November 12, 2012
The most common irregular heart rhythm is called atrial fibrillation (AF or AFib) and involves the two upper chambers (atria) of the heart. Over 2 million Americans are affected by AFib and it is responsible for 15% of all strokes. Treatment options may include medications, lifestyle changes, invasive therapies or surgery. In some cases, no treatment will be necessary.
Dr. Walid Saliba, Dr. Sergio Pinski and Dr. David Van Wagoner from the Cleveland Clinic and Mellanie True Hills, Founder and CEO of StopAfib.org, answered your questions about atrial fibrillation.
The Atrial Fibrillation Web Chat had to be cancelled as the chat functionality was not working properly and the hosting company was out of the office due to Hurricane Sandy. Those who were registered were invited to submit questions that were answered offline. The transcript appears below.
Please note that the comments below are the opinions of the Cleveland Clinic doctors, and if you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.
Katie: Can Afib ever go back to being normal by itself just got diagnosed in physical on EKG by accident cannot feel it on pradaxa and digoxin and hate I’m 73 and read all sorts of things like shorter life and dementia because of it. It scares me doctor not fond of doing procedures.
Dr. Saliba: It is very unlikely that atrial fibrillation would go away by itself. While sometimes, atrial fibrillation can come and go by itself; the usual natural history of the disease is progression to a more persistent form for atrial fibrillation. Because you do not have significant symptoms, it is reasonable to treat you with Pradaxa and controlling your heart rate, however, it is also reasonable to give you a chance at restoring normal sinus rhythm and see how long you are able to maintain normal rhythm. The aggressiveness of the therapy down the road will be dictated by whether you feel better in normal rhythm and how long are you able to maintain it. We do not know if atrial fibrillation really changes longevity and whether putting you back in normal rhythm would change your risk of developing dementia or heart failure. However, early studies are underway to answer these questions.
Diana McNeil: My brother is 49 years old & was diagnosed with Atrial Fibrillation in his early 40’s. He has been shocked into a regular rhythm a couple of times & is on medication & anticoagulants. While I had begun to experience heart palpitations approximately 7 years ago, it wasn’t until the past few years I began to experience multiple symptoms. Unfortunately, due to other health issues, most symptoms were excused away. It wasn’t until about one month ago (when I suffered a serious attack), that I was definitely diagnosed with Atrial Fibrillation. Due to the length of time I had been experiencing an attack (more on than off for 10 days); they were not able to shock my heart into a regular rhythm. I am currently on Diltiazem (60 mgs 4 times a day).
Thank you for taking the time to read my email & respond.
Dr. Saliba: Atrial fibrillation can be a manifestation and the product of several diseases. Clearly, some atrial fibrillation have genetic predisposition. There have been some genes related to atrial fibrillation, but not all patients with atrial fibrillation have a clear cut genetic etiology for their disease. Furthermore, genetic based therapy does not exist at this point for atrial fibrillation. Treatment of your atrial fibrillation depends on the amount of symptoms you are having and how persistent the atrial fibrillation is. If you have significant symptoms, then despite the duration of the atrial fibrillation, it would be reasonable to attempt to maintain normal rhythm with suppressive medical therapy initially and subsequently, potentially with ablation. We cannot talk about a cure for atrial fibrillation; mainly, because we do not understand the true mechanism of the disease. Therefore, the goal of atrial fibrillation is to minimize, rather than eliminate the occurrence of atrial fibrillation as much as possible to a point that is satisfactory to the patient. The idea is that if you have symptoms related to atrial fibrillation and you have a lot of atrial fibrillation, minimizing the occurrence of atrial fibrillation will minimize your symptoms to an acceptable level. It is still possible to reduce the burden of your atrial fibrillation to the satisfactory level despite the duration of your atrial fibrillation especially if you are still having on an off episodes rather than a persistent form of the disease.
Dr. Van Wagoner: Diana — in response to your first question, when 2 siblings have AF, the odds are quite high that there is a hereditary / genetic component contributing to AF risk. It has been estimated that if one parent has AF, the children have a 1.7x increased risk of AF. If both parents have AF, the children have about a 5x increased risk of AF. Ongoing studies have documented a number of regions that are associated with AF risk (P. T. Ellinor, et al. Meta-analysis identifies six new susceptibility loci for atrial fibrillation. Nat Genet 44 (6):670-675, 2012). While significant progress is being made and it is a long-term goal to use the genetic information to guide personalized care of individual patients, we are not yet there.
Tom K: 75 years old. In June, 2011 had a significant AFib episode. Catheterization showed no obstruction or coronary disease but a very significant myocardial bridge. A pacemaker was installed, taking warfarin and 80 mg sotalol twice a day. The AFib burden until recently has been around 10% with 80 -95 heart rate when in AFib. Over the past few months the AFib episodes started to significantly increase and now I am in AFib essentially all the time, still about the same heart rate. Have compensated cirrhosis that limits the anti-arrhythmic drugs that I can take. What course of action would you recommend? What is the long range impact of being in AFib all the time?
