Mohamed Kanj, MD
Mohamed Kanj, MD

Peter Aziz, MD
Peter Aziz, MD

Tuesday, May 30, 2017


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. Kanj and Dr. Aziz answer your questions about arrhythmias in children and adults.

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Abnormal Heartbeats

heartline: How is it determined that you have an arrhythmia?

Peter Aziz, MD: Arrhythmias are classically diagnosed through monitors that determine the electrical activity in the heart. Many arrhythmias have typical symptoms that lead your doctor to that diagnosis.

davidX: During the 1st 5 years my heart did not get out of rhythm, you said. How did you determine that?

Peter Aziz, MD: Sorry, not entirely sure what your question is referring to. Determining if your heart goes out of rhythm is usually accomplished with a monitor of some sort which your doctor may prescribe.

Atrial Fibrillation and Atrial Flutter

sjbassoc: How do the procedures differ on an ablation for Afib versus Aflutter?

Mohamed Kanj, MD: They are two different arrhythmias originating from different areas in the heart, but can occur together. Thus, different areas will need to be ablated to address each one of them.

canada88: Can you tell me how the treatment for atrial flutter differs from atrial fibrillation?

Mohamed Kanj, MD: Please refer to the prior response.

sjbassoc: What factors reduce the success rate of an ablation?

Mohamed Kanj, MD: Presence of structural heart disease, type of AF (paroxysmal vs. persistent), presence of lung disease.

DJR: I'm an 83-year-old female with history of a stroke (with limited residual effect) and CHF in Jan., 2017. Past history of paroxysmal a-fib 2/13, treated w/Xarelto for 8 wks., discontinued due to hematuria. (Placed on baby ASA daily). Right kidney, total nephrectomy 5/10, IVC filter inserted after PE 11/07, (one wk. after abdominal surgery), Right hemicolectomy after colon perforation, 10/07. My CHA2DS2-VASc is 7 pts. Ejection fraction 60%. BNP - 652.03 pg/mL. BUN 26 mg/dL. Creat 1.29 mg/dL. EGFR - 39. Meds taken - Eliquis 2.5 mg q 12hrs, Metoprolol Tartrate 75 mg q 12hrs, Verapamil ER 360 mg daily, Triamterene/HCTZ 37.5/25 mg daily, Simvastatin 10 mg daily, Allopurinol 100 mg daily, Sertraline HCL 50 mg daily, Folic acid 800 mcg daily, CoQ 10 300 mg daily and Tylenol PRN. My symptoms are SOB, fatigue and generalized weakness. My cardiologist recommended a Watchman device since I had to discontinue Xarelto in the past due to bleeding and have since had a stroke. No problems with Eliquis at present. What are your thoughts?

Mohamed Kanj, MD: It is reasonable to continue on the Eliquis for now. For some reason, Eliquis has shown lower risk of bleeding compared to the other available agents. However, in case we started seeing bleeding with Eliquis then I agree with your cardiologist about the consideration of a Watchman device. However, I do recommend you get it done at a tertiary center with expertise in this device. (N.B. the lower dose of Eliquis is only approved if you have two of the following: age> 80, Cr > 1.5 and weight < 60 kg; I only see one factor. This may also explain why you are not having bleeding on the Eliquis).

rainbow78: My 93-year-old aunt, who suffers from COPD, recently was hospitalized with pneumonia. During treatment in the hospital it was discovered that she is in valvular AFib. Her Cardio put her on Plavix and aspirin, stating that more aggressive blood thinners are dangerous for her due to the possibility that she might fall and injure herself. What is your opinion regarding this treatment and what would you recommend?

Mohamed Kanj, MD: Oral anticoagulants are preferred over Aspirin and Plavix. For patient who we think are not great candidates for long term anticoagulation, I favor consideration of a left atrial appendageal closure device (Watchman) over ASA and Plavix. Further discussions will be needed.

rainbow78: I had mitral valve surgery eight years ago. During the 1st five years, my heart did not get out of rhythm. In the last three years I have needed Cardio version to put my heart back in rhythm. I had the 3rd CV two weeks ago and worry that I keep going out of rhythm. I have thought about having and EV study done. At this point, what treatments do you recommend?

