Peter Aziz, MD
Peter Aziz, MD

Mina Chung, MD

Tuesday, June 5, 2018 | Noon


Arrhythmias (irregular or abnormal heart beats) are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that may result in cardiac arrest and sudden death in both children and adults. There are several different types of arrhythmias ranging from atrial fibrillation to ventricular arrhythmias and even inherited arrhythmia disorders. Treatment options for these conditions depend on the type and severity of the arrhythmia. Dr. Chung and Dr. Aziz answer your questions about arrhythmias in children and adults.

More Information

Atrial Fibrillation

eddiebee: I am a 71-year-old male. A-fib was controlled with flecainide for over a year with no problem. Two months ago I had a STEMI while having a stress test in the hospital. The blockage was opened with stents within 60 minutes but I was taken off the flecainide and was back in a-fib within two days. Can you please explain exactly what flecainide does that caused it to be contraindicated after MI? Are there other drugs that might work as well without severe side effects? What are the positive and negatives for using Tikosyn? For an ablation? I am very active. I hiked across Spain last year for five weeks with a 25 pound backpack walking 17 to 25 miles each day. A-fib is lowering my quality of life. Thanks for having this forum.

Mina Chung, MD: Three plus decades ago there was a recognition for patients with PVCS (many chambers from lower chamber of the heart) after MI were at higher risk for sudden death. There was a big trial called CAST trial that tested this PVC hypothesis that suppressing PVCs would help people live longer. They took some of the most potent anti-arrhythmic drugs at the time and tested this and it turned out that some of these drugs were actually associated with higher mortalit -flecainide happened to be one of those. So, we don't use that drug for patients with prior MI. But it is a very effective drug for Afib. There are other drugs and you mentioned Tikosyn which is one of them. You must be hospitalized to start it because there is a risk for pro-arrhythmia that can be life threatening and so we admit patients to start it in order to adjust the dose and make it safer. It is generally tolerated very well. An ablation certainly sounds like something you should consider and could improve your quality of life.

ArrhythmiaAlliance: What is the success rate of a first ablation for Afib?

Mina Chung, MD: Depends on whether or not the heart is structurally normal or if the Afib is persistent or paroxysmal. In a structurally normal heart with PSVT, success rates may be as high as 80-90% but this may require more than one procedure. For more persistent forms the success rate can be under 50%. Also, your body tends to heal across our ablation lines so some late recurrences can happen.

bnrk: I've experienced a cold water near-drowning incident in March of this year. Subsequently, Afib was detected, even though I do not feel the irregular heartbeat. Unfortunately, I'm impacted by shortness of breath/lack of endurance. Cardioversion has been attempted twice but Afib returned after each attempt. As I would like to resume an active lifestyle, what would you recommend?

Mina Chung, MD: You may want to consider an anti-arrhythmic drug and/or ablation.

johnny angel: I have been taking flecainide since 1/1/2016, for Afib. Is it possible to be allergic to the medication? I developed a full-body rash in January of 2017. A skin patch test said I was allergic to flecainide. What do you think? Thanks, Johnny Angel (I wish!)

Mina Chung, MD: It is possible. You could try to hold the flecainide and see if things get better and then re-challenge. Consider using the brand rather than generic form - or vice versa. There are other options.

not2worryluv: My husband is 83. HA in 1999. Three stents since HA. Developed persistent AFib in Feb. 2018. 2nd cardioversion with amiodarone got him back into NSR. In NSR for over a month with 200mg amiodarone daily. Had ejection fraction tested 30 days after cardioversion. EF at 20%. Heart muscle damage such that pace maker won't help. Told ablation too risky. Any hope for the future? He's fit, low cholesterol, labs are excellent. Any hope for increased EF. Electrophysiologist believes medications will keep him out of AFib.

Mina Chung, MD: Ablation has some risks especially at his age, but could be helpful. The question is why EF remains so low and if optimal medical therapy can help improve this. If it remains low, he may be a candidate for an ICD (defibrillator), which can reduce risk for sudden death. We would be happy to evaluate him here.

syang19: My father, 64, was diagnosed with atrial fibrillation in 1992. He had a left heart failure in 2009 and had a radiofrequency ablation, which is not effective. Proparacaine hydrochloride (six years), aspirin (two years), warfarin (< six months) and bisoprolol fumarate (three years) have been taken since surgery. He suffered two consecutive cerebral infarcts in 2017. After hospitalization, he took anticoagulant drugs: rivaroxaban, rosuvastatin and sotalol hydrochloride. He had 2nd heart failure in April 2018, cardiac ultrasound check results as following: left ventricular diastolic function reduce, mild pulmonary hypertension, mitral valve small amounts of reflux, tricuspid valve, aortic valve and mild aried disc degeneration, mild aortic valve closed. The precursors of nt-probnp amino-terminal natriuretic peptide were 776.1, and the diuretic drugs spironolactone and furosemide were taken. What medicine can restore normal heart rate? If no effective medicine, any other radical cure method? Any rehabilitation treatment?