Dr. Pinski: The main priority would be to prevent stroke, in his case with warfarin or another anticoagulant. Second priority – alleviate symptoms that he does not mention. If he is bothered by the atrial fibrillation it may be worthwhile a trial of dofetilide (which is not contraindicated with compensated cirrhosis). If atrial fibrillation becomes permanent despite dofetilide and the ventricular response still fast, one could consider AV nodal ablation down the road, as a pacemaker is already in place.
Eleanor: I use an Omron HEM-7901 T blood pressure monitor which allows me to print out graphs of all my readings. At least 50% of the readings show an irregular heartbeat. My doctor says this is nothing to worry about. But I’m wondering if an irregular heartbeat can have some correlation with my afib? Any other information about irregular heartbeats would be appreciated. Thanks.
Dr. Saliba: Irregular heartbeats can result from atrial fibrillation, but also can result from extra beats from the upper or lower chamber of the heart despite the fact that you might be in normal rhythm. The only way to find out the nature of the irregular heart beat is to perform an EKG or monitor that would allow your physician to make the correlation of the irregularity with nature of the abnormality in your heart rhythm. Based on that, specific therapy can be given.
Victor P: I have A-Fib. My condition is as follows: Have enlarged atrium (per echo test) 78yrs old diagnosed with AFRIB 3 yrs ago I had bypass surgery in 1993 with five by passes Now have 6 stents ( mostly in original by-pass grafts) What can be done to correct my A-fib.
Dr. Pinski: We need more information. Is the atrial fibrillation permanent or on- and off? Are you on a blood thinner? Do you have symptoms related to the atrial fibrillation? What is the rate during sinus rhythm and atrial fibrillation? Assuming that something needs to be done to correct your case of atrial fibrillation, a trial of an antiarrhythmic drug, sotalol or dofetilide would be the first to try.
Raymond Sousa In the introduction to the A-fib session tomorrow, Mellanie mentioned “life threatening irregular heart beat” as a medical condition associated with A-fib. This is the first time I have seen a reference of “life threatening” with A-fib medical condition. Can you expound to this reference? Under what conditions is A-fib considered life threatening? I have persistent A-fib and am wondering about the possible connection.
Dr. Saliba: While atrial fibrillation by itself is not life-threatening and its burden is mainly symptomatic, the associated complications that occur with atrial fibrillation might be. Mainly, the risk of stroke carries with it a certain amount of mortality. From that stand point, it has been reported that strokes that result from atrial fibrillation are usually more severe and result in a higher mortality compared to strokes that occur from other etiologies. Therefore, the treatment of atrial fibrillation consists predominately of reducing the symptoms and more importantly of reducing of the risk for embolization and stroke formation.
Dr. Van Wagoner: When discussing “life-threatening” heart rhythms, one usually thinks about ventricular fibrillation (VF), a condition in which function of the ventricle (the main pumping chamber of the heart) deteriorates within minutes, typically leading to death within 15 minutes of persistent VF. While the electrical properties of AF and VF are related, AF is not acutely life-threatening in the same manner as VF. However, AF significantly increases the risk of clot formation and stroke. Stroke can be life threatening or lead to significant disability. In addition, AF can lead to increased ventricular rate and decreased ventricular pump function. Both of these factors increase the risk of developing heart failure. Thus, due to the risks associated with stroke and heart failure, Mellanie is correct to say that AF can be life-threatening, but this is not typically a risk associated with the acute onset of AF.
Chris M: I have several questions
1. Aside from working at a large heart center, performing a large number of ablations each year and having a “good” success rate, what makes someone a good EP? E.g. good hand eye coordination, inquisitive mind, knowledge of physics, computers, electronics, medical school, residency or specialty training, etc. I have heard other physicians refer to EPs as “spooky” but in a good way.
Dr. Pinski: A good EP is first a good doctor. Second, has the capacity to continuously learn from his or her experience and that of the others. Third, professes realistic optimism. I don’t think that a practicing (i.e. not in research) EP has to be an engineering, computer, or physics genius. You don’t need to know the inner workings of the telephone or the phone company network to be a good conversationalist on the phone.
Chris M: 2. How many ablations a year should a competent EP perform?
Dr. Pinski: There is no strict number. Once an EP is over the learning curve, a huge number of ablations are not required to maintain the skill. If the whole team, including lab staff, anesthesiologists and nurses are stable, 2 or 3 a week should suffice.
Chris M: 3. What is your opinion of the FIRM ablation and why do you hold that opinion?
Dr. Pinski: I do not have personal experience with FIRM ablation and I am eager to see more studies coming out in the future. For now, I am remaining skeptical that it is a “magic bullet”. In my experience and that of others, termination of atrial fibrillation during ablation has not been a predictor of long term success. Furthermore, when patients with recurrent atrial fibrillation undergo second ablation we almost invariably find reconnection of several pulmonary veins. Re-isolation of the veins generally results in long term success. My hopes in atrial fibrillation ablation reside in developing techniques for more reliable and durable pulmonary vein isolation.
Chris M: 4. Is there an outside limit on the number of cardiac ablation procedures performed on one individual? If the answer is “it depends,” upon what does any such limit depend? If the amounts of radiation or atrial scarring are factors can you explain why and to what extent they impact the decision on whether or not to perform multiple procedures? What is “atrial mechanical dysfunction” and how does it impact a decision as to whether to perform multiple ablations?
