the range of 110 to 150 (under very severe exertion at 150) which is about 20 to 25 beats faster than normal. When the wrist is felt, there is usually only a slight irregularity under AFIB She has low blood pressure and an extremely healthy diet. For some time now, the AFIB appears to come and go throughout the course of the day. We suspect that coumadin would probably pose a greater risk to her than does her present condition with only aspirin for treatment.

Walid_Saliba,_MD: She is at low risk for stroke and aspirin per current guidelines is acceptable. With increasing age, she will need to switch to full anticoagulation as the risk increases. Per European guidelines, she would be candidate for full anticoagulation in view of her age and gender.


Medications – Pill in Pocket

morsch: About once every six months, I get an irregular heartbeat I have a "pill in the pocket"--Propafenone 300 mg--which I take at the onset of the episode. The irregular heartbeat lasts from 8 - 24 hours. I have had this condition for about 15 years and have never needed anything else in order to return to normal rhythm. I am a 71 year old male, jogger and consider my health to be excellent. I take a low dose aspirin once each evening. Is this course a good one to follow? What other options would be recommended?

Walid_Saliba,_MD: If your arrhythmia has been documented previously to be atrial fibrillation then the current course is reasonable. The option for ablation is possible and would eliminate the need for you to take medications.

liesel: What to do during A-Fib? I have been dealing with acute A-Fib with rapid ventricular response since June of 2010. But my events are so far apart :) ) Nine events in almost 3 ½ years, that my cardio is just keeping an eye on it so far and told me to go to the ER after four - six hrs. My protocol during the A-Fib is: I sit quietly in bed w/pulse monitor. I chew one Aspirin-325 mg; take one Xanax; and the last episode I took Metoprolol tartrate. 25 mg when the A-FIB started, then another 25 mg within one hr., two more after that. I am on Metoprolol ER (generic Toprol) 25 mg which I take with dinner; also on Crestor, Plavix and 81 mg Aspirin. I am not on any specific anti-arrhythmia meds. Was on Sotalol for two weeks once, but discontinues due to too low pulse.

My question is: Should I be on an extra anti-arrhythmia medication or just wait until the A-Fib episodes get closer together. The last four events were eight months apart.

Walid_Saliba,_MD: The frequency of the episode is not high enough to warrant a more aggressive approach. I would continue with the current regimen and consider upgrading the treatment if the episodes become more frequent.


Ablation

Bristolpainter: I had an RF AF ablation12 weeks ago. The day after the procedure my resting heart rate was 95-it used to be 60. My BP was also elevated. My RHR is now around 83, and my BP around 125/75 (used to be 110/60) My Dr. says the BP isn't high enough to treat, but it worries me- I exercise, eat a low sugar, low grain diet and don't feel there is anything else I can do to lower it myself. I also have a lot of PVC's/PAC's, especially when I lie down at night. My CRP is four, whereas it used to be <1 -- do you think this is related to the ablation still after three months? I can't think of any other reason why it's elevated atm. I haven't been sick, and I'm otherwise very fit and active. Do you think; a) this will right itself, b) should I be taking meds to lower my BP;c) is this level of inflammation, high BP and RHR damaging my heart? Thank-you so much. Your comments are much appreciated.

Walid_Saliba,_MD: It is not unusual to have slightly elevated HR after the procedure because of the partial damage to the nerves that supply the heart. I would not worry about it as long as it is not causing symptoms. Continue checking your blood pressure and if consistently elevated it will need to be treated. CRP is nonspecific and I would not worry about it for the present time soon after the procedure.

jamesnz: Hi, I am a long sufferer of AF ( 16yrs) aged now 77 . I am almost totally drug intolerant (except for low Propranolol dosage especially to help during an attack). My Cardiologist advises against any ablation procedure except for Pacemaker implant and ablation of the AV node. As I am now worsening with daily occurrences , what would you agree? Also I have a reoccurring kind of tremor which happens while I am in Sinus rhythm . Over the years it has become more and more magnified. So far I can stop it by holding my breath . No one can tell me what it is that causes this . I reiterate that it is over and above my normal heart beat. Have you ever encountered this before? Thanks in advance. James

Walid_Saliba,_MD: It is less likely that the tremor is related to your heart beat and might need to be evaluated by a neurologist. In regards to your afib, if symptomatic, I think you should be at least evaluated for possible ablation of atrial fibrillation by an electrophysiologist who performs this procedure.

jpwhite1: Can an ablation be used to try and treat a fib and then later have valve replacement if necessary?