Mohamed Kanj, MD: Atrial fibrillation and flutter are not uncommon in patients with valvular heart disease. If the arrhythmia is atrial flutter and it i quite symptomatic, then an EP study and ablation is a reasonable strategy. However, I favor you address this arrhythmia at a tertiary center given the prior valve surgery. If this is atrial fibrillation, then as needed cardioversion or trial of antiarrhythmics may be a reasonable strategy.

J@CC: What are the risk and complications of ablation surgery? What are the benefits if successful and what are the cons if not successful. What are the restrictions of physical exercise after an ablation surgery? Ralph C.

Mohamed Kanj, MD: Please refer to our website for a detailed information about the procedure, success rate and outcomes. Patients after ablation are advised to limit activity for a week until the groin heals well: No weight lifting more than 10 pounds; no jogging for a week; no bathing or swimming for a week (Showers are fine however).

Camomile: I am an A-fib patient since my open heart surgery in September 2014. Now, my medication, Dofetilide, is not handling my symptoms. I have scheduled Cryoablation in June in Springfield, Illinois. My question is; how safe is this procedure and is a successful outcome going to last or is it probable I'll need follow-up?

Mohamed Kanj, MD: Given the prior history of structural heart disease and prior heart surgery, I recommend having this at a tertiary center.

TKR: Hello Doctor, My 67-year-old husband was diagnosed with paroxysmal a fib eight months ago. He has three stents in the LAD. He has been cardioverted two or three times during hospitalizations. A fib has been well controlled since January. We are concerned about the long list of meds and looking for alternative therapy. He is on triple therapy, warfarin, Plavix, aspirin, plus Sotalol plus Carvedilol, Lisinopril, Lasix and Chlorthalidone, and recently started Pravastatin. He is 6'3", 330 pounds. BP 120/60. He has ~60% liver function, being a former heavy drinker, slightly pre-diabetic. Never smoked. He is starting on BIpap therapy now and walking somewhat more throughout the day. He has Ankylosing Spondylitis from supposed Muir-Torre Syndrome. We have heard of the Watchman Device...what are your thoughts on this and other therapy, please? Any information and suggestions is heartfully welcome. Thank you so much.

Mohamed Kanj, MD:  The Watchman device is a good alternatives to patients who are not great candidates for long term anticoagulation. It is FDA approved and accumulating data about this device from multiple studies are very encouraging. Thus it is a reasonable strategy in a patient on multiple antithrombotic agents and arthritis. However, I do strongly recommend having it done at a tertiary center. We will be more than happy to see him.

jfkacres: In 2008, during a routine annual physical, I was diagnosed with A-fib. I have been successfully taking Rythmol (Propafenone) for about eight years, with very occasional, short-term (20-min. - 2 hours) breakthroughs. I received a Pacemaker in December, 2015 due to a low heart rate (often 38-48 bpm range). At my annual check-up in December, the report showed no signs of A-fib since the Pacemaker was inserted. In your opinion, will it be necessary for me to continue taking Propafenone indefinitely? Thank you!

Mohamed Kanj, MD: Yes as long as there is no evidence of structural heart disease (normal stress test and normal echo) and there are no side effects. If you are suffering from side effects then it is reasonable to try a lower dose.

Gjongsma: The Heart Rhythm Society at their recent May meeting issued a new report on AFib. Would you comment on the report and any recommendations that you think are important in that report.

Mohamed Kanj, MD: I am very sorry but my opinion about the report is beyond the scope of this web chat. I appreciate your understanding.