Dr. Pinski: Of course it depends on many factors, such as the clinical impact of atrial fibrillation, age, anatomical substrate, and findings on previous ablations. In my practice, I have had a few patients with 5 total ablations (but not all with me). Generally in those cases, earlier ablations resulted in elimination of atrial fibrillation and the last couple of procedures were aimed at eliminating focal atrial tachycardias.
Chris M: 5. What is dofetilide/tikosyn and how does it impact post ablation care and/or sinus rhythm?
Dr. Pinski: Dofetilide is an antiarrhythmic agent that is safe and effective in the treatment of persistent atrial fibrillation, including patients with structural heart disease. We think it is also useful in controlling some regular atrial tachycardias that can appear early after ablation, although to my knowledge this has not been studied extensively. We use it very often.
Chris M: 6. Is there anything that can be done to alleviate patient anxiety immediately post-ablation when, in the recovery room, a patient is subjected to constant beeping of the heart monitor and can see the posted heart rate? For example it can be stressful as you listen for an inconsistent beep or see ones heart rate increase. It would seem less stressful if the patient could simply relax without all the chaos resulting from hearing and seeing the constant monitoring. Any comments?
Dr. Pinski: Education before ablation and a reassuring recovery room staff should take care of this. It has not been a problem in our experience. Furthermore, because we use general anesthesia, patients often have amnesia for the events immediately after the procedure.
Chris M: 7. Are then any cardiologists or other practitioners who can explain all the various realistic options for someone with afib? E.g. meds, ablation, FIRM ablation, maze, mini-maze, etc. It seems most cardiologists are frustrated with afib because the patients are hard to deal with, meds are not particularly effective and have bad side effects, and don’t totally understand the nuances of ablation or surgical options. Where would you find these practitioners?
Dr. Pinski: In general, EP doctors are best suited to guide a patient through the complexities of atrial fibrillation management. There are some outstanding clinical cardiologists that can also do it, but they may be hard to find.
Chris M: 8. From an EP’s standpoint with respect to an ablation what is the significance of atrial flutter vs… afib? E.g. is it necessary to do the left chamber of someone who is in flutter?
Dr. Pinski: Currently, We perform isolated cavotricuspid isthmus ablation for atrial flutter much less frequently. Many patients with atrial flutter also have (or will have) atrial fibrillation.
Chris M: 9. Is there anything new on the horizon regarding the treatment of afib? E.g. new techniques, new instruments, new meds.
Dr. Pinski: Atrial fibrillation ablation is a somewhat mature field by now. I expect incremental improvements and not a “revolution” in the next few years.
Chris M: Please convey my gratitude to the physicians who answer these questions. Thank you.
Nick D: We have a few questions-a little background if we may. My father is 81 years of age-within the last year & a half, he has suffered (4) TIA events with one of them causing him to be in a unresponsive state (Encephalopathy?) for (2) days. Both his cardiologist & neurologist are concerned about Atrial Fibrillation as a possible cause. His medications include Plaviix-75 mg, Crestor-5mg, Lisinopril-10 mg,& Amlodipine 2.5 mg. He also has encountered weakness and fatigue the better part of the last (2) years (my own opinion is that he is deconditioned because of a decrease in physical activity over this same two year period).He has been experiencing lightheadedness the last 4 months or so, but that occurs less frequently, if at all, with increasing water intake, more physical activity,& increased salt intake somewhat as well as some common sense practices like getting up slowly from sitting/lying positions. Incidentally, kidney testing, blood testing, etc. are coming in well.
Dad has worn the Holter monitor (with accompanying mobile event recorder) by Cardionet for (28) days-testing revealed no Atrial Fibrillation. Our blood pressure checks at home show Dad’s pulse rate within the normal range-50-100 beats/minute.
Doctors are now suggesting that Dad try an implantable loop recorder because the (28) day window may have been insufficient to detect Atrial Fibrillation. Dad has a Right Hip Replacement as of 10/27/2011-we are extremely concerned about infection with his new hardware.
In your opinion, how common is it for A Fib to reveal itself outside of the 28 day window?
What are the other risks associated with this device/procedure i.e. internal bleeding, infection, & so on?
Why should we believe there is A Fib present when testing reveals otherwise?
Many thanks for this very valuable service-we appreciate any help we can receive concerning this matter and we look forward to your response.
Dr. Saliba: Your dad has suffered already for TIA events. While it is very possible that atrial fibrillation might have contributed to these events, one would expect a higher burden of atrial fibrillation that would have been caught on 30 day monitoring. Nevertheless, in view of his age, it is still possible that atrial fibrillation is contributing to his symptoms and if found, the only change in therapy would be the addition of full anticoagulation. An implantable loop recorder is a relatively safe procedure with minimal risk of infection and might prove to be useful in this situation. I have to assure that further workup including carotid ultrasound and imaging of the aortic arch did not show any possible etiologies for your dads TIA events. As you know, while atrial fibrillation is one of the main risks for a stroke in the elderly population (up to 25%), there are other reasons why patients in this age group develop a stroke including the possibility of vascular disease, carotid disease, among others. Your dad is on Plavix. The only difference, the finding of atrial fibrillation would make, would be the institution of full anticoagulation. Therefore, the choice comes down to proceeding with empiric anticoagulation with its associated risk of bleeding –vs.- continuation of further work up to confirm the presence of atrial fibrillation (or not) and accordingly decide on further anticoagulation issues.
