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Atrial Fibrillation - Dr Lindsay

Monday, April 13, 2009 - Noon
Dr. Lindsay

Bruce Lindsay, MD
Staff cardiologist
Section Head, Cardiac Electrophysiology and Pacing
Tomsich Family Department of Cardiovascular Medicine

More Information

MedHelp: Welcome Dr. Lindsay. Thank you for taking the time to answer questions today. We look forward to learning more about atrial fibrillation.

Bruce D. Lindsay, MD: Thank you for having me.


Atrial Fibrillation

Shiaya: What causes atrial fibrillation?

Bruce D. Lindsay, MD: Atrial fibrillation is caused by abnormal electrical activation of the atria. Sometimes, this is caused by extensive damage to the atrium from underlying heart disease. In many patients, it originates at the attachment of the pulmonary veins to the left atria.

The muscle cells at this junction send out rapid electrical discharges that trigger atrial fibrillation. Nerve inputs to the heart, stretching of muscle fibers and other factors seem to be important in starting atrial fibrillation.

Yapi: How common is atrial fibrillation in children under 5 years old? What sort of treatment options are there?

Bruce D. Lindsay, MD: Atrial fibrillation is very rare in children. Sometimes it is associated with congenital heart disease. The treatment would depend on whether the child has congenital heart disease or some other heart disorder.

Lishibelle: How dangerous are a-fibs? Is it hereditary?

Bruce D. Lindsay, MD: Atrial fibrillation is not a life threatening condition but it can cause severe symptoms in some patients. Others tolerate it without any difficulty. We are beginning to understand that certain genes predispose patients to atrial fibrillation. This is one of the current studies at the Cleveland Clinic.

kat4: Although I have an a-fib episode once or twice a year, my main problem is frequent episodes of frequent ectopics. These cause me a lot of distress from anxiety, even though I know they are supposedly not dangerous. (1) Can an ablation help those? (2) I have heard that Flecainide can help them, but my cardiologist says it is too dangerous "just for ectopics." Is there a med that can help? I am currently on Toprol 100 mg a day, which is the max I can take without substantial shortness of breath even though I do not have asthma, and magnesium. Thank you.

Bruce D. Lindsay, MD: The response to your question is similar to one of the prior questions. It might be feasible to treat your problem with either medications or an ablation. The choice of medicines depends on balancing the risk of taking the medicines with the severity of your symptoms. If your extra beats are debilitating you should talk to your doctor further or consider a second opinion.

TraynFab4: Hello Dr - I'm a 40 yr old male and had a single bout of lone a-fib just over a year ago. Testing revealed no problems. How likely am I to have another episode of a-fib? Is there anything I can do to prevent it from happening again? Thank you.

Bruce D. Lindsay, MD: It is quite possible that you will not have another episode of atrial fibrillation for many years. Patients can reduce the risk of atrial fibrillation by limiting or avoiding alcohol intake, keeping their weight under control or undergoing treatment for sleep apnea if they have that problem.

peachescream53: I had a heart attack in May 2006, had 4 stents put in. After the heart attack I was found to be in atrial fibrillation. I am on Coumadin, plavix , aspirin and sotalol. My cardiologist attempted cardioversion twice, neither time worked. What other non surgical options are available? Since I have been in atrial fibrillation for almost three years am I still a candidate for ablation?

Bruce D. Lindsay, MD: The success of ablation procedures is highest in patients with paroxysmal atrial fibrillation (intermittent) as opposed to long standing persistent atrial fibrillation like yours. You might benefit from another medication or an ablation procedure. Good results can be achieved in patients like you but the success rate is lower and you are more likely to require a second ablation procedure to achieve a good long term result.

terk: I have read that if someone is in a-fib for 48 hours then they should go to the emergency room. What is the significance of this 48 hour mark and what happens at the ER? Thanks.

