Daniel Cantillon, MD
Daniel Cantillon, MD

Christine Tanaka-Esposito, MD
Christine Tanaka-Esposito, MD

Monday, September 28, 2015 - Noon


An arrhythmia (also called dysrhythmia) is an irregular or abnormal heartbeat. There are many different types of cardiac arrhythmias; atrial fibrillation, premature beats, supraventricular tachycardias, ventricular tachycardia, and heart blocks are just a few. Many arrhythmias are benign and do not require any specific treatment. However there are some arrhythmias that need to be controlled with the use of medications, electrical cardioversion, implantable devices such as defibrillators or pacemakers and catheter ablation. Electrophysiologists Daniel Cantillon, MD and Christine Tanaka-Esposito, MD answer your questions.

More Information

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  • View previous chat transcripts.

Symptoms of arrhythmias

tlsiravo: I have had issues for quite a while now (I'd say at least a year, if not longer), where my heart starts racing, pounding hard to the point that I can feel it through my chest very easily. It also "skips" or "misses" beats when this is going on. I get somewhat nauseated as this is happening, and at times, very nauseous. It usually lasts several hours, if not all day, or several days... I have gone to the emergency room, and was recently admitted for observation, but either it stops, or the severity decreases after a short time there, so they aren't getting a good look at it at it's worse. They did say that an irregular heartbeat is common in women, however, this is alarming. Also, I have been on blood thinners (xarelto) for several years due to pulmonary embolisms. Thank you, Tracy.

Daniel_Cantillon,_MD: Tracy, we’re very sorry to hear about what you’re going through. We’d suggest making an appointment. A wearable monitor device would seem appropriate to diagnose the type of heart rhythm disturbance you are experiencing.

tdujan: Sometimes I will wake up in the middle of the night and my heart beat with be running way above normal. My normal resting heart rate is between 60 – 65 beats per minute. At times during the night it will be racing 85 - 110. However, once I am awake for 5 +/- minutes the HR will drop back to 70 - 75. I do have AFib, however, not an issue in over 18 months.

Daniel_Cantillon,_MD: Hmm... Are you sure? I'd consider wearing a monitor to document the cause of those elevated heart rates. Is it possible you are going in and out of AFib?

Medications to treat arrhythmias

Angelcu: I was prescribed metoprolol er 25mg once a day. I’m scared to take it due to side effects. I also take xanax 1mg and I have mitral valve relapse regurgitation.

Daniel_Cantillon,_MD: This is an anti-adrenalin drug. Common side effects include dizziness, fatigue, depressed mood, shortness of breath and loss of libido. However, we generally recommend allowing 1-2 weeks for your body to adjust. Talk to your doctor if side effects persist beyond that window, or for any severe symptoms.

mrnaples: Which anti arrhythmia drugs are safe with chronic renal disease?

Christine_Tanaka-Esposito,_MD: Amiodarone, dronedarone, Flecainide, propafenone are generally safe for use in patients with renal dysfunction. Regardless, regular monitoring of your kidney function is necessary. Avoid sotalol and dofetilide.

mrnaples: Which anti arrhythmia drug is least toxic?

Daniel_Cantillon,_MD: It all depends on how you define toxic. I don't mean to dismiss the question, but I think you really have to look at each drug in terms of its individual side effect profile.

ablation1: I am on Amiodarone and mexiletine again following a Ventricular ablation in June, at NYP Cornell, Dr. Christopher Liu. I sparked again two months post. I am scheduled to go on Sotalol next month here in Florida and wean off the other drugs. What concerns should I have?

Daniel_Cantillon,_MD: Sparked? I love that metaphor. Think I'm going to borrow that if you don't mind. Sotalol is a good drug once amiodarone and mexiletine have been washed out. Another catheter ablation is another consideration.

Thyroid and Arrhythmias

Jack_in_Florida: I have no thyroid gland so take supplements. There seems to be a balance between TSH levels above 4.0 and irregular heartbeats. Which is preferable -- keeping the TSH in the "normal range" (2.0-3.0) and experiencing more arrhythmias or allowing it to go up to 4.0 and have fewer episodes?

Daniel_Cantillon,_MD: Good question. Probably better for an endocrine expert. However, generally recommend keeping the thyroid levels in range and managing the arrhythmias around that.

Atrial Fibrillation (AFib)

chibievans: Does the person with AFib ever smell an unusual smell when AFib is active? What foods may reduce AFib?

Christine_Tanaka-Esposito,_MD: I have not in my clinical practice encountered olfactory hallucinations described by patients as a manifestation of atrial fibrillation. In regards to your second question: While there are no particular foods that we know that might reduce AFib, dietary choices do matter. A heart healthy diet low in salt, saturated fat/cholesterol and simple sugars/carbohydrates; high in fresh fruits, vegetables, whole grains and lean meats; and which limits caffeine and alcohol reduces the risk for heart disease, hypertension, diabetes, obesity, sleep apnea and in turn reduces risk for developing AFib. There is some data to suggest that healthy food choices can reduce the severity of symptoms in patients with atrial fibrillation.

dricke: I am 67 years old with a mitral valve problem. I had rheumatic fever when I was 11. I was unaware of the bad valve, even though I had a physical every year. Then in 2006 I had a very bad AFib attack that sent clots to my kidney and me to the hospital. I am on warfarin now and handle it quite nicely. No other medications to control heart rate are needed any longer. I have been in warfarin range 95% of the time or better. My question is if I have the mitral valve repaired or replaced will that help with the AFib or is it too late? Secondly does repair or replace make a difference in the calculations? Thank you for being here and helping all of us.

Daniel_Cantillon,_MD: Great question. Unfortunately, it’s impossible to answer without detailed information from your history, ECGs and the echocardiogram. An appointment with both a cardiologist specializing in valvular heart disease and also an electrophysiologist like us would be beneficial in answering your question.