Mina Chung, MD: There are several anti-arrhythmic drugs that could be tried to restore normal sinus rhythm and other AV nodal drugs that can control heart rate. Another catheter ablation could be considered as well as surgical options.

Suehopeful: I am a 51-year-old woman. I have ascending aorta dilatation of 4.1 cm and had two episodes of Afib last fall (end of November and mid-December). Both times I was cardioverted back to NSR. They increased my metoprolol and tried Multaq the second time but I didn't tolerate well. I am on warfarin, metoprolol, furosemide and fosinopril. My questions are: Could the dilatation and the Afib in any way be related? Do you always have more Afib episodes? Can weight loss help? I have really been trying and avoiding large amounts of salt and caffeine. I get so scared sometimes to have both these things going on.

Mina Chung, MD: It sounds like the dilatation is in the mild range and it is hard to know if it is related to your Afib - do you have any valve disease (leaking ) too, because this can contribute. Afib tends to progress with time so once you have it, it tends to recur. Yes - weight loss can help.

Suehopeful: How do they diagnose valve disease? I don't have it to my knowledge.

Mina Chung, MD: An echocardiogram would be the test to diagnose valve disease.

Suehopeful: Can pacemakers treat Afib?

Mina Chung, MD: Pacemakers will keep you from getting too slow a heart rate but will not keep Afib from happening.

Pattiern9ff9: I am 62 years old, nonsmoker with recent dx of A-Fib on Flecainide and concerned about the black box warning of sudden death.

Mina Chung, MD: We generally use flecainide in people who have a structurally normal heart and the risk of sudden death would be quite low in this situation.

memaw: I have Afib. My last visit, ECG showed arrhythmia. They want to shock me does this sound like the right move?

Mina Chung, MD: It sounds reasonable once you are on a blood thinner.

mariannebr: My son is 20 years old - he is in college and having rapid heartbeats. He was diagnosed with atrial fibrillation. Is that common in young people. His doctor says he can be treated with medications or ablation. What do you do in that case? What is the chance it will go away and then come back. Are you at higher risk later in life?

Mina Chung, MD: It is uncommon in young people but can happen. Medications or ablation can be reasonable. It probably will come back in at least 1/2 of people it will recur. He probably will be at higher risk for it coming back later in life.

charlesG: I had an atrial fibrillation ablation five years ago at my local hospital in Virginia. I recently started having symptoms and found to have atrial flutter. Is that different? Is the treatment different? Is repeat ablation the way to go for this?

Mina Chung, MD: Atrial flutter is a more organized atrial rhythm with the activation going around in a circuit (or more than one circuit) in the atria. Selection of antiarrhythmic drugs may be a little different but anti coagulation need is no different. Repeat ablation can be considered.

Pattiern9ff9: Hello. I was recently diagnosed with A-Fib. Is medication the primary treatment? Are there other things I can do to increase my chance of a better outcome?

Mina Chung, MD: Medication, anticoagulation and ablation are the primary approaches. If you are overweight, losing weight; also increasing fitness may be helpful.

lilbit: I am female, 56 years old, BMI of 20, low-ish blood pressure (9x/6x) with Afib that is nearly always triggered by drinking water, usually only during or after exercise. Also sometimes laying down or standing up. I prefer to be very active but am now limited since most days I exercise, Afib will trigger. I have tried a beta blocker and am now trying a calcium channel blocker but am thinking I’m destined for an ablation. From what I have read, vagal type Afib such as mine often has stray signals from areas other than the PV. These studies seemed to concern people that got this type of Afib after an ablation. My EP prefers cryoablation and says first ablations always go after the PV area. My question then is: is cryoablation right for my type of Afib or should I be getting RF ablation with some sort of signal mapping approach. I have made every lifestyle change I can think of: no alcohol, no caffeine, no drugs, no added sugar, no inflammatory foods...