Bruce D. Lindsay, MD: Patients are advised to go to the emergency room immediately if they have severe symptoms. For those who have less severe symptoms, a trip to the emergency room can be delayed to see if the atrial fibrillation converts spontaneously. If it persists for more than 48 hours, the risk of stroke increases in patients who are not appropriately anticoagulated. This is not as great a concern for patients who are treated with warfarin.

kat4: A previous questioner mentioned going to the ER after 48 hours in a-fib. I had thought the deadline was 24 hours?

Bruce D. Lindsay, MD: The recommendation is 24-48 hours, but it is not that specific. In some cases I would be willing to wait 72 hours. I would be more concerned about patients who do not tolerate atrial fibrillation, who have a rapid rate, or those who are at increased risk for stroke. Risk factors for stroke include coronary artery disease, valvular disease, heart failure, hypertension, age > 65, diabetes, and a prior history of stroke. Most patients with these risk factors take warfarin, so the risk of stroke would not be great if the dose is in the therapeutic range.

eshghi: Does atrial fibrillation lead to any chest pain?

Bruce D. Lindsay, MD: Patients often experience chest discomfort when they are in atrial fibrillation even if they do not have coronary artery disease. This may be related to the rate and irregularity of atrial fibrillation - you should discuss your symptoms with your doctor to see whether he is concerned about underlying coronary artery disease.

fattie515394: I have had 3 episodes of a-fib over a year's time in 2007 and ending in March of '08. Twice when I experienced it was when I stepped off of my recumbent bicycle after 45 minutes of strenuous exercise achieving a heart rate of 130 to 140. I was on BP medication that slowed my heart rate. The other time, I ate a lot of chocolate candy at Halloween and I believe the caffeine brought on the irregular heartbeats. Since that time, I have not gone over 107 to 110 heart rate on the recumbent bike, limited my caffeine intake, lost weight (6'1" and 214lbs), no alcohol intake. I have not had another episode. My cardiologist thinks a-fib will come back and the exercise and caffeine did not cause it. What research has been done on lifestyle changes to address a-fib?

Bruce D. Lindsay, MD: Lifestyle certainly can affect the risk of atrial fibrillation. While I agree that you are prone to atrial fibrillation and you may encounter this problem in the future, it is encouraging that you are doing so well now. I recommend that you continue to do what you are presently doing. If the atrial fibrillation recurs you may require treatment in the future.

Shiaya: Can you ever get rid of a-fibs, or does it require on going treatment?

Bruce D. Lindsay, MD: Atrial fibrillation generally recurs if it is not treated. Medications suppress it but do not offer a cure. Ablation procedures are performed to cure atrial fibrillation and eliminate the need for medications.


Ablation for Atrial Fibrillation

dsennet: Does it make sense to postpone an a-fib ablation as long as possible in hopes that techniques will improve OR is my best chance of success with ablation now since I have only had a-fib for about a year? I always self convert and I am on 100X2 flecainide.

Bruce D. Lindsay, MD:There is no urgency to undergo an ablation. The technology continues to improve. On the other hand, there is evidence that the more you have atrial fibrillation the more episodes you are likely to experience. It appears that atrial fibrillation begets atrial fibrillation. I would consider an ablation procedure if the episodes start occurring more frequently or last longer.

skywalker3: I had a Cox Maze procedure done during by-pass surgery three years ago. Approximately a year ago I had a minor stroke. The genesis of the stroke was attributed to paroxysmal a-fib. Is another ablation in order to avoid life long warfarin therapy? Thanks!

Bruce D. Lindsay, MD: Strokes are uncommon with the Maze operation as it was originally designed but the risk may not be eliminated if you underwent a modified Maze operation. An ablation procedure could eliminate the atrial fibrillation if the surgical procedure did not successfully isolate the pulmonary veins but I would be extremely cautious about stopping your warfarin. Further information would be needed to make that decision.

bcat: I have been told that I am not a candidate for pulmonary vein ablation because my a-fib is permanent and my left atrium is enlarged (52 mm). An AV node ablation was recommended. My a-fib is mostly under control with cardizem and digoxyn and a pacemaker. Would there be any advantages or disadvantages to the AV node ablation?