30swithafib: Hello. I am a 37-year-old male who was diagnosed with AFib in Oct. 2013. Ever since my first AFib event, I suffer from increased heart palpitations when both when lying down and when dealing with indigestion. I have been checked out by both my GP and cardiologist and I am in great health otherwise. I also know my symptoms can be common for people with "vagal" AFib. My question is, do we know why this is the case? It seems like a light switch has been flipped and now I am prone to heart palpitations when I was not before. Could exploring things that could help a "damaged vagal nerve" help me here? Would an ablation help these sorts of issues? I am lucky in that I have only had one AFib event for about five hours in the past six months, but it gets tiring to always worry if lying down may cause an event. Thanks for your time. -Eric.

Christine_Tanaka-Esposito,_MD: Eric, oftentimes once diagnosed with atrial fibrillation, one may be more self-aware such that "skipped or extra heart beats" that were present before, are now commonly noticed. Vagal mediated AFib is an uncommon form of atrial fibrillation, occurring in patients without structural heart disease. Characteristically, this form of AFib occurs during periods of rest and relaxation, rather than activity or emotional stress. Vagal mediated atrial fibrillation is believed to be manifestation of a heightened response of the cardiovascular system to changes in the autonomic nervous system, rather than a "damaged vagal nerve." Treatment options, if episodes of AFib are frequent to cause bothersome symptoms include certain antiarrhythmic (i.e. Flecainide disopyramide) and/or catheter ablation.

jhays: Please discuss the pros and cons of Rhythm Control versus Rate Control.

Daniel_Cantillon,_MD: In rhythm control, we are trying to keep the heart beating in normal (sinus) rhythm through the use of medications, or procedures like cardioversion and ablation. In rate control, we accept the presence of atrial fibrillation and focus on simply controlling the heart rates. Both strategies require the use of “blood thinners” (anticoagulants) for individuals who are at risk for stroke. In clinical studies, it has been shown that life expectancy is the same between those two strategies as long as we are protecting both groups of patients equally from stroke. However, patients with a rhythm control strategy may have an overall better quality of life due to efficiency gained in their heart by beating in a normal rhythm. In a nutshell: Some patients are symptomatic with AFib, and for those patients a rhythm control strategy is usually best. Some patients are without symptoms for AFib, and for those patients a rate control strategy is usually best.

20rls: I am a 70-year-old male and was diagnosed with AFib in March of this year. I have worn a heart monitor for a month and the results show the arrhythmia is constant. The medications I am taking - Diltiazem 180 mg once daily - Eliquis® 5 mg twice daily - Carvedilol 6.35 mg twice daily; appear to have my arrhythmia under control. I have two questions: First - How do I know this combination is working? Second - My cardiologist has suggested either a TEE or the use of drugs to try to bring the heart beat back to normal. Is this an option to consider?

Daniel_Cantillon,_MD: The results of the monitor you wore will tell your cardiologist if the heart rates are controlled (i.e., if the combination is “working”). The suggestion of a TEE guided cardioversion is to verify that there is no blood clot inside your heart followed by shocking it back into normal rhythm. The advantage of doing so is that it will allow your cardiologist to understand if you feel better in normal (sinus) rhythm. This helps your doctor decide which strategy (rate control or rhythm control) is best for you over the long-term.

sbdavisrn: Been in AF for over 25 years - rate controlled - on Digoxin, Atenolol, Avapro, Coumadin, Norvasc, Imdur, Lasix 20 - also have pulmonary hypertension, hypertension, s/p mitral valve repair, and a touch of heart failure. EF = 50%. Only symptom is SOB on exertion. Never had cardioversion. Have been told that at this point, no new meds or treatments would benefit. Right heart caths and echoes have been stable. Should I not rock the boat? 72 years old - do yoga, swimming and walking.

Daniel_Cantillon,_MD: Yep. Don’t rock the boat. Keep up the yoga, swimming and walking.

rmoynihan: How is AFib quantified--what is "too much"?

Christine_Tanaka-Esposito,_MD: AFib is quantified as either paroxysmal or persistent. Paroxysmal AFib by definition is an episode that spontaneously terminates within seven days of onset, with sinus rhythm returning. When an episode of AFib sustains beyond seven days, it is classified as persistent. "Too much" is subjective for an individual patient and cannot be objectively quantified for all patients. For a patient with symptoms of AFib that affect quality of life, one episode a year lasting one hour may be "too much." Alternatively, weekly occurring episodes that are asymptomatic may not be "too much." This is an excellent question because the concept of "too much" is very relevant, as symptom burden largely dictates treatment. The more symptomatic a patient is the more beneficial suppressing AFib will be for him/her and the greater the justification for therapies that may carry more significant risk.

darkit: I have A-fib (with a leaking heart valve), catheter ablation was tried but was not successful so the doctor did cardioversion instead. I take Flecainide and metoprolol to control my condition. Are there any other treatments for A-fib that could improve my condition?

Daniel_Cantillon,_MD: There’s nothing wrong with combining an anti-arrhythmic drug like Flecainide after an ablation. There’s some evidence that anti-arrhythmic drugs that were previously ineffective prior to an ablation can provide effective control after an ablation. The other option would be to pursue a second ablation, which may obviate the need for Flecainide if successful. It’s very clear from multiple studies that outcomes are much better across-the-board following a second ablation. So your options are to stay on the drug or seek a second ablation.

larryccathy: I have been in atrial fib for over a year. I have had cardioversion eight times and ablation once...am taking verapamil, digoxin, & metoprolol....doctors tell me there is NOTHING else that can be done...I am so tired, depressed and feel like I am just existing and waiting to die....I'm only 69 years old...is there nothing that can be done to correct this?