Trykkergirl: 72-year-old non-diabetic female with Stage 3 CKD and Afib on and off, PLUS Sick Sinus Syndrome. Last week couldn’t get BP or pulse down first three days, was in and out Afib. Thursday was fine. Friday when I was riding my recumbent trike, I had to stop three times, go like 3 mph, even more SOB than usual, and pulse rate on app was 36. Started back, got back to van, ranger loaded my bike. Pulse then 30 after short rest. Made weird deep noises breathing, scary. Drove self to local cardiologist who lowered my Lisinopril dose in half to 10mg. Dizzy, weak. Sat. BP was off the charts, so went back to my 20mg Lisinopril plus added 1/2 of another midday. BP is normally too high, rather than too low. Pulse normally 51-53 except when in AFib. Take Metoprolol 25 at night. Earlier in week it was 90-100. That always puts me in AFib. Now scared to exercise! Time for a pacemaker or ICD? Take Flecainide 100 and Eliquis 5 twice daily. Lots anxiety. Suggestions? My EP is out of town this whole week.

Mohamed Kanj, MD: Pulse rates detected by non-medical equipment may not be very reliable. I recommend you get a stress test or wear a monitor.

davidX: Does, AF being a common arrhythmia, have risk classifications in your book? What are they? As a 24-hour-a-day AF male, age 89, it seems to me that the literature seems to disregard classification. I have never seen "controlled AFIB" defined except in the HUFF ECG Work Out book. What is your experience in this regard? Perhaps, if this is true, it is because patents don't monitor their hearts often enough to know what risk there is and you cannot be there to define the risk, unless by holter, to define the risk for them, and that would rarely be in real time? This is important for this patient to understand. If I am on the right track I will use your response to encourage my AF associate patients to monitor their hearts much more than they are. DavidX

Mohamed Kanj, MD: We have three medical concerns with AF:
1. Need for anticoagulation: If one's risk is high then oral anticoagulants or closure devices are recommended.
2. Rate: Is the heart rate during AF reasonably controlled. If not then it needs to be addressed
3. Symptoms: If patient is symptomatic (shortness of breath, fatigue, palpitations,…etc.) then treatment is indicated.

Murphy10923: I will not be able to attend your arrhythmia session on May 30, as I will be in Columbia Hospital (NYC), for a full ablation. However, after mitral valve prolapse repair with maze (2009), two ablations and numerous conversions, is there any hope for a permanent a-flutter fix? Thank you and for all the good work that you do.

Peter Aziz, MD: Yes, some arrhythmias are more feisty than others. Do not lose hope. Many patients undergo multiple procedures for the same arrhythmia.

elmer1229: I am a male, will be 58 in July. Weigh about 250. I thought I had Atrial Fib for years (25+). It would come and go. About 19 years ago I woke up and it was constant. Went to my doctor. He did EKG, called ambulance. Said heartbeat was about 180 bpm. They gave me a shot, it stopped within 30 sec. They gave me Cardizem, to me it made it worse, so I stopped it. I have had it for many years sometimes more than others. It scares me and very annoying. Depending on what I eat, and when I am bloated, it is worse. I am bloated a lot. If I sit up and make myself burp for a while it stops. A doctor told me recently that afib is constant. He said you have Tachycardia. And he is my Panic Attack Doctor. I just had an echo done on Friday. Didn't hear anything yet. About the panic attacks: A year ago at work just out of nowhere I almost passed out. Said my BP was over 200; heart rate was up. By the time I got to ER, pretty much back to normal. They said it was probably panic attacks? I need more space.

Mohamed Kanj, MD: I would advise a monitor to see if the symptoms do correlate with atrial fibrillation or not. If so then treatment for AF is recommended.

tramols: What is the key criteria in determining whether Afib/flutter is treated by Ablation versus a medicine regime?

Mohamed Kanj, MD: Actually there is no criteria. The CABANA trial is trying to answer this question. Ablation is reasonable as first line therapy for younger patients with no structural heart disease. Patients with structural heart disease: valve surgery, enlarged atria it is reasonable to attempt a trial of medicine first. In patients with heart failure: we are not sure which is a better option and thus we are conducting a trial here at the clinic to help answer this.

normaneon: I have had A-Fib for several years, had a stent in LAD, my ejection fraction percentage is 48, I am concerned because I am so tired all the time. Dr. stopped my Atenolol and put me on Carvedilol twice a day. I have been on it now for four weeks, no change other than my heart rate has improved from 50-55 up to 65-70. My cardiologist does not seem to concerned, Should I be?