Dr. Van Wagoner: While AF is a common and important cause of stroke and TIA, it is not the only cause. Surgery of any type can lead to a temporary increase of inflammatory cells and cytokines that injure blood vessels and increase the risk of clot formation. It is possible that the TIA events are related to inflammatory changes associated with the hip replacement. Given your father’s age, it is also possible that occasional episodes of AF have occurred (and may recur).
Bill O: Several Questions: 1. Are there any identifiable causes of AF? I have paroxysmal AF. I’ve had 6 episodes that lasted over 1 hour in past 10 years; over 50% were when I was taking steroids for sinus infections. The others occurred last year when I lost 40 lbs. and my BP was low (below 100/60). It seems to me that anything that increases my HR appreciably will trigger an episode. I also have a pacemaker for tachy-brady syndrome.
Dr. Pinski: There are a few direct causes of atrial fibrillation, but many risk factors and potential triggers. All the things you mention could be consider triggers or risk factors. Most patients with pacemakers with sinus node dysfunction have atrial fibrosis that can also predispose of atrial fibrillation.
Dr. Van Wagoner: Inflammation is a primary cause of atrial fibrosis, and this can lead both to sinus node dysfunction and increased risk of AF. While you might expect anti-inflammatory drugs to uniformly reduce the incidence of AF, high dose steroid therapy has been shown to increase risk of AF, probably due to changes in the expression of ion channels that affect atrial electrical activity. Relevant references with links to PubMed are listed below.
M. K. Chung, D. O. Martin, O. Wazni, A. Kanderian, D. Sprecher, C. A. Carnes, J. A. Bauer, P. J. Tchou, M. Niebauer, A. Natale, and D. R. Van Wagoner. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circ. 104:2886-2891, 2001. PubMed
C. S. van der Hooft, J. Heeringa, G. G. Brusselle, A. Hofman, J. C. Witteman, J. H. Kingma, M. C. Sturkenboom, and B. H. Stricker. Corticosteroids and the risk of atrial fibrillation. Arch.Intern.Med. 166 (9):1016-1020, 2006. PubMed
Bill O: 2: If there are identifiable causes, which treatment modality would likely eliminate the episodes?
Dr. Pinski: In the absence of a direct single cause, prevention of atrial fibrillation is based on management of upstream risk factors (high blood pressure, sleep apnea, etc) and elimination of triggers (such as alcohol). When these measures do not suffice, one resorts to an antiarrhythmic agent or ablation.
Bill O: 3. The newer anticoagulants seem to cause hematomas from simple bumps against something. How can these drugs be better managed?
Dr. Pinski: The newer anticoagulants (dabigatran, rivaroxaban) have demonstrated in controlled studies to be safe and have a risk of serious life-threatening bleeding equal or lower than warfarin or aspirin.
Bill O: 4. Studies show that by taking anticoagulants reduces one’s risk of stroke to about 1%, taking aspirin reduces stroke risk to about 4%, but the risk of hemorrhagic stroke is about 2.5% by taking the anticoagulants. Are the relative risks worth taking anticoagulants over ASA?
Dr. Pinski: In patients with atrial fibrillation at risk of stroke, anticoagulants are clearly superior to aspirin and should be prescribed.
Bill O: 5. During every episode of AF recently, I’ve taken a 10mg diazepam and the episodes subsided within a short time period, always before I could get to the cardiologist’s office or hospital for cardioversion. How does this medication work, if it is the critical med, to correct AF?
Dr. Pinski: Many studies have shown that 90% of episodes of acute atrial fibrillation terminate within 24 hours with a placebo (i.e., an inert drug). In your case, Valium may help you to reduce the anxiety until the episode terminates on itself. If you really want to know, you could conduct an n-of -1 blinded randomized study. You would need the cooperation of your physician and pharmacist to produce a placebo that looks identical to your diazepam and to generate a random allocation schedule. After you have had many episodes treated with diazepam or placebo you could un-blind the results and conclude if diazepam speeded up conversion. I doubt this is worth the effort.
Dr. Van Wagoner: AF and other arrhythmias can be triggered by sympathetic nerve activity. Diazepam has been shown to improve heart rate variability and reduce sympathetic nerve activity. T. Ikeda, M. Doi, K. Morita, and K. Ikeda. Effects of midazolam and diazepam as premedication on heart rate variability in surgical patients. Br.J Anaesth. 73 (4):479-483, 1994. PubMed
Bill O: Thank you very much for offering this valuable service. If any answers to my questions have clinical research citations, I will appreciate that reference.
Robert M: My question re Afib is that I have had afib for 25 years. Is there any treatment at this point that might get me back to normal?