Bruce D. Lindsay, MD: An av node ablation would be indicated if your heart rate cannot be controlled by medications. On the other hand, it would not be necessary if your heart rate is well controlled.

ksig: Six weeks ago I had an AVJ ablation due to many years of A-Fib and treatments. I have felt tremendously better but I still have A-Fib and I can feel it. At this point I can live with what I have but fear that A-Fib will continue to get worse. I am off all drugs except for Coumadin. Are there any more treatment options for me if A-Fib becomes intolerable again?

Bruce D. Lindsay, MD: Your residual symptoms may be related to lack of synchrony between the atria and ventricles. Sometimes, ablation of atrial fibrillation restores that synchrony and alleviates symptoms. I would need further information to decide whether you would be a candidate for an ablation procedure.

dsennet: What is the risk of stroke during an ablation for a healthy 57 year old male with no heart disease or any health problems? I have normal BP. I have a-fib but always self convert. It is fairly well controlled with flecainide but I have some breakthroughs. What is the risk of death? I am one of those tall skinny runners who seem to get a-fib more often.

Bruce D. Lindsay, MD: The risk of dying during ablation for atrial fibrillation is approximately 0.1 - 0.2 percent. The risk of stroke is approximately 0.5 percent.

Bilbo1933: What is on the horizon for advances in A-fib ablations?

Bruce D. Lindsay, MD: We have made a great deal of progress in developing ablation techniques for atrial fibrillation over the past 10 years. Recent work involves improved 3 dimensional imaging to help position catheters and identify scar tissue. Robotic and magnetic navigation may help to improve control of the catheter and reduce the risk of complications. We are still working on developing new technologies that will make these procedures more effective and safer.

terk: What are the long-term effects on the heart of intermittent a-fib episodes? At what point is ablation recommended?

Bruce D. Lindsay, MD: Brief intermittent episodes of atrial fibrillation are not dangerous. Over time (months to years), the episodes tend to become more frequent and last longer. Most patients tolerate them well if the heart rate is controlled. Ablation is recommended for patients with symptoms that are not alleviated by medical therapy.


Atrial Fibrillation and Medications

oreothecat51: Hi, on January 26th of this year I had a pulmonary ablation performed. For the first two months I felt great, now I am experiencing PVC's and PAC's (holter monitor for 48 hours showed 500 PVC and 400 PAC--I take Prevacid, Benicar, Tricor. I have had no a-fibs since the ablation--in fact I can walk and do a little running, but the PVC's and PAC's are killing me--any help would be appreciated.

Bruce D. Lindsay, MD: PVCs and PACs are common in patients whether or not they have undergone a prior ablation procedure. Some patients are not bothered by these extra beats while for others they are debilitating. While they are not dangerous, they can effect your quality of life. Treatment with medications might help to suppress these beats or a second ablation procedure might be effective. You will need to discuss these options with your doctor.

Bilbo1933: I have had 3 ablations for paroxysmal AF and one for Aflutter. No other comorbidities, no CAD, HTN, etc. What a about a 4th ablation? I'm in the hospital now to start tikosin loading. What are the side effects and efficacy of tikosin?

Bruce D. Lindsay, MD: Patients often require more than one ablation to achieve a good long term result. However, if you have already had 3 ablations your problem may be more complex and may not be curable using catheter ablation techniques.

Tikosyn is approved by the FDA for treatment of atrial fibrillation. It must be used carefully but it is well tolerated by most patients and often alleviates symptoms.

Kent29946: Two and a half years ago--at age 60, I was diagnosed with A-Fib and put on solotol which did not stop the episodes, and in fact, they became worse during the last year. Four weeks ago my doctor changed my medication to metoprolol and rhymotol and since then I have not had any episodes. Is it likely that I will remain episode-free or should I continue to prepare myself--mentally--for an ablation as I was doing before I switched medications?

