Arrhythmias&Devices (Drs Borek&Wilkoff 8 27 12)
Monday, August 27, 2012 - Noon
Arrhythmias are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that result in cardiac arrest and sudden death. There are several treatment options for this condition, one of which is often with devices such as a pacemaker or defibrillator. Dr. Wilkoff and Dr. Borek answer your questions about arrhythmias and device therapy.
Symptoms and Diagnostic Testing
Patrice: Hello. I am Patrice from Jamaica. Recently began having palpitations with feeling faint. Started after a very stressful period and still occurs periodically. EKG, echo, stress-echo, CT angiogram - all normal. Doctors here suggest an EPS and further action as necessary. Very scary. I'm 45, female, essentially living alone, cut down from almost 30 cigarettes/day to less than 5 but still trying to stop completely. Bisoprolol 5mg dropped BP to 77/50, and 2.5mg didn't help the symptoms much. I'm on verapamil HCL SR 120mg and 5 mg valium for the past 3 days and today was the first time since starting those modes that I felt 2 flutter/skipped-beat type palpitations (but no fainting). Waiting for response from your Weston clinic for an appt date. Don't know what - if anything- I can do in the meanwhile. Any advice is welcomed.
Dr__Borek: I applaud your smoking cessation. You should stay hydrated (drink enough water). Skipped beats even though highly symptomatic are rarely associated with any serious consequences.
The medications you are on aren't always completely effective. If your symptoms persist despite medical therapy, further workup would include holter monitor for 24 hours or an event monitor to better characterize your symptoms. If frequent premature beats coming from the upper or lower chambers of the heart are found and medical therapy proves to be ineffective, proceeding with EP study and possible ablation are not unreasonable.
petesuszc: please describe procedure to determine what type of palpitations a person is having
Dr__Borek: Determining the relationship of one's symptoms to their rhythm is typically done by having the patient wear a holter or event monitor. Both are outpatient tests. The patient wears the holter typically for about 24 hours. Event monitors are generally worn for about 30 days. Requiring one or the other depends on the frequency of your symptoms.
Patrice: Can you give me a brief idea of what an EP study involves and whether I would have to be awake during such a procedure?
Dr__Borek: This has been answered. See electrophysiology study.
Atrial Fibrillation (Afib)
Lydia: Are there new type of drugs for Arterial Fibrillation. I take Metoprolol, Digoxin, and Pradaxa. My doctor would like to put me on another drug that is newer because my AFIB in not managed with successfully with the above medication.
Dr__Borek: The newest drug that came out for treatment of atrial fibrillation is Multaq however its efficacy in treating afib is marginal at best. Tried and true agents, which we use here frequently such as flecainide, sotalol or tikosyn are reasonably effective. Typically when these fail we recommend proceeding with an ablation procedure.
charles2297: I have atrial fibrillation and have a pacemaker due to AV node ablation. I still feel symptoms of my atrial fibrillation - racing heart, feel tired. Is there anything more I can do?
Dr__Borek: If the AV nodal ablation procedure was successful and there is no slow atrial flutter you should not be feeling the racing heart rates. Unfortunately the fatigue is usually related to the presence of atrial fibrillation which in your case has not been eliminated.
If your symptoms persist, further approach could include trying medications and even proceeding with an ablation procedure if appropriate. Occasionally, reprogramming the pacemaker device can help alleviate some of the symptoms, especially palpitations
kellwill: I had atrial fibrillation associated with mitral valve prolapse starting in1995. I got normal sinus rhythm via cardioversion. In 2003 l had the mitral valve replaced with a bovine valve and underwent the maze procedure at the Cleveland Clinic. Afib has returned recently and I am taking coumadin and digoxin. My cardiologist has said he is willing to try cardioversion if I wish, but he feels staying with the coumadin/digoxin regimen is also fine. I am wondering whether I should have cardioversion. I am not bothered by the Afib and have no noticeable symptoms that would cause me to be in a hurry to have the cardioversion. Is there a reason I should do it?
Dr__Wilkoff: This is a question that doctors looked to consider in a trial called AFFIRM. The study which was a worldwide study looked at restoring normal rhythm with cardioversion and meds or controlling heart rate and controlling risk of stroke with anticoagulation (blood thinners).
Before the study it was expected it was better to stay in normal rhythm. But the study showed there was no difference and if anything a slightly better outcome with control of heart rate and anticoagulation. This is the approach often taken when someone has no symptoms with their afib.