Mina Chung, MD: I think cryo ablation is a very reasonable first approach. I agree with pulmonary vein isolation being the cornerstone of Afib ablation including vaginally mediated Afib.

jjzanthony: I had a cryonic catheter ablation about three years ago which seemed to work quite well until recently with only one or two AFib episodes per quarter of fairly short duration until about a month ago when an episode began and has not stopped. I am being treated with a couple of new medicines for a 30 day period after which I will be evaluated by my cardiologist for a possible cardioversion if my AFib episode has not subsided. So far, it has not. It has been going on now for just over three weeks. I was told when I received my cryonic catheter ablation that if my AFib became uncontrollable again with medications that I could be a candidate for a 2nd cryonic ablation or even the more severe maze treatment. I note that the Cleveland Clinic does electrical ablations rather than cryonic ablations. Can an electrical ablation be done as a 2nd ablation when a cryonic ablation was done as your 1st ablation? And do you recommend a 2nd catheter ablation after the 1st one begins to fail?

Mina Chung, MD: Both cryo and radio frequency ablation both direct toward the electrical system pulmonary veins. We do both at Cleveland Clinic and the approach with a redo ablation could be either. Either medications or a second ablation are reasonable approaches to recurrence of Afib after a first ablation. You may also need a cardioversion at this point.

beat159: Hello - My husband is in constant Afib. He had an AICD pacemaker implanted in 2014, due to an EF=16, METS < 3 and he was diagnosed as having cardiomyopathy. They diagnosed his condition as Chronic Congestive Heart Failure (CHF). His medical records indicate that his NYHA classification was III. Upon review of the Cleveland Clinic "Heart Failure: Understanding Heart Failure: Stages", publication, we understand that "Chronic Congestive Heart Failure" is a redundant term? It appears that once you're diagnosed with CHF you have it forever, and that you do not move back and forth through the stages, even though treatment may control a stage, which slows progression. In this case, the AICD, may have allowed the cardiomyopathy to be resolved, but he would still be considered as having "Congestive Heart Failure”? In other words, is Congestive Heart Failure, ever not Chronic? Thank you.

Mina Chung, MD: We often will categorize congestive heart failure as chronic or acute. The term chronic congestive heart failure is not necessarily redundant. People can move between different NYHA functional classes. Some reversible cardiomyopathies may actually improve. Whether or not he has congestive heart failure depends on whether he has symptoms and whether his heart is keeping up with the demands of his body.

memaw: I was diagnosed with Afib about 18 months ago. They prescribed Eliquis®, this was at Mayo Clinic in Florida. They said I didn't have to do anything else. I went to my cardiologist here in Illinois last week. Because I was having fatigue and short of breath. He took EKG and said I had atrial flutter. Now he wants to try shocking back in rhythm. If that doesn't work he wants to do ablation. Does this sound like the right thing to do and what are the dangers. I walk/jog 45 minutes most days. I had angiogram in 2012, no blockage. I am 76 years old and thought I was in pretty good shape.

Mina Chung, MD: It does sound like reasonable approaches. You will need to be on consistent Eliquis® use before cardioversion as one of the risks is stroke if you have not been on adequate anti coagulation. If it is atrial flutter, ablation is also reasonable. There are some risks with ablation but typical atrial flutter ablation can be very safe. Afib can happen in very healthy people. It is possible that ablation may be needed eventually for both Afib and flutter.

wazzu78: I was diagnosed with Afib two months ago. I had cardioversion five days ago which was successful. Doctor started me on Multaq, along with Lopressor and Xarelto (which I was already taking, along with Diltiazem (which she discontinued). I am still experiencing shortness of breath when I do anything other than sit. The doctor stopped Multaq and I'm currently wearing a 24-hour Holter Monitor. I've read that exercise during Afib has shown to be beneficial in preventing recurrence. However I don't understand how you exercise with this shortness of breath. Is it safe to exercise during Afib and if so, can you recommend a website that provides guidance on how to do this?

Mina Chung, MD: Are you back in atrial fibrillation. If you are still in normal rhythm it is possible that your shortness of breath is related to medications such as Lopressor especially if your heart rate is too slow. If you are back in atrial fibrillation, then potential options for treatment include anti arrhythmic drug or ablation. The goal would be to reduce your shortness of breath so you can exercise because exercise would be beneficial for Afib.

Pattiern9ff9: Concerning the structurally normal heart and flecainide, I was also dx with an enlarged heart and CHF, with mild pulmonary hypertension. In addition to the Flecainide, I was put on Pradaxa and digoxin and developed severe fatigue and trace to +3 lower extremity edema in spite of taking Lasix. Can any of these drugs have those side effects?

Mina Chung, MD: Generally flecainide does not typically cause CHF; but perhaps there are other drugs that are better for you at this time. If your heart muscle is weak at this time you may need to change from flecainide to another medication and have your heart failure treated.

ArrhythmiaAlliance: What is the treatment for symptomatic AF with heart rates less than 100?

Mina Chung, MD: You can consider a cardioversion possibly with an anti-arrhythmic drug and/or ablation if you have continuing symptoms.