Daniel_Cantillon,_MD: Second ablation? Anti-arrhythmic drugs? Not sure I fully agree with what you've been told. We would be happy to see you here for a second opinion.

JMWVA.15: (1) I was diagnosed with AFib almost 18 months ago and have been on Tikosyn 250 mg twice a day for about 15 months with very few problems until recently. I know that my potassium and magnesium levels must stay within normal range. The potassium level is quite good but keeping the magnesium level up has proved problematic. Magnesium oxide was prescribed first, but that caused serious and substantial digestive issues. Magnesium chloride (Slow-Mag) was then prescribed (4 a day, 143 mg. magnesium each) but the last test was 1.6. My normal magnesium level has been at or just below the 1.7 or 1.8 listed as the labs' lows for years. Even in the hospital while having magnesium given intravenously, there was difficulty keeping the number up though they achieved a 2.0 once. Suggestions? (2) What part does exercise (walking or light housework) play in triggering AFib? (3) Are there specific signs that the medication needs to be increased or treatment changed?

Daniel_Cantillon,_MD: Re: electrolytes, I sometimes will ask a nephrologist to provide commentary on patients who seem to lose a greater-than-expected amount of potassium or magnesium. There are specific conditions, such as renal tubular acidosis that can cause electrolyte abnormalities. Not suggesting you have that, but I'd keep those things in mind. Re: exercise, I always tell my patients to exercise regardless of whether or not it will provoke their AFib. If it does, then the treatment plan isn't very robust. Exercise is a healthy activity and I never discourage it. Not even for patients with chronic heart failure as the long term studies suggest a mortality benefit. Re: meds, yes. If it is not working or poorly tolerated. :)

rtanz: CABG patient (2010). Workup for Syncope event in 2014 included a 30 day CardioNet monitor which recorded two AFib events (longest 2 min.) and a single 31 beat VT event. Eliquis® and MRI/with contrast of heart recommended. Concerns: no antidote for Eliquis® and I am a Stage 3 CKD patient (nephrologist not in favor of MRI work-up). I just turned 80.
1) I am not convinced I am an AFib patient. Want to have my heart EKG self-monitored for a longer period of time to provide convincing evidence of AFib
2) Do you recommend Eliquis® @ this time based upon isolated AFib events observed?
3) What is the criticality (risk-reward) of having MRI imaging of heart at this time?

Christine_Tanaka-Esposito,_MD: I agree with you. The documented episodes of AFib durig the 30 day period were brief. While such short episodes are not generally believed to be associated with stroke - they can certainly be markers of other longer episodes, that definitely would place you at increased risk, occurring at times when you are not monitored. While it is reasonable to initiate anticoagulation therapy (ie Eliquis®) based on this finding alone and presumption; taking a blood thinner also poses risks, particularly given the risk factors you describe. I recommend that you discuss risk to benefit assessment with your doctor. In my opinion, even in spite of the few short lasting episodes, if your risk factor profile is high, it would seems reasonable to initiate anticoagulation therapy. Eliquis® is a reasonable choice. Your renal function will need to be monitored while you are taking it, and if progresses to severe dysfunction may warrant a switch to warfarin. In reference to your question about a cMRI. The greatest value will be its quantification of your heart’s pumping function. If there is weakening of the heart muscle, then a non-sustained episode of VT carries greater relevance. The value of a cardiac MRI versus other imaging study like an echo, is that a cardiac MRI can provide additional diagnostic information about the etiology of a weakened heart if it exists.

jjrob11: I was diagnosed last year with AFib...approx. two weeks after this, I woke up with a very fast heart rate and went to another hospital, they kept me for three days. The team of Cardiologists told me I did not have AFib but have tachycardia. The Cardiologist put me on a medication (Amiodarone), 30 day supply. My Primary Care doctor would not renew the prescription (side effects)..so, I take an aspirin (81mg) each night...On 8/30/15 I woke with a strange feeling in my chest...(fluttering)...I was diagnosed as having Palpitations, PVC's, which the nurse told me is not life threatening.. they kept me for a couple hours and let me come home...my question is...with my history, is this Palpitations, PVC's something that needs further investigation or is there a medication I can take for it...it still happens quiet often but stops after awhile.

Daniel_Cantillon,_MD: There's a lot here. Probably best to parse through it in an office visit. I think a lot of the things you raised need to be evaluated. It's true that amiodarone does have a very significant long-term toxicity profile and so I think there needs to be clarification on why it's being used.

markf: Does Cleveland Clinic have the current technology...(3D imagery and 5D computerization) for identifying exact location of Afib problem.

Daniel_Cantillon,_MD: Yes, we use 3D mapping systems and have the latest tech including the mapping systems for FIRM guided ablation, which is the latest on the scene in AF procedural management.

herbie424: I am writing to ask about the effects of consuming alcohol and atrial fibrillation. While I know that consuming alcohol makes AFib worse, does the kind of alcohol make any difference? For example, is a lower alcohol content beverage like wine less likely to set off an episode than a high content such as liquor? Likewise, is there any difference in caffeinated beverages such as tea vs. coffee? Thank you kindly.

Daniel_Cantillon,_MD: You shouldn't drink more alcohol than your doctor. :) On a serious note, I typically advise patients to keep it in moderation. Excessive amounts of alcohol can place an oxidative stress on the heart that can be acutely provocative of AFib. What exactly is a safe amount (or alcohol content) is a little unclear from the literature. I think 1-2 per occasion and several per week is probably OK for most people. For coffee vs. tea, it comes down to how much caffeine is in it. Caffeine is a weak cardiac stimulant. I start my day with one Starbucks every day, and sometimes one more in the afternoon on crazy days (like WebChat). :) If one cup of coffee or tea is putting you into AFib, then I'd say the treatment plan is pretty flimsy and could probably be improved upon. Again, don't drink more coffee than your doctor.

granitebear007: What types of life style changes could I make to help with AFib? Another concern is the Tambocor (Flecainide) gives me very fast heart beats that only last for few seconds but are very concerning. Dosage is 100mg twice daily if I take only 50mg twice daily no problems but heart is always in AFib. Not sure which is best A-Fib with no side effects or no A-Fib with these heart runaways. My heat doc tells me that all drugs used to treat AFib can cause these abnormal heart conditions. Am I stuck with this condition and drug therapy?