Mandeep_Bhargava,_MD: Usually if you have a reason to have an open heart surgery, it is best to have the surgery and concomitant ablation of the AF during the surgery with a MAZE procedure. An ablation can be done to treat the AF only if the valve surgery is not needed at this time or in the immediate future.

coljake1: Chat--afib
1. PVI is successful the first attempt--what %?
2. PVI is repeated the second time--what %?
3. PVI is 100% successful after two attempts--what %?
4. PVI may damage pulmonary veins--what %?
5. PVI is recommended for age 84--what %?
6. PVI is recommended for age 84, with 3 years afib--what %?
7. With av node ablation/pacemaker death occurs if pacemaker fails--true?
8. Pacemaker failure is what % with av node ablation?
End of questions. Thank you.

Walid_Saliba,_MD: 1) 50- 80%. 2) 30%. 3) 100% does not exist. 4) 2%. 5) It is possible - even in octogenarians. 6) based on patients preferences and doctors recommendations. 7) very rare. 8) less than 1%

astorian: Assuming a low to moderate stroke risk per CHADS2, will a successful ablation for paroxysmal AF further reduce the risk of stroke -- that is, if fibrillation ceases, would that reduce possible clot formation in the LA/LAA?

Walid_Saliba,_MD: Theoretically, yes. But we do not have firm scientific evidence to that effect. Therefore, at this point the results of the ablation should not change the management of anticoagulation.

shrkstr: My Mom and I both have afib. I successfully underwent a PVI ablation a year ago. My Mom is 71 years old and does not tolerate medication well. She has been cardioverted five times in the last year and she is now constantly in afib with a heart rate that varies from 100-180. Her EP wants to do an AV node ablation since she already has a pacemaker. It is my understanding that an AV node ablation should only be considered as a last resort. Do you know why she would not be considered a candidate for a PVI ablation?

Mandeep_Bhargava,_MD: If she does have significant symptoms during atrial fibrillation, our usual bias is to consider a catheter ablation for the atrial fibrillation (PVI) before considering an AV junction ablation and pacemaker unless the patient is not comfortable with the slightly increased risks of the former.

tomcal223: Hello. I had my first diagnosis of afib twenty six years ago. I have always converted to normal rhythm within weeks with quinidine and then flecanide and an occasional cardioversion. I’ve had two pulmonary vein ablations done. After each time i would be in normal rhythm for almost four years without medication, although i would have some days of a thousand plus single pvc`s. I`ve recently went into afib and had to be cardioverted again. What do you think should be my next option? Ablation again or medication. Afib runs in my family, all three of my brothers have had it and also my father. Do you think my children are at risk?

Oussama_Wazni,_MD: I think it is reasonable to try an anti-arrhythmic medication first (optimal choice at this time may be Tikosyn on a scheduled basis) and if this fails, then consider a redo-ablation.

Captain Bob: Second Ablation April 2013, no lasting effect. What would you recommend as my next step in this pursuit of "Best Possible Heart Health"?

Mandeep_Bhargava,_MD: If you are truly symptomatic with the atrial fibrillation, you could either try a cardioversion in conjugation with an antiarrhythmic drug or you could consider another ablation at a more experience center.


Types of Ablation

mfgold: What has been your experience with cryoballoon ablation for Afib? If you are doing this procedure, what is your long term success rate to date at one year and beyond?

Walid_Saliba,_MD: We do cryoablation with a success rate of 70 - 80% for paroxysmal atrial fibrillation. Overall, we still prefer the RFA ablation approach.

mfgold: What is your experience with cryoballoon ablation? How successful is it in eliminating Afib? How often is a second or additional procedure required to completely eliminate Afib? Thank you in advance for your reply.....Marshall , Oak Harbor, WA

Walid_Saliba,_MD: Cryoablation has worked well for patients with predominantly paroxysmal afib - it has limited value for persistent atrial fibrillation at this point. No procedure completely eliminates afib.

Swimgal: I am interested in finding out more about the FIRM technique and the CONFIRM technique.