Bruce D. Lindsay, MD: Sometimes medications will work for years before the underlying problem becomes unresponsive to treatment. Ablation procedures can be considered at that point but for now you are doing well and may continue to do well for a long period of time.

Kent29946: Thank you for your response to my earlier question. As a follow up question--when I was taking solotol, although I would experience episodes, I could, with moderate exercise--15 to 20 minutes on a treadmill or elliptical machine--restore my regular heartbeat. My cardiologist said this was unusual, but after reporting the same results over a year and a half, it was clear that the exercise was having a positive result. Is there an explanation for what was happening while exercising to restore my regular heartbeat?

Bruce D. Lindsay, MD: I have heard other patients say the same thing. It may be related to the effects of nerve reflexes on the heart, but nobody knows the exact answer.

GrammaHoney: I'm 69 with a history of PSVT, heart failure, and now A-fib. Tikosyn keeps me in NSR for the past 6 weeks, and I also take Coumadin. I am considering the sinus node ablation due to long term effects of Tikosyn. What are your thoughts on that procedure at this season of my life?

Bruce D. Lindsay, MD: Sinus node ablation is not used for treatment of atrial fibrillation so you may be confused about the use of terms. Sinus node ablation has been performed for other conditions but the results are not so predictable. Perhaps you are thinking of AV node ablation which in combination of a pacemaker is used to control the heart rate. it is not curative. The alternative if you do not respond to medications is to undergo a pulmonary vein isolation, which is curative. Tikosyn can be taken for long periods of time without any known cumulative toxicity.

danforth: I was put on a beta blocker for slightly elevated blood pressure and racing heart. I recently was switched from Toprol XL to Lopressor. Do beta blockers make you tired? Also, are these two meds really comparable?

Bruce D. Lindsay, MD: Toprol XL and Lopressor are different brand names for Metropolol. Most beta blockers can cause some fatigue.

kat4: In general, do medicines for a-fib also prevent ectopics? Or only certain a-fib meds? Which are the most effective at preventing ectopics?

Bruce D. Lindsay, MD: Some medicines do not prevent ectopics or atrial fibrillation but they are helpful in controlling the heart rate when you go into atrial fibrillation. Other medications help to prevent atrial fibrillation. These include sotolol, propafenone, flecainide, dofetilide, and amiodarone. Other drugs are under study and may be approved soon.

Followme: I have asthma so I can't take beta blockers. I was diagnosed with PVCs last year after wearing a 24 hour Holter. They were not bad then, so we decided no meds. Then last month those PVCs got much worse. So bad that I was having them non stop all day long, with short burst of rapid beats in between and chest pains in the middle of my upper chest that lasted about 5 minutes after the last PVC. The only relief I got was to lay down when they occurred. My doctor tried another EKG but of course nothing happened, so I have carte blanche with the EKG only my problems don't seem to occur until after 5pm or on weekends. Is there some other form of meds that I can take to get rid of these annoying things without messing with my asthma meds? Since my PVC, PACs have been getting worse, should I get another Holter reading? I am a 55 year old female.

Bruce D. Lindsay, MD: An event monitor is a device that would allow you to record your heart rhythm at your convenience from at home and would help to determine what is causing your symptoms. If you cannot take medications or they are ineffective, then you might be a candidate for ablation of your premature beats.

runnertom: I am a lifelong runner and cyclist who at age 54 was found to have a bifurcation lesion in the LAD that was treated with CABG. I have 6 years later continued my exercise regimen but have bouts of A-fib brought on by near maximal exertion while biking. They self convert normally after 24 hours. My doc gave me some amiodarone 100 mg/day but I have cut it back to about 200 mg/week with no episodes in the 4 months I have been on it. Do you think this is a good long term plan as I have read that the bad side effects of this drug seem to be related to the total lifetime dosage? P.S. Cardiac CT scan shows my mammary graft to be occluded and I am apparently living off of my collateral circulation.