Mohamed Kanj, MD: It is reasonable to get a second opinion. It is absolutely reasonable to see if restoring sinus rhythm will improve your symptoms.

Nama4: I asked this question 18 months ago but want to see if answer has changed. My 74-year-old, otherwise healthy, husband was diagnosed with afib and 29 bpm heartbeat two years ago. Has pacemaker now, takes BP meds, cholesterol meds, and Eliquis. Two attempts at cardioversion at time of pacemaker implant were unsuccessful. He is asymptomatic and works out hard in gym 3x week. Any reason to consider trying again to get heart back into rhythm?

Mohamed Kanj, MD: It is reasonable to keep him on the current medical regimen since he is asymptomatic.

tramols: If Tikosyn causes long QT syndrome and therefore not indicated as a treatment regime, what are the alternative medicines to manage Afib/flutter?

Peter Aziz, MD: Tikosyn does not cause long QT syndrome, but it can prolong the QT interval. Often times patients that have problems with QT prolongation do so when the medication is first started and are therefore hospitalized during the first 72 hours. Once that time frame is lower, data shows that the risk of having issues with the QT interval are much lower. It can be a very useful medication for flutter/fib as long as necessary precautions are in place.

yogacat: Do you think Magnesium supplements help with paroxysmal afib?

Mohamed Kanj, MD: Only if Mg is low!

Arrhythmogenic Right Ventricular Dysplasia (ARVD)

worriedmom: I would like some guidance with reference to ARVD genetic testing. I am the mother of a daughter who passed away at age 15, last month. It was a sudden death and the autopsy results diagnosed it as ARVD. I have three other children. We would like to have genetic testing done on them - do you have advice on what to ask; what type of testing?

Peter Aziz, MD: Genetic testing for ARVD is complicated. The first question that your EP doctor will ask is "how sure are we that your 15-year-old daughter had ARVD?" Commonly, this diagnosis is used on autopsy but it may not be the actual cause of death. We tend to be quite critical about this piece given the implications. If in fact ARVD is suspected, the next step would be a combination of both genetic testing and clinical evaluation for all first-degree relatives. This should be a family approach in a center that has an inherited arrhythmia clinic and is equipped to manage the complexity.


KimmieL: I was recently found to have Brugada Pattern to my EKG. How do I find out if I have this? Also - I have children and want to know if they should be tested as this is inherited.

Peter Aziz, MD: The important question is whether or not you have Brugada Syndrome. Some people may have what appears to be a Brugada ECG but may not have the syndrome. The diagnosis depends on an evaluation of your ECG and a thorough evaluation of your family history. It is reasonable for your children to also be screened, preferably in one center that can manage the screening of all family members.

Children – Abnormal Heartbeats

kittykat4: My 10-year-old daughter was playing outside - at one point her heart was beating so fast I could see it in her chest. She said she could feel it beating really hard. After that it took some time to come down but it has not happened again since. This was last week. Should I be concerned? Does she need to see a heart specialist?

Peter Aziz, MD: Reasonable to see a heart specialist. Typically these symptoms in an otherwise healthy 10-year-old represent an arrhythmia called SVT, which is not life-threatening. Your doctor may prescribe an ECG and/or an event monitor. If there has only been one episode, it is unlikely that treatment will be prescribed.

kellyo: Hello. I have an appointment for my 6-year-old son on Friday - but wonder if you can help me. He has been having irregular heartbeat. I can feel it in his pulse - erratic sometimes - but sometimes it feels normal. What can it be? Is it serious to have an abnormal rhythm in a 6-year-old - can he grow out of it?

Peter Aziz, MD: The most common cause for an irregular heart beat in an otherwise healthy 6-year-old child is "sinus arrhythmia." Sinus arrhythmia refers to the normal respiratory variation that occurs in the heart rate, which is again, totally normal. There is a possibility that he has a heart rhythm disorder, but that is less likely. Your doctor will likely prescribe an ECG and possible a Holter monitor to further assess your son's rhythm.