The other consideration is the age of patient. The avg age of the patients in the AFFIRM trail was 70 years of age. In younger patients and in patients which afib started more recently more effort is placed on restoring normal rhythm.
jackpat2: Please discuss "Pill in the pocket” concept for patients with intermittent fib/flutter, and are presently on Toprol to suppress these arrhythmias. Thank you.
Dr__Borek: Pill in the pocket approach is very reasonable in patients who have a very low afib burden - meaning - their afib occurs no more than once per month. Metoprolol typically is not a very effective drug to treat afib but has to be on board while using the pill in the pocket approach. If presence of afib causes significant symptoms or requires visits to the emergency room, this approach is less desirable. In those situations we typically recommend prophylactic treatment with daily dosing. Pill in the pocket approach involves taking the medicine only when atrial fib recurs.
Dale-S: I have had two afib ablations, and one aflutter ablation. Plus numerous cardioversions. Latest did not work at all. At present, I am in permanent afib. What should be my next step? Respectfully
Dr__Borek: Depending on the degree of your symptoms related to your afib, you may consider proceeding with rate management and stroke prevention approach. This would involve taking either beta blockers or calcium channel blockers to better rate control atrial fibrillation and taking either coumadin or one of the newer anticoagulants (blood thinners) in order to decrease the risk of stroke.
KenAFIB: My cardiologist suggested taking fish oil capsules to help prevent future attacks. Has this been shown to help?
Dr__Borek: I am not familiar with data that supports that.
SMDTS: I am on tikosyn and have previously had an ablation which was not effective. Can the ablation be repeated?
witter123: I have been taking Multaq for exactly 2 years and it has been very successful keeping me in NSR. Am I that unusual for that success?
Dr__Borek: No. Multaq is indicated to treat paroxysmal atrial fibrillation.
FJL: I am on Toprol, digoxin and pradaxa and I have AFib. My AFib causes me some tiredness, small balance issues and heart palpitations which can be strong. My cardiologist is suggestion I take a different medication rather an ablation. I do not know the name of medication at the present time, I was wondering which has the better success rate in managing my A fib?
Dr__Borek: Each case is different but atrial fibrillation ablation is significantly successful in managing afib than medical therapy.
ndpaulh: I am 76 years of age and have been on pradaxa, tekturna and bisoprolol for the past two years. is there any long term problem staying with pradaxa?
Dr__Borek: Since this is a newer medication, long term affects of pradaxa are not well established, however generally speaking it is considered a safe medication. You will require careful monitoring through your local cardiologist.
Premature Atrial Contractions (PACs)
David101: PACs, particularly 9 or more in 30 seconds can be a trigger for Lone AFIB. If Catheter Cryoablation is used to isolate the pulmonary veins will that isolate the PACs also?Sometimes I have a HR in the 40 to 42 range along with many PACs and I am taking 80 MG of sotolol twice a day. Am I a candidate for a pacemaker?
Dr__Borek: Catheter ablation may eliminate the PAC if the PAC comes from the pulmonary veins. The site of PAC origin may however be different than the pulmonary veins at which point obviously the ablation would not affect it. In those cases I usually try to map out the PAC origin and ablate it as well.
As long as you are not symptomatic from the HR of 40 I would say that PPM therapy would be not be appropriate. By symptomatic I mean feeling dizzy, passing out or having a hard time with exertion.
Supraventricular Tachycardia (SVT)
LPyle1958: Are there any other options for SVT other than ablation, defib or medication?
Dr__Borek: Medications are always a reasonable option for treating SVT typically because success rates of ablation are very good we recommend proceeding with an EP study and ablation if indicated.
LPyle1958: Are there any other heart issues that can result from SVT?
Dr__Wilkoff: If someone's heart rate goes too fast for too long, it puts a strain on the heart and the heart function can deteriorate with time. The good news is that if the heart rate is then controlled, often the heart can heal and pump normally.
Sherlann: I am feeling very discouraged. I have had two failed ablations for SVT. I am wondering if I should try another place or if it is possible to treat my SVT. Is it even safe to have that many procedures - can't it damage your heart? Any help you can provide would be appreciated.
Dr__Borek: SVT ablation can sometimes be difficult and require more than one or even two procedures. Generally speaking proceeding with a third ablation would not carry any higher risk than the prior ablations unless there may have been some damage that was done to the conduction system. It sounds as though your SVT is more complex and seeking a second opinion at a more experienced, higher volume center would be appropriate.
Premature Ventricular Contractions (PVCs)
StuCA27: I have PVCs and have one failed ablation. The doctor said that is because the beats are firing from the outside wall of the heart. Does that make sense to you? Is there another type of ablation or treatment to fix this type of beat?