Walid_Saliba,_MD: This is a new modality for mapping atrial fib that still needs to be proven on a large scale. We are acquiring this technology and hope to start the process within the next few months.

jswig: Can you please tell me the pros and cons of cryoablation and heat ablation and which procedure do you use the most? Contraindications for cryo? I have been told that it does not result in heart damage like thermal does and it is just as effective. If this is true then why is it not used across the board? Thank you, Jacqueline

Oussama_Wazni,_MD: There is really no difference in the outcomes by using cryoablation vs. radio-frequency ablations. Both have the same safety profile. The efficacy will depend on the experience of the performing electrophysiologist. The notion that cryoablation causes less damage is not scientifically proven. In our experience, there has been more complications using cryoablation mainly due to phrenic nerve injury.


Pacemaker

MikeN: I received a dual chamber pacemaker August 2013 for chronotropic incompetence and sick sinus syndrome. It is currently programmed AAIR, originally programmed DDDR. There was a problem with the DDDR programming that was causing my pulse to increase to 115-120 while I was sitting down. They have seen PVC, PAC, SVT, VT, sinus tachycardia, sinus bradycardia, 1st degree block, 2nd degree block type I & II, right bundle branch block, and various fusion, ectopic and escape beats on holter monitoring. Low voltage QRS and borderline long QT have also shown up periodically on EKG. I currently wake up in the middle of the night with my heart beating very rapidly, and then it subsides after 30 seconds or so. The pacemaker download shows bpm up to 330. Would that be AF?

Oussama_Wazni,_MD: The pacemaker interrogation should be able to identify the rhythm. It could be afib, but it could also be any of the arrhythmias you listed above. If you would like a second opinion, we'd be happy to see you.

jamesnz: Hi, further to my previous questions concerning my problems with Paroxysmal Atrial fibrillation, I now have had a two lead Pacemaker Implantation. If it does not prove helpful we will then have the AV ablation done . So far I have had ectopic beats which seem to fool the Pacemaker into reading the normally set beats of 70 or more . Is there any way that it could read the ectopics out and then stabilize at the set 70? Or better still what is recommended to stop the ectopic beats happening ? I must admit that modern Pacemakers are the be and end all of heart monitoring and as it is early days as yet my cardiac team will be able to come up with a viable setting to help further as I do not like the idea of AV ablation. Thanks in advance, James.

Walid_Saliba,_MD: This is a very technical question whereby we would need to look at the rhythm strips and the interrogation of the pacemaker to be able to give a satisfactory answer.


Surgery

scrn: I am a 59 y/o female with history of mitral and aortic stenosis( Dx 1983). In 2009 I had my first episode of A fib. I went to the ER and was given Cardizem. I had an anaphylactic reaction. I was started on coumadin. I have had six cardioversions. The first two kept me in NSR for a year. I had my last one about five months ago. I was taking Betapace at the time. I have been told that I am not having symptoms that would justify a valve replacement at this time and correcting the a fib would not help unless I had the valve replaced. I consider myself healthy. I recently walked in a 5K. I try to exercise and eat right. I can tell that I am in a fib. The EP has recently asked about Tikosyn. I am considering it but the side effects concern meshed told me I had a up to a year to decide. He said if I stayed in a fib for longer than a year I would probably never be able to convert to NSR. My question is should I try to find someone that would consider the surgery?

Oussama_Wazni,_MD: It seems to me that you need coordinated care to make a final decision regarding whether you need valve surgery or not. If you do need valve surgery, then I would suggest at MAZE procedure to be performed concomitantly with surgery. If no surgery is deemed necessary, then the choices are Tikosyn or Afib ablation. If you would like a second opinion, we would be happy to see you.

shawnh: I have already had multiple ablations for Afib and Aflutter. Non have been successful. It is being suggested that I undergo the Convergent Maze procedure. Does your group perform this operation? If not, is there someone you can recommend that does not work through Largo Hospital? I am willing to travel and go to the doctors that have the most experience in this procedure. Thank you for your suggestions.

Oussama_Wazni,_MD: I am not familiar with Largo Hospital. We do not currently offer the Convergent procedure. We are not convinced that the Convergent procedure affords superior outcomes.


Ending

Mellanie True Hills: On behalf of the afib patient community, I’d like to thank Dr. Walid Saliba, Dr. Oussama Wazni, and Dr. Mandeep Bhargava for answering our questions.

Reviewed: 12/13

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