Bruce D. Lindsay, MD: You are on a very low dose of amiodarone and are unlikely to experience any bad side effects on such a small dose. I do recommend that you undergo a stress test if you have not already done so - the purpose is to confirm that it is safe for you to continue exercising.

neelaMD: Hi Dr Lindsy, I am an internist. After a node ablation, if a 70 year old man is in sinus rhythm for one year, can I take him off Coumadin and put him on aspirin?

Bruce D. Lindsay, MD: The decision to stop coumadin depends primarily on the risk of stroke. These risk factors include underlying heart disease, age, diabetes, hypertension and prior stroke. It would be reasonable to use aspirin if the stroke risk is low to begin with but I would not stop it otherwise if the patient has significant risk factors. One reason is that the patient may still have unrecognized atrial fibrillation.

fattie515394: I have had 3 episodes of a-fib but have been free of them for over a year. I have been taking sotalol with a dosage of 120mg twice daily and Diovan. Since the a-fib is no longer an issue, I would like to return to Nadolol instead of the sotalol since I can take Nadolol once per day instead of twice. Would you recommend me asking my cardiologist to give this a try? I am a 61 year old male with hypertension.

Bruce D. Lindsay, MD: It is likely that the atrial fibrillation will recur if you stop the sotalol, so I do not recommend it.

Bilbo1933: My EP told me that a new amiodanone without the side effects of amiodarone. What do you know about it?

Bruce D. Lindsay, MD: He is referring to dronedarone. The physician panel recommended that the FDA approve it and we await their final decision.

Despite some hype in the press, the reality is that the long term effectiveness of dronederone is probably in the range of 35%. It will be useful, but it is not a panacea.

Chris2519: I am 41, have sleep apnea and am using the C pap machine, but otherwise healthy. I was dx'd with paroxysmal a-fib and take 50 mg metroprolol 2x a day plus one 81mg aspirin. Since I started the meds, my palps have become more frequent (every day) and I get lightheaded when I get up too fast. I lift weights 4x a week and walk 6x per week but feel sluggish when training. I cannot lay back flat or in a 45 degree angle without palps. Have taken a nuclear stress test, holter test, blood work, chest x ray and ECG (all ok). My heart is slightly enlarged (4.7) but the cardiologist said it was nothing to be concerned about. The cardiologist wants to do cardio version and also commented that we should consider Cardiac catheterization. What alternatives do I have? I read that 80% of the people that do cardio version end up back in fibrillation within 1.5 yrs. Could the metroprolol make the palpitations worse? Would something natural like vitamins help? If I wanted a 2nd opinion, what facility/doc would you recommend?

Bruce D. Lindsay, MD: If you chose to seek a second opinion, my recommendation is to see a board certified electrophysiologist who treats a large number of patients with atrial fibrillation. Some patients do not tolerate metoprolol, but it is likely that the palpitations are worse because you are having more atrial fibrillation or the rate is not well controlled. Cardioversion does not cure atrial fibrillation. Sometimes it must be repeated on other medications that are more effective in preventing atrial fibrillation. There is no evidence that vitamins will help.

Lishibelle: My mother has atrial fibrillation. Her doctors disagree as to whether she should be on warfarin. Cardiologist says definitely. Neurologist / trauma surgeon say definitely not. (She is very unsteady on her feet and has already had a serious fall that resulted in subdural hematoma.) Why is a-fib associated with increased risk of stroke? How high is this risk?

Bruce D. Lindsay, MD: Atrial fibrillation is associated with strokes because clots tend to form in the left atrial appendage where the blood flow is "stagnant" during atrial fibrillation. The risk is in the range of 1-8% per year depending on specific risk factors. Unfortunately, the patients who are at greatest risk of stroke often have greater risk of complications from warfarin. A history of falls resulting in a subdural hematoma is a genuine concern. The decision becomes a matter of judgment and sometimes physicians have different opinions when there is not absolute right or wrong answer.

terk: Besides a-fib, I have a clogged artery that I'm taking low dose Metoprolol and low dose statin as well as aspirin. My doc said low dose aspirin (81 mg) would be enough but this forum has mentioned the full or 325 mg. aspirin. Which do you recommend and if the concern is that the full dose might be irritating to the stomach, what do you feel about alternating between low and full doses? Is the full dose 4x more effective?