Christine_Tanaka-Esposito,_MD: Lifestyle changes are important - such as adopting regular exercise and a heart healthy diet - and have been described to reduce the severity of associated AFib symptoms in some. If drug therapy results in symptoms that are bothersome and intolerable, alternatives include trialing a different agent or considering a catheter ablation for AFib (pulmonary vein isolation).

Paroxysmal Atrial Fibrillation

eaglehawke185: I have AFib since 1999. I continue to have AFib every two-three months. I have listed my Medical history. Can you advise if my AFib condition can be improved with any of your procedures? What is the success rate? In my condition, being diabetic and with heart disease, would I be able to undertake this procedure? How long does the procedure take and how long does one have to stay in hospital? Thank you.

Christine_Tanaka-Esposito,_MD: Dear Anthony, based on my general assessment of your provided medical history, assuming you are < 75 years of age and in good general health and symptomatic with the recurring episodes of AF you seem to be a reasonable candidate for a catheter ablation (PVI). In most cases, such a procedure is considered and offered after anti-arrhythmic drug therapy is trialed and either proven to be ineffective or intolerable. While I cannot assure you a cure - this procedure offers a means of reducing ones burden of AF and thus symptom burden. The efficacy rate is 80-85% for patients with episodic type AFib and limited structural heart disease, with a single procedure. For those with heart disease and longstanding, persistent types of AFib , efficacy is 60-65% with a single procedure and 70-80% following a second procedure . A PVI typically takes 4-6 hours. This is followed by an overnight stay.

Runner101: Does paroxysmal AFib ever go away by itself. I do exercise, eat carefully etc...

Christine_Tanaka-Esposito,_MD: While there are a few reversible triggers (thyroid disorder, pneumonia, excess alcohol intake, pericardial inflammation (i.e., post open heart surgery)) for AFib that if eliminated or avoided may prevent future recurrence, most patients with atrial fibrillation particularly if they have concurrent cardiovascular disease obesity or sleep apnea are prone to recurrences and over time progression of AFib. Adopting a healthy lifestyle, as you have done, including regular exercise and a heart healthy diet has been shown to decrease the burden of AFib episodes and lessen the severity of symptoms associated with AFib.

Runner101: I am a 72-year-old runner who had a stroke five months ago. While using a Holter monitor it was discovered I experienced a paroxysmal AFib small episode during my four mile run. Yes, I am on my feet and running again. Have no symptoms. Does this paroxysmal AFib ever go away by itself? I am taking 5 mgs Eliquis® twice daily and prefer to avoid meds in place of healthy eating and exercise. Thank you, John.

Daniel_Cantillon,_MD: Hi John. Unfortunately, probably not. I tell my patients that the good news about AFib is that it is a highly manageable condition. The bad news is that there is no ‘cure’ in the classic sense of that word. We manage AFib and are able to provide many patients many years of total freedom from the arrhythmia with our treatments, but the bad news is that the limited long-term studies we have show it will eventually come back. Many of us think about managing AFib much in the same way that other chronic conditions are managed like high blood pressure, diabetes, etc. Our goals are to prevent strokes and optimize quality of life by applying the medical and procedural treatments we have in our tool-kit.

Blood thinners for Atrial Fibrillation

adourian: What is your recommended blood thinner for paroxysmal AFib patients?

Daniel_Cantillon,_MD: I do like the 'novel oral anticoagulant drugs' including Eliquis® (apixaban), rivaroxaban (xarelto) and dabigatran (pradaxa) for the right patients (nonvalvular AFib and good kidneys). Warfarin is the drug we love to hate, but there's also something to be said for a drug with easy pharmacologic reversibility -- not true *currently* for the newer drugs.

Pacemaker: I have AFib and was placed on Plavix in 2010 and then on blood thinners in 2011. My PP stopped me from taking Plavix with a baby aspirin when my platelets dropped to below 100. Recently, my cardiologist took me off all blood thinners after first prescribing Warafrin, then Pradaxa, then Xarelto. He said long term use of blood thinners have caused me to recently pass blood in my urine. I am now taking baby aspirin. Will baby aspirin cause the same problem?

Christine_Tanaka-Esposito,_MD: This is a good question. Aspirin (and Plavix) block platelets, the cells in blood that come together at the site of an injured blood vessel. Warfarin (and Pradaxa and Xarelto) block the production of fibrin, the glue that holds platelets together to form a plug at the site of injury. Via a similar mechanism, patients with AFib can develop blood clots made of platelets and fibrin. A blood clot if mobilizes and travels to the brain, can cause a stroke. This is the rationale for treating patients with Afib with aspirin or warfarin (or Pradaxa or Xarelto). Use of any of these agents will not "cause" bleeding, but rather exacerbate bleeding if there is reason to bleed from an underlying cause. Aspirin is less potent in its "blood thinning" effect compared with warfarin (Pradaxa or xarelto). As such, it is likely to be associated with lower bleeding risk. However, keep in mind that aspirin offers less protection from stroke risk and is not preferred for stroke prophylaxis in the majority of patients with AFib.

tabialex: I am a 73-year-old female. Last year, after having the Zio Patch test, I was diagnosed with paroxysmal atrial fibrillation (3% of monitoring period) and SVT. Sometimes when I have palpitations, my neck and shoulder aches. Why does this happen? My angiogram showed minimal CAD. Would the aches be from the minimal blockage or from my arrhythmias? I am doing well on Eliquis® and metoprolol. When and if can Eliquis® be discontinued if you have a history of atrial fibrillation? Thank you for your help.