Dr. Saliba: If you have had atrial fibrillation persistently for 25 years, then it is less likely that suppressive medical therapy or ablation or even surgery, would lead to any long term maintenance of normal rhythm. If on the other hand, you have had on and off atrial fibrillation and you are still experiencing that same pattern, it is then possible to administer such therapy. Obviously, the indication to proceed with any therapy would be the burden of the atrial fibrillation in terms of how much symptoms is it causing you and how much limitation to your daily activity that you are having from this arrhythmia. Otherwise, provided that you have good rate control and adequately anticoagulated, if you are asymptomatic, then there is no need to proceed with any further therapy. Obviously, there other factors that come into play such as your age and the presence of any associated cardiac disease which would influence the aggressiveness of the therapy at this point.
jimm: how is irregular heartbeat differentiated from AFIB? THANK YOU
Dr. Pinksi: An ECG at the time of the abnormality is necessary to diagnose atrial fibrillation and differentiate it from other cases of an irregular heartbeat such as atrial or ventricular premature contractions.
Melinda F: I am female, 68, Lone Afib, had 1st ablation July 11, scheduled 2nd ablation Nov 12th, on Pradaxa 150 mg 2x/day since June; added Sotalol 80 mg 2x/day after 1st ablation. Digestive discomfort. Since 1st procedure, in and out of rhythm (day or two either way); Recently, mostly out. Several questions:
Dr. Saliba: Atrial fibrillation is a progressive disease. The usual natural history is more episodes of atrial fibrillation until it becomes persistent. Sometimes we have seen recurrence of atrial fibrillation several years after a successful ablation. The aim of an ablation is to try to minimize the occurrence of atrial fibrillation and give you long periods of normal sinus rhythm. It is difficult to say that we are actually curing atrial fibrillation per se. On the day of your surgery, you should not take any food or drink after midnight. Physicians differ in whether they want you to take Pradaxa and/or Sotalol the morning of the procedure and that would depend on your physician performing the ablation. I would definitely not eat any plain yogurt the morning of the procedure. While your doctors might ask you to swallow the TEE, it is not the swallowing process that is the problem at the time of the surgery, but we do not like to perform the procedure on a full stomach as you might experience some regurgitation with aspiration in your lungs of the content of your stomach. Your doctor will perform a cardioversion at the time of the ablation if the ablation is not able to restore normal rhythm. Therefore, a separate cardioversion is not needed.
Your question regarding renal artery denervation is interesting. There are no true studies at this point in time looking at concomitant renal denervation in conjunction with ablation, but I am sure over the next couple of years, such studies will be emerging.
Dr. Van Wagoner: The vagus nerve is part of the autonomic nervous system that is responsible for controlling breathing, digestion, and slowing heart rate. Holding your breath (or swallowing, eating, etc.) can all increase vagal nerve activity and sometimes can provoke AF episodes. Ablation procedures often decrease the influence of autonomic nerve activity on the atria, and would likely decrease – but probably not eliminate – the effects of these nerves.
BandBH: My grandmother had heart surgery for some sort of arrhythmia about 50 years ago (not at the clinic) and died because the doctors could not help her to regain her heart rhythm on the table while she was under anesthetic and she began to fibrillate. I know little else about her condition, but here is my question. My 18 year old, otherwise healthy daughter has recently been diagnosed with hyperactive thyroid and has a t3 of 1.89. She is scheduled for surgery in December and her local endocrinologist is not concerned about anesthesia at her current thyroid level. I am wondering if my grandmother might have had an undiagnosed thyroid condition that may have caused a thyroid storm or weakened her heart. Would you have concerns about operating on a patient with this level of hyperactivity? She has noticed some palpitations and shortness of breath at times when walking up hills (she is normal weight and has history of normal to active routines).
Dr. Saliba: We do not have enough information to answer this question in an accurate fashion. However, ventricular fibrillation, rather than atrial fibrillation is most probably the reason of your grandmother’s problem when she was under anesthesia. In regard to your daughter, the anesthesiologists are usually well aware of the problems that are associated with hyperthyroid states and you might want to ask them these questions specifically. It is less likely that there is any relation between your grandmother’s fibrillation problem and the condition of your daughter undergoing surgery.
Dr. Van Wagoner: Thyroid disease is associated with increased risk of AF, and it is relatively easy to treat thyroid problems with medication, radiation treatment or surgery. A thyroid condition is not a significant deterrent to surgery, and addressing this condition will likely have significant benefits, potentially including a reduction in palpitations and decreased risk of AF. Many aspects of surgical technology, care and monitoring have improved over the past 50 years.
John CA: Why do many medical experts say that once you have experienced an afib episode, even one diagnosed as a lone paroxysmal one, that chances are you will have another? I just experienced such an episode with the probable trigger being hypokalemia. I was hoping that keeping my potassium at a healthy level, reducing my salt consumption and avoiding dehydration would keep me from having another. If I do this am I still prone to experience another and if so what is it about afib that causes that exposure?
Dr. Pinski: As a rule of thumb, I believe that “only “50% of people with a single episode of atrial fibrillation, especially with a clear identifiable trigger develop recurrent episodes over the next few years. So, yes, you have a higher risk than somebody your age who did not have atrial fibrillation but you should not be doing anything different from what you are doing at this time.
Tom E: Why take meds for Afib that occurs random; 2-4 times a month?