Bruce D. Lindsay, MD: There is no definitive answer to your question. Most of the stroke prevention trials used a dose of 325 mg, but 81 mg is an option if you cannot tolerate the higher dose.

TraynFab4: Hello. I'm a 40 year old healthy male and had a single episode of lone a-fib over a year ago. My BP has been creeping higher over the years (now consistently around 140/80) and my doc is considering putting me on a beta blocker to bring it down. My normal resting HR is about 60-65 and I understand that beta blockers lower HR. Would a beta blocker be a good choice or is there another med that might be better? Thanks again...

Bruce D. Lindsay, MD: A beta blocker is a reasonable choice. It is largely a matter of trying it to see how you tolerate the medicine. If your heart rate gets too slow your doctor can stop it and try another medication.


Atrial Flutter

raksha69: I am 40, male. Operated for ASD in Oct 1978, was diagnosed A-Flutter in Jan 2005, cardioverted in Mar 2005. Off and on A-Flutter while taking Sotalol/Warf. EPS/RFA done in June 2008 in India. EP confident A-Flutter cleared after ablation. For no apparent reason (even w/o exertion) HR goes to 120, most times stretching/vagal will bring it down to 60-66. No chest pain/fatigue during palpitations. Can continue doing regular activity. Taking Seloken XL 37.5mg. EP says it is unspecified atrial tachy, not to worry. Will the HR of 120 cause heart muscle weakness? Do I need any tests?

Bruce D. Lindsay, MD: Yours is a complicated question. Sometimes patients develop atrial tachycardias after ablation procedures. Treatment with medications or a second ablation procedure might help to control the problem. It is unlikely to damage your heart as long as your heart rate decreases when you are not physically active.


Atrial Fibrillation Surgery – Maze

Bilbo1933: Do they ever do surgery just for A-fib? Other than when doing maze procedures while going valves, etc?

Bruce D. Lindsay, MD: The Maze operation is performed in patients who are not good candidates for catheter ablation. In recent years the Maze operation has been modified to become less invasive. The long term results require further study.

The so called Mini Maze is not really a Maze operation. It is analogous to a limited catheter ablation procedure. Results will vary depending on the experience and skill of the surgeon.


Premature Atrial Contractions - PACs

bama jane: I have had atrial arrhythmia problems for 10 years paroxysmal atrial tachycardia, PAC's daily in different forms-pairs, couplets, trigeminy, bigeminy, wandering pace maker sinus arrhythmia, junctional rhythm, accelerated junctional rhythm. I have 100's daily of these and am very symptomatic. Can tracings from holter and event monitors tell if these extra beats are coming from the same spot? Are PAC's ablatable? How many a day can damage your heart? My father had SVT that turned into a-fib after developing COPD, then developed heart failure from chronic COPD then died. Is a-fib hereditary? If so can I change that?

Bruce D. Lindsay, MD: Sometimes Holters and event monitors can distinguish differences in origin, but they often not provide enough detail. PACs can be ablated. It is unlikely that PACs will cause any damage to your heart. The main reason to consider ablating them is to alleviate your symptoms. Some genes have been associated with atrial fibrillation, but the relationship is complex and does not have any direct clinical implications yet.


Ventricular Arrhythmias: Ventricular Fibrillation, Defibrillators, and PVCs

feelingood: Hello, I am 50 years old female; I had a MI at age 40. I went into fibrillation when I had the MI. I have CHF. I have not had any pain or went into fibrillation since the MI. I walk regularly and feel good. My EF is 32 and my Qwave is .0014 (not sure about that number). My cardiologist wants me to have a ICD. I really don't want it but I really want to live as long as possible. Isn't there something else I can do to improve my EF? Is it OK to wait until my EF is at 30? What can I do to improve my risk against going into defibrillation?