Dr__Borek: Depending on the epicardial (outer surface of the heart) location of the abnormal heart beats one could consider performing what is known as epicardial ablation or ablation through the coronary sinus.
Because of the presence of epicardial fat on the outer surface of the heart reaching those places may be difficult. As a result the success rate of epicardial ablation is significantly lower. Seeking a second opinion at an experienced VT ablation center may not be unreasonable.
stimpysan: I was diagnosed with stress induced PVC's a couple of years ago. I also get them when lying down, reclining in a chair and when over-eating. Since being put on 10 mg of propranolol 4 times a day my symptoms have diminished but are still bothersome. Is it safe to exercise even if I have PVC symptoms and will it help?
Dr__Borek: Exercise is generally safe in patients with normal hearts with our without PVCs. However if there is any history of passing out, a more thorough evaluation may be required to clearing you for exercise.
clara: I have developed PVC's - 1000 extra. I had the monitor for 24 hours. I know they are not serious, but I would like to know if they can develop to A fib. I have had open heart surgery - aortic valve and grafts 6 years ago and 7 stents in the last 4 years. I am now told that I will need surgery for the triscupid valve that is severe, and the mitral valve has gone to moderate. I am having symptoms - SOB / lightheaded / fatigue / water retention. My stents are in all the major arteries none are restented.
Dr__Borek: PVCs are very unlikely to cause atrial fibrillation.
nursjess: I'm 32 yo female with history of PVCs for 10+ yrs, became worse (bigeminy) with onset of pregnancy 3 yrs ago and have not improved. Last wk, holter showed 20,000PVCs, mostly bigeminy, diagnosed with RVOT. Cardio says I can't tolerate Beta Blocker b/c of b/p 110/60 and HR in 60s. Recommends ablation. Anything I could try prior to jumping into ablation? Is RVOT an "easy" ablation? Is it OK to leave it untreated? Is there any chance hormones are causing this? I also have 10 mo old twins and had to use fertility treatment due to "perimenopausal hormones" Thanks for any advice!
Dr__Borek: You can consider medications such as flecainide, 50 mg twice daily or so.
Typically however because RVOT ablation is relatively easy to perform, proceeding with ablation is typically more desirable because of the side effects related to the medications. 20,000 PVCs over a 24 hour period will most likely not cause any significant damage however you will require yearly monitoring with your cardiologist if you choose to leave it untreated. Hormonal changes such as that occur around time of menopause or menstrual cycle have been known to contribute to PVCs.
nursjess: What is first line treatment of RVOT (right ventricular outflow tract)?
Dr__Borek: If the patient is symptomatic we typically recommend proceeding with ablation or medical therapy.
nursjess: Are RVOT PVCs considered dangerous?
Dr__Borek: These are generally considered benign although on very rare occasions have been associated with sudden cardiac arrest. Simple history and evaluation of your EKG are generally required to make that determination.
Ventricular Tachycardia (Vtach or VT)
tom24oh: I have had a holter which has shown runs of vtach. However, my echo shows I have a normal heart. My doctor is talking about an ablation. I am wondering if this is the treatment for Vtach with normal heart. What does that involve? What is the success rate?
Dr__Borek: Normal heart VT has a favorable prognosis. Typical approach to therapy may include either medications or proceeding with an EP study and ablation. The latter being quite effective in greater than 90% of patients.
VT ablation procedure is generally performed under conscious sedation. The patient usually comes in the day of the procedure and leaves the following day. Catheters are placed through the groin into the heart. The abnormal rhythm is induced or caused and very carefully studied. If appropriate an ablation involves delivery of heat energy or cooling of the affected area.
carolineK: I have a pacemaker put in for abnormal heart beat and sometimes I feel a pounding in my chest or shortness of breath. My friend told me she saw something on the news about pacemaker syndrome. What is it? and can that be what is causing my symptoms?
Dr__Borek: Pacemaker syndrome is a condition where the patient develops symptoms as a result of pacing. They may include palpitations, shortness of breath especially with exertion or chest pain. Your symptoms could be related to that. Further investigation would include a thorough device check. No invasive tests would be necessary. This could be handled as an outpatient visit.
AnitaC: and I am very interested hearing in hearing Dr. Wilkoff’s answers and comments about pacemakers and ICD devices; I’ll be very grateful to get an email transcript; My main question is if there is any chance to create a device which will treat the atrial -fib(flutter). There are people who tried almost all the medicines including heart surgery and MAZE procedure have a pacemaker device but could not say YES to AV node ablation. THANK YOU for taking my question. Anita
Dr__Wilkoff: There is a pacemaker that uses rapid pacing to end atrial flutter but the atrial flutter can recur. These devices are most effective in patients who are better treated with an atrial flutter ablation. There have also been pacemakers used with multiple leads in the atrium to reduce the frequency of atrial fib but again ablation of the atrial fib is usually more effective in maintaining normal rhythms.