Catecholaminergic polymorphic ventricular tachycardia (CPVT)

SheilaR77: I have HCM and also recently tested positive for CPVT. I am scheduled for a defibrillator. What does this mean for me?

Peter Aziz, MD: Defibrillator implantation is a useful strategy to prevent sudden death in many patients that are thought to be high risk with either condition. The implications of implantation are many and are difficult to discuss over messaging. I encourage you to ask your implanting physician specifically about limitations, device longevity, inappropriate therapy and device recalls.

Devices: Pacemaker and ICD

sundancer: What brand of dual chamber pacemaker is recommended by Cleveland Clinic?

Peter Aziz, MD: The Cleveland Clinic does not endorse a particular brand of pacemaker as they all have pros/cons. We attempt to implant a wide variety of brands should there be a manufacture recall.

johnnnita: Aside from endorsing or recommending specific brands of pacemakers, what pacemakers do you use? I'm guessing one day I will require one.

Peter Aziz, MD: It depends on the indication but there are several forms and brands for pacemakers. Though we do not endorse specific brands, an electrophysiology (or heart rhythm) doctor will assess the indication for implantation as it is specific for you, and determine which type of device is most appropriate. For example, if you will need MRIs of your heart later in life, getting an MRI safe device is reasonable. There are many other factors that go into this decision.

JSS: Can a leaky Mitral valve be a source of an arrhythmia which might require an implanted defibrillator?

Peter Aziz, MD: It certainly can be. There are forms of mitral valve prolapse/regurgitation that can predispose to ventricular arrhythmias and a defibrillator may be indicated. I encourage your to speak with your physician about that type of valve regurgitation you have. Perhaps there are other factors that also play into the decision.

Lead impedance: 84-year-old female with atrial fibrillation had St. Jude pacemaker implanted (RA-Lead and RVA- Lead) on 12/17/12 and is taking Sotalol 120 mg twice per day. During a device check in 12/16, we were told there was “noise” and lead impedance for which the reason is unknown. The doctor said “come back for a re-check in three months, keep an eye on it and let us know if any symptoms change/begin”. We were told it could be a fracture in the lead, a loose screw, an air bubble but nobody would know unless an invasive surgery was done that no doctor would do given it is working/pacing properly. I feel a heightened sense of importance and would like to know if there is anything between "waiting" and “surgery”. While I certainly do not want an unnecessary surgery, I am concerned that the lead may need to be removed/replaced and only want the best/safest for her. What would you do if this were your mother?

Mohamed Kanj, MD: The right atrial lead is less important than the right ventricular lead. Thus it is absolutely reasonable to take a wait and see approach especially that the lead is five years old and the patient is elderly.

outlyarr: I have an ICD and take amiodarone 100 mg QD, The device sometimes paces me, I never notice, but is has never fired, Last week I had to stop amiodarone (after three years) because of lungs (decreased CO2 diffusion). My EP wanted to start Tikosyn but my general cardiologist wants to wait and see how I do without an antiarrhythmic because my primary diagnosis is V-tach not afib. The EP said OK we could always add Tikosyn later, what is your opinion? (Thanks).

Mohamed Kanj, MD: It is reasonable to take the wait and see approach.

Jerry: How do you know if lead extractions will be by the subclavian or femoral approach before surgery? Are lead extractions necessary if you are getting the leadless pacemaker?

Mohamed Kanj, MD: For leadless pacer, the extraction is through the femoral approach. For intravascular pacemakers, we always attempt a subclavian approach before we go to a femoral approach unless the patient have a femoral pacemaker.

Bbird: When should a biventricular pacemaker be considered for heart failure with LBBB? The patient was diagnosed with heart failure in October 2016. Is currently taking 15 mg of Bisoprolol 25 mg Spironolactone 10 mg of Lisinopril and .5 of Bumex. The EF was 16% in Oct 2016 and was 25-30% in May 2017. The patient feels good and has no symptoms of heart failure currently. What is the success rate of this type of pacemakers improving EF?

Mohamed Kanj, MD: Often patients underestimate their symptoms; thus it is reasonable to do a metabolic stress test to see if they are truly "asymptomatic" or not. Further recommendations will depend on that as well as the presence of coronary artery disease.