Daniel_Cantillon,_MD: Probably easier to tackle the last question first. We make decisions to stop oral anticoagulation strictly based on a patient's individual risk profile. Your age and gender already place you into a risk group where lifelong anticoagulation may be recommended by your doctor. On the first question, we generally look to see if your pains correlate with cardiac arrhythmias. If so, it is reasonable to expect the symptoms to improve with achieving better control of the arrhythmia. That kind of information should already be available from the Zio patch you wore.

Medications for Atrial Fibrillation

rustybear: Is there long term concerns using Digoxin for a long period of time? I have AFib for about eight years now and long term meds concern me.

Daniel_Cantillon,_MD: Your concern is certainly understandable. Digoxin is a medication that requires monitoring of kidney and electrolytes, in addition to ECG findings. With that said, there are patients who have been on it for decades (since it is a very old drug really) and have done quite well with it.

Nama4: When my husband received a two-lead pacemaker earlier this month, his EP also tried but could not shock his heart out of a fib. He suggested Sotalol, but my 72-year-old husband is having no symptoms of a fib. As we understand, the medication is for symptom control only. Why should he consider Sotalol? We read about side effects, and they sound dire. He does take Eliquis® without side effects.

Daniel_Cantillon,_MD: The goals of AFib treatment are stroke prevention and preserving quality of life. Eliquis® is used to prevent strokes, and sotalol is used to maintain the heart in normal rhythm. However, if your husband experiences no symptoms from the AFib as you stated, then it is appropriate to question the role for sotalol and this should be discussed with his doctor.

Sginnc: Recently hospitalized for first onset of AFib. I am taking a blood thinner and beta blocker. I am experiencing what I believe is commonly called the "beta blues" i.e., tired, not much appetite, occasional lightheaded but all of this is manageable. Will I adjust as time goes by? It has been a month.

Christine_Tanaka-Esposito,_MD: It is possible that you will adapt to what are likely side effects of the beta blocker you are now taking. Alternatively, the dose may be higher than you tolerate and reducing such may possibly be an option.

mrnaples: Which drugs are most effective for the prevention of AFib episodes?

Christine_Tanaka-Esposito,_MD: Antiarrhythmic drugs alter the electrical properties of the heart and can suppress AFib. Common agents used in management of atrial fibrillation include Flecainide (Tambocor), propafenone (Rythmol), dronedarone (Multaq), dofetilide (Tikosyn), sotalol (Betapace), amiodarone (Pacerone).

xdwl: Hi, Dr. Cantillon. I am 57-year-old female, taking Metoprolol Succinate 47.5mg/day for three years for: 1) hypertrophic cardiomyopathy (post-surgery). 2) heart function insufficiency NYHA II. 3) Prevent AF recurrent (I had 3 short AF (<10') in first week post-surgery in 2012. AF was quickly converted with Amiodarone). I am in sinus rhythm without Amiodarone. My HR was 60+- before taking Metoprolol, and 55+- for first two years. But my HR drops to 45 this year. I felt lightheadedness in early this year but the symptom disappeared without changing medication. BP 96/62mmHg. I do moderate exercise and HR goes up to 110 without any uncomfortable effects. My 48 hours holter: Degree-1 AV block, the lowest heart rate 42, average HR 46 bpm, sinus rhythm. My father had sick sinus syndrome. I would like to get your advice how should I continue Metoprolol Succinate 47.5mg/day, or I need to reduce the dosage? What is the likelihood of AF recurrent in my condition? Thank you very much!

Daniel_Cantillon,_MD: Tough one. First the easy question, the recurrence rate for AFib in patients with HCM is high... so regrettably, yes, the AFib is likely to come back. Second, the tough one: You have correctly identified that both amiodarone and B-blockers are associated with slowing your heart down. Pacing can help with that, but the decision to do so really needs to be carefully thought out in an office visit. I say that because there are other anti-arrhythmic drug options that should be considered that don't cause bradycardia. Not sure if you're a candidate for that.

Trykkergirl: 70-year-old obese female persistent? AFib three years, three mild leaking valves, grade oen heart block, level oen diastolic dysfunction. 100mg Flecainide twice daily. In and out AFib. Increase to 150mg and add 350mg Magnesium Powder, extra Metoprolol. to get me out A Fib..Do I need to be on Flecainide indefinitely? Don't want ablation. Could I reduce to 50 mg Flec twice daily till I go back in AFib? Or 75mg? What are long term effects? Last episode a week ago, pulse rate went from normal high 50's low 60's to 107, lingered in high 90's for several days. Was dehydrated and hospitalized two days.. Did I have Ventricular Tach? Dr. said A Flutter which went to AFib and many PVC's with IV fluids to rehydrate. Had taken Spironolactone two days in row for lower leg swelling. What can I do when legs swell? Dr. took me off Spiron. Should I get another BNP to determine CHF? Was 47 when dehydrated. Heart Cath June, no CAD, clear.

Daniel_Cantillon,_MD: There's certainly a lot in your question. I think an office visit would probably be the best way to sort it out. But to address your concerns regarding Flecainide, I would say that it is a safe anti-arrhythmic to be taken over the long-term provided that certain conditions are met.

Cardioversion for Atrial Fibrillation

mfbasil: What is the success rate of cardioversion to correct AFib. Do you use that often? How else does Cleveland Clinic correct AFib? Which blood thinning drug do you prefer and why?