The goal in atrial fibrillation is to control the rate and the regularity of the heart beat. And then if possible to restore the sequence from the atrium to the ventricle. Afib disrupts all of these issues - rate, regularity and sequence between the atrium and ventricle. By its essence, pacemakers only prevent the heart from going too slowly and medications or ablations are required to prevent new fast heart rhythms from occurring.
vateton: What are the dangers of having a pacemaker with a defibrillator if you only need the pacemaker itself?
Dr__Wilkoff: Pacemakers and defibrillators have a lot in common - in fact every defibrillator includes all the functions of a pacemaker as well as a defibrillator.
Defibrillators are slightly larger and last less long because the battery is used for more activities. Other than the increased size and the more frequent replacements that occur with a defibrillator, only the potential of receiving a shock is something you would see as a risk. On the other hand a pacemaker will not be able to rescue you from sudden cardiac arrest. There are specific indications for defibrillators and specific indications for pacemakers - you should only receive what you have an indication for.
vateton: I’ve been diagnosed with right bundle branch block and trifascicular block, and have a pacemaker installed. I sometimes worry that I don't have combination unit with a defibrillator - is that generally installed in cases like this?
Dr__Borek: Heart block as in your case, generally only requires implantation of a pacemaker. Defibrillators are not indicated in this case.
Hudson: What changes in technology can I expect when replacing an 8 year old Medtronic defibrillator?
Dr__Wilkoff: The most important changes in technology in ICDs has to do with the ability to remotely evaluate the function of the defibrillator, the leads and the patients in their home no matter where they live in the world.
It has been possible for patients to have a monitor in their homes that they place a wand over the device to send info to their doctors periodically. However, now - the device checks itself and will send that same info to the doctors while the patient sleeps as the information is sent from the ICD over the internet to the doctor only if there is something important to tell. The patient also can send information through the defibrillator and monitor if they have symptoms then the patient can talk to their doctor to see if there is any relationship between their symptoms and how the device is working.
The other change in technology is more of the doctor's understanding of how to best adjust the defibrillator to avoid unnecessary shocks and to improve both the patient’s heart function and longevity. The defibrillators have so many choices that it was unclear what the best choices were in the past but that has become very clear at this time.
JohnM: I have an ICD installed. It has been suggested that a third lead Would improve my current fatigue problems. What do you consider the likelihood of this and what risks? Thanks you
Dr__Wilkoff: Implantable defibrillator therapy can be employed with 1, 2 or 3 leads. The main function of the ICD is to prevent sudden cardiac death. When a third lead is added it is used to help restore the pumping function of the heart.
In order to assess the likelihood of your feeling better with 3 lead defibrillator therapy, I would need to know what your ejection fraction is, what the width of your heart beats are on your EKG, and what the pattern of block on your EKG consists of. Usually defibrillators are implanted in patients with EF of no more than 35%. 50 - 55% is normal but when the percentage of blood pumped out with each heart beat is reduced then less blood goes to your body parts and fatigue can result. The third lead helps to narrow the heart beat on the EKG and if successfully employed can improve the percentage of blood pumped out with each heart beat.
The risk associated with a three lead defibrillator is similar to that of a 1 or 2 lead defibrillator and would include the risk of infection and some risk of bleeding. But overall, it is a good choice when used in the right patient.
bas46: What is the possibility of heart damage when an ICD fires approx. 50 times in about a 2 hour period?
Dr__Wilkoff: The most significant damage is the emotional health of the patient as it is very uncomfortable to receive ICD shocks especially that frequently in that short of time. Some damage has been detected in patients who receive many shocks from their defibrillator; the amount of damage to the heart is relatively minor.
There are many ways of responding to that many shocks - sometimes medications, sometimes programming of the defibrillator, sometimes ablation are all ways of managing the situation. It is never appropriate to allow that situation to continue with out addressing the possibility of receiving more shocks.
jpow717: I have an ICD for small runs of VT. I exercise and lift weights to stay toned. I'm worried about my heart rate getting to high when I'm lifting. Is there a heart rate I should stay under?
Dr__Borek: The answer to this question depends on how your device is programmed. For the majority of patients this is typically about 180 bpm. In this case, I would not go over 150 - 160 bpm during exercise. You should discuss this with your doctor who placed and programmed your device.
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