Trykkergirl: Can you still take Eliquis 5 mg if you have a pacemaker or ICD or both?

Mohamed Kanj, MD: Yes.

Bbird: How long is it reasonable to continue drug therapy for heart failure before considering a pacemaker? EF was 16% in October 2016 and is now 25-30%. ECG also shows LBBB. How successful is biventricular pacemaker at improving EF?

Mohamed Kanj, MD: If the heart failure is from prior heart attacks then will need to wait at least 30 days. If not, then we have to wait at least three months. On average, the response rate to BiV devices is around 66%. Higher with female gender, presence of LBBB, presence of wide LBBB > 150 msec, and the lack of prior heart attacks.

Heart Block

johnnnita: I was recently diagnosed "probably" with Heart Block Two - Type One by my cardiologist. At this time he stated that I would not need to wear a pacemaker. He based his opinion after an ECG and a follow up 24-hour monitor review. Since my mitral valve repair surgery at Cleveland Clinic in January 2007, I've had continual annual heart checkups, have been asymptomatic, feel fine and stay active. I am now age 67, and coming up on 68 in August. This annual checkup was a surprise. Should I be concerned?

Mohamed Kanj, MD: Type I second degree AV block is usually benign. Thus a pacer is only indicated if symptoms are present.

bergem: I am 89 with CAD, AFib, CABG + Stents and controlled HTN. I had a dual chamber PM inserted on May 2016 and had 15 interrogations and adjustments made until January 2017. I was diagnosed with sick sinus syndrome, and my PR interval went up from 226 to 422 ms and I was told my ventricular pacing has deteriorated since the insertion in May 2016.  EKG: showed Left BBB. Chart diagnosis: Bifascicular block+ Complete A/V block+ Sick sinus syndrome + Right BBB + Paroxysmal A-Fib.
St Jude Biventricular PM was inserted on January 27, 2017, but still have some dyspnea even at rest sometimes.
I take Coreg, Clonidine, Lasix, Aldactone, Lipitor, Warfarin, Fish oil, Probiotic. I am 5' 7", 154 lbs, on Mediterranean diet, but my exercise routine on my treadmill had to be reduced from 3 mph to 2 mph 30 min daily. Thanks, bergem

Mohamed Kanj, MD: Shortness of breath is multifactorial: heart, lung, deconditioning...etc. With respect to the pacemaker, your doctor will need to make sure that your heart rate picks up with exercise.

Long QT

ShaneK: I just read about long qt. I have heart disease on both sides of my family. My dad has a defibrillator - he has irregular beat but he has never been told he has long qt. Both grandfathers had heart disease - my dad's dad died in his 50s - I have racing heart beat at times. I am 22. How do I know if I have some type of inherited heart rhythm problem?

Peter Aziz, MD: The first thing to do is see a cardiologist. There is nothing in your history to support the diagnosis of long QT syndrome. Typically that problem presents with passing out spells in childhood. It appears that older patients in your family are having cardiovascular issues. I would recommend getting screened and having a cardiologist assess your symptoms of palpitations more thoroughly.

Stace: Is LQT 11 a benign gene? Or is it a variance of unknown significance? Would the VUS mean it is not disease causing or life threatening? Is it that there is not enough information yet?

Peter Aziz, MD: LQT11 is the gene. The mutation in the gene determines whether this causes long QT syndrome type 11 or not. LQT11 is quite rare. An experienced clinician will take into account this genetic information, along with other data (your history, family history, ECG...) and determine whether you have the clinical diagnosis of LQT11.

Wolf Parkinson White

JENI-SLO: My younger brother is suffering of WPW for the last four years. Now he is suggested to undergo the treatment of radiofrequency ablation by one cardiologist. Second cardiologist says no – he is on Verapamil. Your thoughts?

Peter Aziz, MD: Typically WPW is treated with radiofrequency ablation. The risk of the procedure is relatively low (in an experienced, high volume center) and WPW does present a small risk of life-threatening arrhythmias.

Reviewed: 06/17

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