Bruce D. Lindsay, MD: The ejection fraction is our best way to estimate the risk of a life-threatening ventricular arrhythmia. The risk increases as the ejection fraction drops below 40%. Current guidelines recommend an ICD if the ejection fraction is less than 35%. The accuracy of the measurement is about 5%, which means that your ejection fraction may be in the range of 27-37%. There is no point in waiting for a value of 30% because the difference between 30 and 32 is not significant. Your exercise capacity is another factor that your cardiologist would take into consideration. Approximately 1 in 12 patients who have an ICD implanted for prevention of sudden death will actually be saved by the ICD. Nothing happens in the other 11 patients. The problem is that we cannot predict more accurately which patient will have the cardiac arrest. Survival is only 5% if you have a cardiac arrest out on the street and do not have an ICD. Based on guidelines derived from clinical studies and approved by a consensus of experts, I think you would meet the criteria for an ICD and should have one implanted. There are medications such as beta-blockers and ACE-inhibitors that help to improve the EF and they have some effect on the risk of sudden death, but unfortunately, medications alone do not provide enough protection.

AKJK406: Thank you so much for answering questions for us. I have had an implanted defibrillator since 1994. Prior to March of last year, my problems were always Ventricular Fibrillation, beginning in March of 2008, I began having Atrial Fibrillation. I cannot seem to distinguish between A-fib and V-fib and just wondered if there is a way for a patient like me to tell whether I'm having A-fib or V-fib?

Bruce D. Lindsay, MD: Ventricular Fibrillation results in immediate loss of consciousness that is treated by a shock delivered from the ICD. Atrial fibrillation may cause an increase of heart rate but it rarely causes loss of consciousness. Sometimes patients with ICDs can experience a shock caused by atrial fibrillation if their heart rate increases beyond the detection criteria that was programmed into the ICD.

oreothecat51: Is there any connection between GERD and PVC's?

Bruce D. Lindsay, MD: The esophagus is immediately behind the heart. Nerves from the esophagus transmit pain or discomfort to the brain and this may elicit reflexes that effect the heart. Sometimes patients note that their arrhythmias are worse when they eat, especially when they drink cold fluids

Brightlight06: I have now been in continuous Bigeminy for 3 months. 54 yowm with long term CAD treated with stents in the past. Normal wt, N/S extremely athletic despite my CAD. Hx of isolated PVCs forever. Had been on Atenolol 50mg for 14 years when this started. Catheter last month, stents patent no other narrowing. Tried verapamil. Did not work. Back on Aten 25mg . All lytes, TSH, T4, CBC, BMP normal etc. EKG unifocal bigeminy, RBBB pattern, maybe septal which means LVOT. No hypertrophy. My choice for attempted ablation or Tambocor. I am leaning toward ablation first since the rhythm is so constant, I assume this would be the best time for ablation to work if you don't have to induce it. Then, if not long term Ic class med which increases the mortality post MI 14 years ago. I have been told 70% success. 1-2 % TE risk. If I was in your office, what would you recommend? What makes the LVOT harder then the RVOT except the risk of TE vs PE?? Thanks.

Bruce D. Lindsay, MD: You are a reasonable candidate for ablation and the risk for ablating premature beats that arise in the LVOT is relatively low in experienced hands. The main risks are related to potential injury to the coronary arteries which are near the LVOT.

latenight: If you have atrial fibrillation is it more likely that you will develop ventricular fibrillation? Is there anything you can do to help prevent it?

Bruce D. Lindsay, MD: There is no direct link between atrial fibrillation and ventricular fibrillation. The risk of ventricular fibrillation depends on whether the patient has severe underlying heart disease.


Sinus Arrhythmia

star26: Can extreme sinus arrhythmia sometimes mean or lead to something serious? My son now has bad collapses but used to just have extreme sinus arrhythmia - but I found his heart went faster and slower even when continually blowing or whistling while on ECG.

Bruce D. Lindsay, MD: Sinus arrhythmia is normal. I cannot comment on the cause of his collapse without more information.