Suehopeful: Are there any foods or substances to avoid when you have atrial fibrillation?

Mina Chung, MD: For some people stimulants can trigger Afib; for some alcohol may also trigger Afib.

ArrhythmiaAlliance: Are there real advantages in having an ablation, and does it bring its own risks of clots forming via the scars used to alleviate the AF symptoms?

Mina Chung, MD: Afib ablation may be more successful than some anti-arrhythmic drugs in maintaining normal rhythm. There are some risks of clots forming during the procedure, but we do the procedure when on blood thinners to reduce this risk. In 2014, a routine exam showed I had Afib. I had no symptoms of any kind. After a series of tests, I was put on Eliquis® and diltiazem. I still have no symptoms but I am told I am in chronic Afib. I am 87 years of age. How often should I be retested? The only complaint I have is I get tired very fast when doing any kind of work.

Mina Chung, MD: Your fatigue could be a symptom of the Afib. It may be worth trying to get back to sinus rhythm to see if you feel any better in normal rhythm. Your fatigue could also be unrelated to your Afib.

Atrial Flutter

PPP: I was diagnosed with atrial flutter and had ablation to seven different places in my R atria. I have never had atrial fibrillation. Am I at higher than average risk for atrial fibrillation?

Mina Chung, MD: Probably, as Afib often co-exists with flutter. If things recur - you could wear a monitor to see if it is Afib or a flutter.

Supraventricular Tachycardia

jackriordan: What are options for treatment of supra-ventricular arrhythmias?

Mina Chung, MD: It depends on the type of supraventricular arrhythmia. If you are talking about the common types of SVT, you could try vagal maneuvers (like bearing down maneuvers during tachycardia), AV node blocking drugs, anti-arrhythmic drugs and/or ablation.

Max85: I was recently diagnosed with runs of SVT by a holter monitor. I have no symptoms other than I felt my heart racing so I went to the doctor. I work out very hard and do cross training. I want to continue to do this. What is the best way to approach this irregular heart rhythm?

Mina Chung, MD: It depends on what type of SVT you have and how long it lasts. You could try a bearing down maneuver and see if it stops. You can consider medications and ablation depending on what was seen on the monitor. Sometimes they label SVT only a short run of beats so it depends on what was actually seen on the monitor.

ArrhythmiaAlliance: I had four Afib episodes in 40 years. But in past month, multiple very short SVT episodes (under 5 minutes) and one short Afib and a flutter episode, all documented by Kardia Mobile. Can SVT ablation help, or could it potentially make my Afib more persistent as I've read?

Mina Chung, MD: The question is what the SVT is. It could be an atrial tachycardia or flutter if it is regular. It could be due to an extra connection between top and bottom of the heart. Ablation could potentially help and could be directed toward the SVT and/or the Afib.

Arrhythmogenic right ventricular cardiomyopathy (ARVC)

hc2018: Have there been cases of ARVC patients developing arrhythmias such as long QT where a patient ends up having more than one inherited cardiac disorder?

Peter Aziz, MD: Usually these diagnoses are single. In the case of ARVC, having QT interval that is prolonged is likely related to the ARVC, as opposed to a separate unique entity.

Long QT Syndrome

Tuxbond: I was diagnosed with LQTS1 and am well managed with 80mg Nadolol. In the last year I have been diagnosed with Afib and am treated with blood thinners. My Afib seems to be flaring up more frequently causing rapid, irregular beats. I have had one conversion. What are my treatment options?

Mina Chung, MD: You can consider some non-QT prolonging anti arrhythmic drugs and/or ablation.

hc2018: What is the frequency of patients who are diagnosed with one arrhythmogenic condition also developing a second? Have we seen any correlation? And what are the most common arrhythmias that patients with long QT syndrome develop aside from the known torsades/ventricular events. Are these patients more susceptible to atrial arrhythmias also?

Peter Aziz, MD: Typically patients with inherited arrhythmia disorders have conditions that are isolated to that - it is rare for them to develop other inherited arrhythmia syndromes. That said, patients with long QT syndrome can be at risk for bradycardia (slow HR) but torsades is the hallmark arrhythmia for these patients. Atrial arrhythmias can occur in adult patients.

Maria Astrid: Hi, is there any recent information regarding the Long QT Syndrome and competitive swimming?

Peter Aziz, MD: There are different approaches to competitive swimming in patients with LQTS. The first is - it is important to know what type of LQTS sub-type you have. Swimming is a very well-known trigger for patients with LQTS Type 1. We have adopted an approach that supports patient autonomy and have allowed some of our LQTS patients to swim. This has to be a thoughtful conversation with your heart rhythm doctor as many factors are involved.