Dr. Saliba: Treatment of atrial fibrillation consists of treatment of the symptoms as well as treatment to reduce risk of strokes. If you have short episodes of atrial fibrillation occurring 2 times a month and not causing any significant symptoms and if your risk of stroke is relatively low based on other clinical parameters, then you will not need to take any medications. However, if your risk of stroke is high, then you need to be on medication to reduce such risk. Medication to treat atrial fibrillation per se is indicated for patients who are symptomatic from atrial fibrillation. This is predominately a symptomatic treatment. Furthermore, if you have fast heart rate associated with your atrial fibrillation, usually you should be on medication to slow down your heart rate as this might lead to some potential problems if persistent down the road. All things considered, the aggressiveness of the therapy of atrial fibrillation, whether with medication or ablation, depends on the burden of this arrhythmia in terms of its symptoms, occurrence and frequency in a typical individual.
liesel: I have had 7 A-Fib episodes in two years. It always happens during rest. Pulse raced from a resting of 50 to between 120-180; takes from 2 -6 hrs. to revert to sinus rhythm. I take Plavix, 81 mg Aspirin, 25 mg Metoprolol succrete ER, Crestor 10 mg. Heart history: MI, 2 bare metal stents in LAD, 1 DES stent first marginal. I do have moderate mitral valve prolapse. During these A-Fib episodes I chew 1-2 whole Aspirin, take 1-2 Xanax, 1 Metoprolol (but the faster acting tartrate). Question: Is there anything else I could be doing to shorten the episodes? I am 73 years old. I exercise daily and live and eat very healthy.
Dr. Pinski: At some point of time, one has to decide if the frequency and severity of the episodes of atrial fibrillation warrant a trial of an antiarrhythmic agent or ablation (It does not appear to be your case at this time). Also one has to estimate the individual risk of stroke from atrial fibrillation. I do not have all the data to calculate your risk score, but if it is high enough it may be sensible to put you on an anticoagulant and stop the Plavix (depending how long you have had the DES stent in). Because of coronary artery disease, you are not a good candidate for a pill in the pocket approach with propafenone or flecainide to try to speed up conversion. Chewing 1-2 aspirins during the episode may do more harm than good.
David H: I am 57, and have an AF attack about once/month. It lasts 6-16 hrs, but goes, when I can fall asleep. This has happened for the last year with the exception of a 4 month AF free period. If I can tolerate the symptoms, why would I need an ablation or to take anti-arrhythmic meds, if the risk of fibrosis is supposed to be very low in episodes lasting less than 24 hrs? At present I use Bystolic to lower the heart rate and rest. Would an ablation greatly reduce the risk of AF later in life? After what period of time in AF does the heart become damaged? Thank you.
Dr. Saliba: The aggressiveness of the therapy for atrial fibrillation depends on how frustrated you are with the occurrence of this arrhythmia in terms of its frequency and its associated symptoms. Therefore, the treatment of atrial fibrillation with antiarrhythmic medication or ablation is to reduce significantly the frequency of occurrence of these episodes. It is not known whether treatment of atrial fibrillation with such therapy would reduce the progression of the disease and the data about the occurrence of fibrosis is also not very definite. There are a lot of unknowns about this disease, especially its long term implications as compared to patients in normal rhythm. The bottom line is that if you are frustrated with the symptoms, then you are more likely to seek treatment with antiarrhythmic medications and if these fail, then proceed with an ablation. If on the other hand, you can tolerate these symptoms and you are satisfied with frequency of these episodes, you can just continue the treatment with medication to slow down your heart rate when you go into atrial fibrillation. Atrial fibrillation is a progressive disease and it is expected that you will have more frequent episodes and longer episodes with time. The rate of progression of this disease is variable in different individuals. There is early data to suggest that earlier treatment of atrial fibrillation with suppression with an ablation might reduce the risk or delay the progression of the atrial fibrillation down the road. However, larger studies are currently underway to answer this question.
Dr. Van Wagoner: As we age, our ability to respond to injury becomes weaker, and the heart responds in a similar manner. There are significant person-to-person variations in the rate of change in AF duration and episode frequency. In general, it is better for you to be at a healthy weight, have well controlled blood pressure, eat well and exercise regularly. It is not always possible to detect episodes of AF. The use of anticoagulants (including aspirin) is meant as a preventive measure to decrease the risk of clot formation during extended episodes of AF. In experimental studies, a significant increase in atrial fibrosis can be detected within a few days of persistent AF.
Dave S: I have infrequent episodes of Afib (once every 2 months or so) where my heart beat suddenly jumps to 180-200 beats per minute. I also have an aortic root aneurism of 4.6cm. I take 75 mg of metoprolol daily. My question is do these episodes of Afib pose a danger to my aneurism?
Dr. Pinski: I do not have sure answer. Common sense tells me that one should at least try to reduce the fast rate during the attacks of atrial fibrillation. Please consult with your physician. Maybe you could achieve this by taking some extra short acting beta-blocker at the onset of the episode.
Don R: Hi, I had signed up for the on-line AFIB chat for tomorrow that was cancelled. Following is my question:
What is the success rate for a first time ablation for a person who has periodic AFIB attacks with no underlying valve conditions? How does that improve after a second ablation?