High Heart Rate

Pam: My Dad had open heart surgery last Sunday, after a massive heart attack the day before. He needed a triple bypass because 2 of the 3 major arteries were 100% blocked and the other was about 95% blocked. He is still in the hospital and his heart rate is high. They are having trouble lowering it and keeping it that way. For a while yesterday, it was at about 112, but lately it's back in the 130's and 140's. I'm very worried about my Dad. Any suggestions?

Bruce D. Lindsay, MD: I cannot make specific recommendations without knowing more about your father. In general, it is feasible to control the heart rate by adjusting medications. Unfortunately, this is easier to do in some patients than in others.

bcat: I'm not sure what is considered a well-controlled heart rate. When I'm not doing much, it stays around 70-85, but even walking sends it way up. It can go as high as 130-150 or more, but I also have COPD caused by methotrexate (for rheumatoid arthritis) and can't exercise much anyway. Would an AV node ablation help the shortness of breath? Thank you.

Bruce D. Lindsay, MD: An event monitor might help to determine whether your shortness of breath is related to the heart rate. If a rapid rate is the cause of your symptoms and it cannot be controlled by medications, then you might benefit from an AV node ablation.

bcat: Sorry to be so complicated (and confused)--I also have Barrett's esophagus. Could that be related?

Bruce D. Lindsay, MD: Sometimes esophageal irritation seems to provoke atrial fibrillation. It is not the primary cause, but it is possible that it contributes to the problem.


Palpitations

Shiaya: I was wondering what should be done. I have heart palpitations frequently (3 times a day at least). They are very painful. I will have a heart monitor put on Wednesday. Is there any way I can reduce my heart rate or why it is happening?

Bruce D. Lindsay, MD: Your doctor is approaching this correctly. The first step is to determine the cause of your palpitations. Depending on what your doctor finds, there are many good treatments for eliminating these symptoms. Patients often respond to medications but when they do not, ablation procedures are effective in curing the problem.

These procedures involve placing catheters in the heart to determine the origin of the problem and to burn out the tissue that is responsible.

MEMZE: Hi. I'm 17 and having palpitations difficulty breathing coughing which are giving me problems with sleep. Should i be worried?

Bruce D. Lindsay, MD: Your symptoms are probably not dangerous but I definitely recommend that you see your doctor to evaluate this problem.

MEMZE: Hi. I'm 17 and having breathing difficulties, palpitations and coughing, which wake me up at night. I also feel like there is blood in my throat. Should I be worried?

Bruce D. Lindsay, MD: It is difficult to say what this is, but I certainly recommend that you see you doctor and discuss these symptoms.

raksha69: Hello Dr. Does anxiety or stress cause palpitations?

Bruce D. Lindsay, MD: Anxiety and stress may provoke atrial fibrillation in patients who are susceptible to this problem. Sometimes lifestyle changes help to reduce the frequency of atrial fibrillation though it generally does not eliminate the risk.


Cardiomyopathy

star26: My 14 yr old son has dilated cardiomyopathy all chambers. I resuscitated him 4 yr ago - I am dr - but cardiologists did not believe me. Then he's had more bad collapses where he looks dead and no breathing or pulse for over 40 seconds and takes 4 hrs to be able to sit up and talk properly - is pale on oxygen until then. Had reveal inserted only 2 mths ago. My son will be told today by cardiologist they do not know how long he will live. Maybe ARVD maybe connective tissue. May do heart biopsy or transplant Any ideas please?

Bruce D. Lindsay, MD: It is difficult to comment without knowing all the facts. The results from the insertable loop recorded are important. My opinion is that patients with severe cardiomyopathy and unexplained syncope should be considered for an ICD.

MedHelp: Thank you everyone for participating in today's chat. Unfortunately, we are now out of time

Bruce D. Lindsay, MD: Thank you for having me.

MedHelp: Thank you, Dr. Lindsay, for taking the time to answer so many of our members' questions.

Printed with Permission – MedHelp Heart Forum 5/09

Reviewed: 5/09

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