Christine_Tanaka-Esposito,_MD: The success rate of a cardioversion is nearly 100%. A cardioversion , which is a very commonly employed noninvasive procedure, only restores sinus rhythm, it does not ensure that sinus rhythm will be maintained. In order to promote maintenance of sinus rhythm in patients with AFib, we utilize anti arrhythmic drugs. If such is ineffective or not tolerated, then an invasive procedure called a catheter ablation (pulmonary vein antral isolation) can be considered. I would be delighted to discuss options further with you. My preferred blood thinner in the majority of patients with AFib is an anticoagulant, as opposed to an antiplatelet drug like aspirin, as the former is clearly superior in reducing stroke risk in all but those at very low risk. Anticoagulants such as warfarin, pradaxa, Eliquis®, xarelto, savaysa are largely equally effective. The last 4 are associated with slightly lower risk for intracranial bleeding, and undoubtedly more convenient to use. So with all else being equal, any of these drugs is my preference over warfarin. Be aware though that these newer drugs can also be more expensive for some. If cost is an issue, warfarin which has been in use for many decades, is an effective and safe option.

sueb: My husband has afib...his cardiologist suggest cardioversion but I am afraid for him to have this. Is it safe? Could someone have a heart attack during this procedure? I am hoping that you will have alternatives to this.....that is why I am joining the chat.

Daniel_Cantillon,_MD: A cardioversion is a very safe and effective procedure. Best way to think about it is electrically 'resetting' the heart into its natural rhythm. The heart doesn't stop. It sort of 'reboots' the heart into normal rhythm. The biggest challenge is always what to do next if the arrhythmia comes back.

Ablation for Atrial Fibrillation

bremick: I recently (8/24/15) had an ablation for atrial fib and my AFib episodes since the procedure, are more intense than prior to the ablation. Some episodes last for days and the dizziness is more intense. It was explained that the AFib might continue, but I did not expect the volume nor intensity of the episodes to be so great. Is this scenario common, for the 3 months post procedure?

Christine_Tanaka-Esposito,_MD: Though not necessarily common, such is not uncommon. We typically continue antiarrhythmic drug therapy for at least three months post-ablation because of this possibility. Sometimes episode of tachypalpitations subside with time. If they persist beyond three months, and symptoms are bothersome, then a repeat procedure can be considered.

wmyoung: Question if a candidate for ablation therapy: 67-year-old active white male with desire to terminate/reduce AF episodes, 25+ year history "paroxysmal lone AF", occurs every 2 months lasting 10-24+ hours; associated symptoms of mild nausea, anxiety. Treated with ASA until stroke 10/2014, no residual deficits from stroke; Rx: warfarin, atenolol, levothyroxine, atorvastatin. I am I candidate for ablation?

Christine_Tanaka-Esposito,_MD: Yes, based on the information provided you seem to be a good candidate for catheter based ablation for AFib. As you are aware, it may not necessarily provide a cure, but certainly offers the potential to reduce symptomatic episodes which you clearly experience. Patients with paroxysmal AFib, in general tend to respond more favorably than those with persistent forms.

giorgio0668: I had two M valve surgery (2008-2013) both for only adjusted (last surgery edge to edge Alfieri method). Now the valve look like working good but i start to suffer of FA and Flutter. From the beginning after second surgery i had 5/6 episode per year. In this two years i received two CVE and from the end of May I’m suffering of chronic Atrial Flutter (and FA episode) and I was taking Lanoxin 0.125 and 5 mg of Congescor to keep low bpm and until the end of July i had 65/75 bpm and 115-70 blood pressure. From August the bpm are increasing and the average bpm is 95/99 with the same blood pressure. My doctor give me an add of Congescor and from 3rd September I’m taking 7.5 mg. + Lanoxin 0.125. Unfortunately the situation is nearly the same; Sometimes with 85/87 bpm but sometimes more. Do you think that i need to change my therapy (Isoptin?).Do you think that the only solution is to ablate a node AV and have a Pacemaker? What about a chance with new technique of catheter ablation? I'm 47 years old. Please Help me.

Daniel_Cantillon,_MD: At that age (47), I would be reluctant to say going for AV nodal ablation and pacemaker is the best option without making sure that all of the other therapies in front of this have been exhausted. By new technique for catheter ablation, I'm not sure if you are referring to rotor mapping (FIRM guided ablation) or contact force catheters -- but yes, those are considerations. An office visit would probably be best to sort that out based on the details of your care.

WN: Are the success rates better with Cryo ablation than RF ablations for AF?

Daniel_Cantillon,_MD: No.

jcschober: I noticed on the Topera website that Cleveland Clinic is listed as a FIRM ablation location. I had a PVI cryoablation about 18 months ago and though improved have recurring AFib on a fairly frequent basis. Episodes last up to a couple days and then I return to sinus rhythm for a day or two. I believe I was in AFib for at least several months before the ablation and my EF had dropped to 25-30%. 3 months after the ablation as well as a year later my EF had returned to 50-55%. I am willing to undergo another procedure, but am uncertain as to which. I would consider a hybrid (convergent) procedure, but am wondering whether a redo ablation using a sequential method, FIRM or some other procedure would be advisable before the more invasive hybrid procedure. Is there anything else I should be considering? Thanks.

Daniel_Cantillon,_MD: Wow. Great insight. I think you covered all of the procedural considerations, and there are some great options there for you. I guess the only other thing to consider would be medication. Have you tried anti-arrhythmic drug therapy?

krice121: How many times can a patient safely have a cardiac ablation? If the first one doesn't get rid of the AFib, are subsequent ones more likely to do so? Are there any studies showing the long term effects of ablation on the aging heart? Thanks!

Christine_Tanaka-Esposito,_MD: There is no limit on the number of catheter ablations, as far as safety is concerned. It does not result in lasting damage. I typically limit ablation for AFib to no more than two good quality procedures. There are some patients in whom an AFib ablation will be ineffective, and for that reason if there is no lasting response (suppression of atrial fibrillation) after at least two, there is little added value and only seemingly risk with subsequent ones.