Dr. Saliba: The success rate of an ablation procedure for paroxysmal atrial fibrillation, with otherwise no valve condition, is between 75-85%. This can improve up to 90% with a redo ablation. However, there are other clinical features that need to be taken into consideration while making this assessment, including the size of the left atrium, the function of the left ventricle and the presence of other associated problems such as hypertension or diabetes. All these fine tune the success rate of this procedure.
Barry W: I have infrequent bouts of afib maybe once a week for half an hour sometimes twice. its always when I am resting or may have eaten or had a couple of glasses of red wine (I am a moderate drinker) my afib has been going on about a year or so recognized. you just feel something isn’t right, check your pulse and there it is. I did have a bout which lasted half a day in April this year and had to go to hospital for observation, they stopped it with a beta blocker and it didn’t re occur for several weeks, it showed up clearly on the ecg. my doctor tells me not to worry and is reluctant to put me on a 48 hour monitor. I am 66 years of age quite fit and healthy otherwise, on smoker and a bottle of wine over 7 days at most. I was diagnosed Celiac 6 months ago. Should I be concerned and push my doctor for a deeper diagnosis such as a heart scan or exercise ecg. Thanks
Dr. Pinski: I would not be surprised if you had more atrial fibrillation than what you actually experience. This could be documented with a longer term monitor. All patients with atrial fibrillation should have some baseline cardiac evaluation, including at least an echocardiogram.
David AE: I am a 73 year old male that suffered a heart attack two years ago. A stent was put in and no surgery took place. The doctors say I have no damage to my heart and I am not restricted from any activity. I am on Metropolol, a time release Diltiazem, Losartan & Doxazosin for blood pressure and heart. Typical BP is 125/70 with a heart rate of 56. Since the heart attack I have issues with A-Fibs about twice a month. Heart rate will go to 70-80+- and is irregular. To control the A fibs the Diltiazem is suppose to help and does somewhat. I would like to know what triggers these A Fibs such as food or drink and what can I do when I get them to stop it? There is no specific or typical time when they come on. Thank You
Dr. Saliba: Unfortunately, most atrial fibrillation do not have a specific and identifiable trigger. As you mentioned, these occur with no specific or typical time. This is one of the frustrations that occur with this specific problem. If atrial fibrillation is occurring quite frequently, then suppressive medications with antiarrhythmic drugs or even consideration for ablation might be reasonable in your situation.
Dr. Van Wagoner: Age is one of the strongest risk factors for AF – and a very difficult one to modify! Things that you can do are: 1) continue to control your blood pressure, 2) eat well to maintain a healthy weight, and 3) exercise regularly. Population studies suggest that individual foods and beverages do not have very strong effects as triggers of AF. However, it is wise to avoid excessive alcohol consumption.
Dennis R: I’m a 64 year old male who had rheumatic fever 50 years ago. The first time I was aware was when my heart went into afib back in 2006. It is controlled with medications. My mitral valve is most affected and I am bordering on severe with few symptoms. Progression of the disease has been mercifully slow. No surgery has been scheduled. My question is if someone with a bad mitral or someone even just diagnosed with rheumatic fever why don’t we do the valve repair or replacement surgery before a fib and enlargement of the heart occurs? My situation in 2006 nearly killed me and it seems like things will just get worse from here. In view of all that I’ve been through this seems like a dangerous way to go when it might be inevitable that further damage will occur if nothing is done. Thank you.
Dr. Saliba: Timing of mitral valve surgery is a complex issue and depends on the severity of the problem associated with symptoms and heart function. Surgery has some risks involved and obviously, one cannot take these risks unless fully justifiable. Furthermore, doing surgery early might require you to have another operation down the road as these valves have finite lifespan. Obviously, the presence of atrial fibrillation adds significant symptoms to a patient who has valve disease and might be an indication to advance the timing of the surgery accordingly. This is usually left to the combined expertise of the electrophysiologist and the cardiologist and the surgeon discussing this together with the patient and coming to a final conclusion.
Dr. Van Wagoner: Rheumatic disease is a common cause of mitral valve dysfunction, and this is a significant risk factor for AF. If you have recurrent episodes of AF, it may be worth having a second opinion from a cardiac surgeon to discuss mitral valve repair and concomitant Maze surgery to decrease AF risk.
Ray L: Atrial Fibrillation Chat Question: Received diagnosis for Afib being caused by moderate-severe mitral valve regurgitation. Blood pressure and heart rate average 120/80 with irregular heart beat and no other Afib symptoms such as palpitations and racing heart rate while taking Diltiazem medication. Echocardiogram results show left ventricle systolic diameter 35 mm, Ejection Fraction 64%, left atria diameter 41 mm, pulmonary pressure 24 mmHg and no evidence of left ventricle hypertrophy. Is mitral valve repair surgery necessary at current time? When is mitral valve surgery recommended for my condition?
Dr. Pinski: Timing of mitral valve repair is a delicate issue, and depends in part of the extent of local surgical expertise. My colleagues here who are experts in valvular heart disease consider atrial fibrillation as a factor that makes them recommend surgery sooner rather than later.