Outflow Track Ventricular Tachycardia

ArtyG: A stress test revealed Outflow Track Ventricular Tachycardia. What is it and would cause that? I smoked for several years – quit five years ago but still drink alcohol regularly. I did start exercising and this was how this started. Any thoughts about cause and treatment?

Mina Chung, MD: Outflow tract of the left and right ventricles are common places of origin for arrhythmias from the lower chambers of the heart. There seems to be cells in that area that can cause extra beats. Usually treatment options depend on symptoms and whether these are frequent enough to affect heart function. Treatment could range from beta blockers, CA channel blockers or anti arrhythmic drugs to ablation.

Wolff-Parkinson-White WPW

conniek: My son has WPW and is 14 years old. His doctor is suggesting ablation. What is the success rate for that? What are the risks?

Peter Aziz, MD: Fortunately the success rates for WPW ablations are very high. The risks of the procedure are similar to other ablation procedures - it would be reasonable to have a thoughtful conversation with your electrophysiology doctor about the risks.

Palpitations and/or Skipped Beats

Arrhythmia2lliance: Are heart pulses of a few seconds followed by tachycardia for about twenty seconds dangerous, and what would you recommend for a person dealing with this?

Mina Chung, MD: It would be good to try to record your rhythm during these episodes - an event monitor with a memory loop would be helpful. It is difficult to assess how dangerous this is without seeing what the rhythm is.

golfrplayr281: Dr. Chung – back in summer of 2015 and summer of 2017, I experienced similar heart rhythm-type symptoms while swinging a golf club on the driving range. While swinging my club through on the follow-through, my heart rate spiked dramatically – if I had to estimate it was easily over 200 bpm, where the beats were steady and not erratic. While this occurred, I experienced no other symptoms – no dizziness or chest pain, though, I did panic since my accelerated heart rate was alarming. Following this I have had several tests done – EKG, 24-hour Holter monitor, echocardiogram, and blood tests, all of which showed no sign of abnormalities. Have you seen symptoms like this in your years of practice? I remember reading something about PVCs but wasn't sure if this was the cause. Perhaps the way I'm swinging the golf club is somehow jolting my system and throwing off my heart rhythm? I also tend to get palpitations a couple times a week, depending on stress or caffeine intake. Thank you very much for your help and insight.

Mina Chung, MD: If the palpitations you get are similar - you could wear an event monitor to help capture what these are. You could have had an SVT (supraventricular tachycardia) episode, it would be helpful to capture an episode on the monitor. There are devices for smart phones that can record an ECG.

ArrhythmiaAlliance: What is the link between the heart and the stomach, patient has noticed every time they eat they get palpitations followed by ectopics?

Mina Chung, MD: The esophagus (swallowing tube) lays right behind the left atrium right between the pulmonary veins, which are the triggers of Afib. Perhaps this contributes to the extra beats.

Hira: Hi my name is Hira. My six-year-old daughter skips heartbeat eight times in a minute, is it dangerous? Please tell me.

Peter Aziz, MD: The short answer is most likely not - it depends on what the cause of the skipped beats are. Typically in otherwise healthy pediatric patients the skipped beats are the result of premature atrial or ventricular contractions which are most often benign. It is useful to be evaluated by a cardiologist as rarely, these conditions can be more significant.

Arrhythmias – Hereditary

Suehopeful: Do arrhythmias run in families?

Peter Aziz, MD: Not always but very frequently they do. Arrhythmias that occur in younger children or in several family members often times will clue us in to look for an inherited cause. Atrial fibrillation tends to run in families also.

General Question

cwife: What is the life expectancy of a 53-year-old man with hypertension, diabetes, arrhythmia, and a mechanical heart valve?

Mina Chung, MD: That is hard to say.


ArrhythmiaAlliance: What are the risk and benefits of bi-ventricular pace and ablate?

Mina Chung, MD: AV junction or AV node ablation would make you dependent upon the pacemaker. Approx. 1/5 of people who are dependent on the pacemaker can develop heart failure. A bi-v pacemaker could potentially prevent that.

Low blood pressure

Afibilateral: Can you take too much Amlodipine CCB to make your BP too low and not responsive to your activities? Is collection of clear fluid in lower legs and ulcers that do not heal normal with proper BP medication? I take Amlodipine-Benzapril 10-20, Carvedilol 12.5, Hydrochlorothiazide 25, and Pradaxa 150 2/d

Mina Chung, MD: If your blood pressure is too low - perhaps you are taking too much. Amlodipine can cause edema.

Reviewed: 06/18

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.