Jill Anderson: I recently had a pulmonary vein isolation ablation. Prior to this procedure, I had a pacemaker put in. Will the pacemaker need to be adjusted now that I have had the ablation?

Daniel_Cantillon,_MD: Probably not; Unless there were also changes in your medication, or unusual programming prior to the procedure.

CocoChanel: I've already had a cardiac ablation in 2011. It really didn't work and I'm still on meds. More meds now than before. I'm now 72. What are the risks of having this procedure again at my age? I had the first one done at NYU.

Daniel_Cantillon,_MD: It all depends, but I would say that four years in the absence of any additional changes in your health status would exclude the possibility of another procedure . As stated in other question responses, the outcomes are better following a 2nd ablation.

vwegen: Does successful ablation lower the risk for stroke? If not, why?

Christine_Tanaka-Esposito,_MD: Not necessarily. A successful ablation is not defined as a cure, such that AF will never reoccur. Rather a successful ablation for AF is one that results in improvement in your symptoms, many times in part due merely to reducing the frequency or duration of episodes of AF, or by virtue of eliminating drugs that were previously necessary to control symptoms. Because AF might recur, the risk for associated stroke continues to exist.

Paroxysmal Supraventricular Tachycardia (PSVT)

MrsG60: I am 65, and have had PSVT since I was 42. I have taken Verapamil for many years and it is mostly controlled. Is the Calcium-channel blocker still the best treatment? Thank you!!

Christine_Tanaka-Esposito,_MD: If a calcium channel blocker is effective in controlling your symptoms, I advise that it be continued . It is a safe medication that also doubles as a blood pressure lowering drug.

Premature Atrial Contractions (PACs)

mfgold: What are the medical and surgical treatment options, if any, for frequent PACs? How well do they work?

Daniel_Cantillon,_MD: Great question. PACs are noisy heart beats originating from the heart’s upper chambers (either right or left). The best treatment depends on how many PACs you’ve got and whether it is just one kind of PAC or multiple different morphologies. Options include starting a medication to suppress them or targeting them with an ablation. In the latter, we map out where the PAC is coming from and selectively deaden that tissue (i.e. apply radiofrequency ablation energy). An ablation would be favored if you’re having a lot of PACs of the same kind of morphology. Lots of different morphologies of PACs favor a medication to suppress them all. With that being said, both Dr. Tanaka and I have spent long hours chasing down many different PACs inside the heart with a catheter during prolonged procedures. It is possible.

mfgold: I have had several cardiac ablations, initially for atrial fibrillation and then for atrial flutter, and now I experience frequent premature atrial contractions. Are PACs inevitable after such ablations? What treatment(s) work best for controlling them? While they're not painful, they're quite distracting and discomforting. Thank you for your reply.

Daniel_Cantillon,_MD: Hmm.. inevitable? Not sure I agree. I guess it's positive that the PACs aren't putting you back into AFib or AFlutter (or are they?). Sometimes an adjunctive medical anti-arrhythmic drug can be useful.

Premature Ventricular Contractions (PVCs)

Xomue: I had a 24-hr holster test that showed "unifocal PVC and occasional bigeminy (no ventricular tachycardia or atrial fibrillation) Several short runs of supraventricular tachycardia were noted. My doctor told me that the PVC's are harmless and not to worry; no treatment was advised except an increase in my Toprol from 25 mg to 50 mg. I do worry, of course, because of the "feel" of an irregular heartbeat (beat, beat, pause, beat, beat, pause)---My heart beats that way much of the day sometimes. My question is: Are PVC's harmless if they are caused only by stress (which I think mine are)?

Daniel_Cantillon,_MD: Great question. We generally reassure patients that PVCs are more of a nuisance than a threat in the absence of structural heart disease, or other specific cardiovascular conditions. Managing stress is sometimes easier said than done, and medications like Toprol can sometimes help reduce the burden of this specific arrhythmia. You might find it helpful.

Ventricular Tachycardia

Lorelei: 66-year-old female; 5/15 - 30 day monitor , 1 run V Tach non sustained 20sec to180bpm. Asleep,unaware. 2013 pac/pvc ER visit,neg nuc stress test and neg monitoring. D/C caffeine, no symp since. Active, feel well. Echo 2013+5/15 slight calc and regurg of all valves. Struc normEF70. CarotidUS 2013, May 2015clear. Since teens,systolic func murmur grade 3-6. Healthy, active, normal weight. Thyroid nodules dx 2010. Just found out when chgd endo's TPO antibodies 77 (norm less than 20) in 2012 and dx is Hashimoto's. Other thy tests normal? Relationship between Hashimoto's and V Tach and how treated? Bilat sil brs implants rupt, need removal. Need colonoscopy /family is cluster for colonCA. What are your recs regarding anesthesia for both? Can I just proceed? HTN five years well cont by coreg 6.25 bid. EKG abnormal. Two Cardios say from HTN. One says? past mild MI ant wall. Do not want invasive or high rad. testing when I am feeling well. Also have exceeded lifetime rads (five screening nuc stress test) Thank you Drs!

Daniel_Cantillon,_MD: Wow. I am impressed you got all that in there. :) I really think an office visit is needed to address all of your very important questions. Let me take one of them. Hashimoto's generally relates to atrial fibrillation and other supraventricular tachycardias, and less so ventricular tachycardia.

outlyarr: Hi, I am a 62-year-old male, non smoker, BMI 24.6, with V Tach....meds are amiodarone 100mg QD, carvedilol 25mg BID rosuvastatin 20 mg QD and lisinopril 5 mg QD. 2 years ago presented to ER with gastric pain, EKG revealed V Tach, cath unremarkable (no stenting needed) EF 37% ( same as cath done 20 years ago 37% EF) ablation could not be done, could not map (attempted) exercise 35 min. treadmill 4X weekly. ICD implanted (2 lead) received a couple of pacing therapies from ICD and amiodarone initiated at 100 mg QD. No more issues since, in fact, I see my EP next week for the first time in a year. Now my question, your thoughts about longevity prognosis? Any other suggestions I should follow?

Daniel_Cantillon,_MD: Great question. I approach discussions about longevity with great humility as we don't have a crystal ball to predict the future. Life expectancy is rising for both men and women, and people are living with chronic heart failure longer than ever before in human history. Regarding suggestions, I'd suggest discussing with your EP cardiologist the long-term implications of amiodarone use at your age and whether there is need to pursue surveillance testing for liver, thyroid, eye or lung function.

Devices: Implantable cardioverter defibrillators (ICD) and Pacemakers

jbrozovich: I have bradycardia with atrial fib. I had a stroke in 2007, and a pacemaker was installed to pace the heart when it falls below 45 bpm. Without the pacemaker my heart rate is 36 bpm. I had an ablation in 2008 that fixed the AFib until 2014 when it came back. I had another ablation in 2014 but the AFib is back. Is there any other treatment options I should be considering?

Daniel_Cantillon,_MD: Yes, sometimes going back to some of the medical anti-arrhythmic drugs that were not successful in controlling the heart rhythm pre-ablation can be useful after a catheter ablation procedure. The heart substrate is changed by the procedure and there's clinical evidence to support that an 'adjunct' medical anti-arrhythmic drug can be useful. The pacemaker will provide back-up support to allow some of these medications to be used that can slow the heart rate as part of the treatment response.

gfox: I am a 63-year-old male with hypertrophic cardiomyopathy. I'm on Tikosyn for paroxysmal AFib, and it seems to be helping. But I'm also having a few runs (that is, every few days or weeks) of NSVT, and am wondering if I should be discussing ICDs with my docs. I don't have a family history of SCD or any episodes of VT.

Christine_Tanaka-Esposito,_MD: For patients with hypertrophic cardiomyopathy, the indication for ICD therapy in absence of a personal history or a family history (one or more first degree relatives) of sudden cardiac death or sustained ventricular arrhythmia, include a personal history of unexplained syncope or having documented massive left ventricular thickness (> 3 cm). Apart from this, an ICD can be useful and considered in a patient with hypertrophic cardiomyopathy and documented nonsustained VT, when associated with at least one other risk factor (drop in Blood pressure during exercise, myocardial scarring seen on cardiac MRI, certain genetic mutations for hypertrophic cardiomyopathy and severe obstruction to blood flow through the left ventricular outflow tract (from the left ventricle to the aorta)). The usefulness of a prophylactic ICD in a patient with hypertrophic cardiomyopathy and only NSVT (without other risk factors (those listed above)) is uncertain, but not necessarily contraindicated. Such a decision must take into consideration your preferences and with clear understanding of the associated risks of lifetime ICD therapy. Dofetilide carries a small yet real risk for pro arrhythmia including sustained and nonsustained ventricular arrhythmia. If NSVT is truly your only identifiable risk factor, it might be reasonable to consider an alternative anti arrhythmic which carries less risk or perhaps catheter ablation which might lessen your burden of AFib, and limit the need for ancillary antiarrhythmic drug therapy.

roberta344: Re: Ventricular HCM, what is the outcome for ICD Implantation for over age 80 patients generally in good health otherwise? Regarding above, can a Subcutaneous-ICD be implanted, rather than an ICD, if not - why not?

Daniel_Cantillon,_MD: Really terrific question. So much to discuss. First, would you want to be resuscitated in the event of sudden cardiac arrest? Some people older than 80 would choose not to be shocked, as sudden cardiac arrest is generally considered to be a very peaceful and dignified death. With that said, I have implanted ICDs in patients over 80 years old and I think your question on subcutaneous ICD vs. traditional transvenous ICD comes down to the likelihood you would require pacing support. An office visit with attention to the details could best answer that.

roberta344: What is Cleveland Clinic's percentage of successful outcomes for implanting a Cardiac Defibrillator in persons over age 80? I have been diagnosed with Apical Left Ventricle Hypertrophic Cardiomyopathy and Arrhythmias, female, age 82, otherwise healthy. Would implanting a Subcutaneous-ICD be sufficient for this diagnosis? If not, why not?

Daniel_Cantillon,_MD: In terms of successful implant? I'd say very close to 100%. Is that the right call, and where does S-ICD fit in? Those are more nuanced questions. I'd go back to a previous comment I made to another individual over 80 that you have to think very carefully as to whether you would view an appropriate shock as a welcome extension of your life, or an intrusion on an otherwise peaceful and dignified death. That's a highly personal question that each individual would approach differently based on their values and beliefs about life/death, etc.

$51WaldoZ2: My wife has nonischemic cardiomyopathy, and will have a pacemaker/defibrillator implant on the 9th of October. Will the pacemaker give her more energy, or lessen how tired she gets at times? Thanks!

Daniel_Cantillon,_MD: Was it a three lead pacemaker? (Cardiac resynchronization therapy device). If so, the answer is yes.

roberta344: Please explain what a Subcutaneous-ICD would be used for.

Daniel_Cantillon,_MD: A subcutaneous ICD is like any other ICD except that it cannot act as a pacemaker. More or less, the same reasons somebody would get a regular ICD would apply to the subcutaneous device. With that said, there are some specific aspects of a patient's care that would prompt us to look at that more closely as an option over the traditional transvenous device.

Ejection Fraction

chefmike: What is a low EF?

Christine_Tanaka-Esposito,_MD: "EF" an abbreviation for "ejection fraction" is the percentage of blood ejected from the heart with each heart beat, and quantifies the heart's ability to pump blood. A normal EF ranges from 50-65%. A low EF is any percentage less than 50%, and reflects weakened heart pumping ability.

Reviewed: 10/15

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