Fit4life: I presently am experiencing persistent/permanent A-fib that has been precipitated by aortic stenosis that is presently classified as “severe”. I was first diagnosed with aortic stenosis in June, 2010. The A-fib could have been present prior to that but I have no way of knowing as it was asymptomatic and still is to a large degree. I am scheduled to have aortic valve replacement surgery in Feb 2013. The cardiothoracic surgeons I have consulted have told me the best chance of returning me to sinus rhythm is to perform a “maze” procedure at the time of AVR. Given the nature of my A-fib, do you agree that the “maze” procedure would be my best option, and if so, what do you think the probability of success would be (success is defined as returning to sinus rhythm).
Dr. Van Wagoner: Aortic stenosis increases the workload of the heart. As you are already scheduled to aortic valve replacement/repair, addition of the Maze procedure may help both to decrease the AF frequency (burden), and to decrease the risk of stroke (by removal or occlusion of the left atrial appendage, where clots that cause stroke often form). You do not provide enough information about your age, condition, etc. to speculate about the likelihood of maintaining sinus rhythm.
Andrew P: What are the latest, most effective treatment medications? Thanks.
Dr. Saliba: The most commonly used antiarrhythmic medications for atrial fibrillation include Tikosyn and Amiodarone. Unfortunately, all antiarrhythmic medications do have potential side effects and some of them require admission to the hospital for initiation. The most recent medication, Dronedarone (Multaq), is also an option, but is less effective than other medications. There are other medications that are effective, but are used in patients without any evidence of underlying heart disease. These medications include Flecainide or Rythmol.
Betty: I am 84 years old. I had open heart surgery March 2009 and a pace maker in Oct 2009. My warfarin levels are relatively stable, but I have tried various beta blockers over the years that have caused numerous harsh side effects. In 2011, I started Digoxin with my Verapamil. My first Digoxin test was a few weeks ago. My physician wants to increase the dosage of both my Digoxin and my Verapamil. I’m very concerned about increasing the dosages when the only side effect I have had this year is low energy. I really don’t want to increase the dosages, but if I have to, I want to make sure of toxicity levels. Will the Digoxin test toxicity levels; and if yes, what would be the appropriate scheduling of testing – monthly, bi-annually…? Any guidance is greatly appreciated.
Dr. Pinski: Digoxin and verapamil are at times used to control the ventricular response in patients with atrial fibrillation. The chances of digoxin intoxication depend in a part on the kidney function. I am personally not a big fan of this combination nor a common user of digoxin levels to guide therapy. In patients with a pre-existent pacemaker, AV nodal ablation is often useful.
Jeannette I: Are some of the side effects using Multaq — weight gain and thinning hair? How do you know if no treatment is necessary?
Dr. Saliba: Multaq side effects include predominately some gastrointestinal symptoms, but less likely weight gain. I am not aware of thinning hair being a side effect of Multaq, but can be a side effect of Coumadin if you are on such therapy. The treatment of atrial fibrillation is mainly driven by symptoms as well as associated disease. Based on your specific situation, your doctor can determine if medications are reasonable or not.
ccafib: My cardiologist recommended Multaq, with the “standard” dosage of 400 mg, twice daily. This made me feel extremely weak and my (resting) pulse rate, normally 60 BPM, dropped to around 42 BPM. The cardiologist cut the dosage in half and this seems to work. Have there been studies on lower-dosages of Multaq?
Dr. Saliba: I am not aware of any effectiveness studies that were done with ½ dose of Multaq. However, remember that treatment of atrial fibrillation is based on symptoms and if this appears to work in your situation, with a lower dose of Multaq, then that would be acceptable for the time being.
EdL: (57 year old male.) I’ve been taking Multaq since October 2009. I’m aware there are potential side effects / issues with this drug. My cardiologist checks my EKG every 3 months and bloodwork every 6 months or so. So far I have shown no side effects from the drug. Are the potential problems with Multaq such that “if I haven’t experienced a problem by now, I should be okay?” Also, would you consider the use of Multaq effective, if the patient goes out of rhythm every 3 – 5 weeks for approximately 12-24 hours?
Dr. Saliba: The main concern with Multaq is in patients who have symptomatic congestive heart failure. Otherwise, it is a relatively safe drug. Multaq is not one of the most effective medications for atrial fibrillation in our experience. The evaluation of the effectiveness of the therapy depends on your satisfaction with the recurrence pattern of atrial fibrillation. If the current pattern is acceptable, then continuation of such therapy is reasonable. If on the other hand you are seeking a better control from the symptomatic stand point, then a trial of a different medication or consideration of an ablation might be a more reasonable option. You can discuss this with your physician.
Harold S: I developed atrial fibrillation about 2 years ago during knee replacement surgery. I take warfarin to thin my blood and Multaq to maintain my heart rhythm. I have never had any symptoms of atrial fibrillation it only shows up on an EKG. I take two 400mg multaq daily. This is quite expensive. What would be the risk to cut back to one multaq daily or none at all? Also is there a less expensive product that I could take?
Dr. Pinski: There are several generic antiarrhythmic agents that could be cheaper than Multaq. In general, Multaq is not considered a drug of first choice. If your only episode of atrial fibrillation occurred 2 years ago in the setting of surgery, it may be reasonable to stop the antiarrhythmic agent and see what happens.
John C: My question for you is, Thyroid pills (Levothyroxine 50 mcg tablets & having Atrial Fibrillation a bad combination? I’m now taking 50 mcg tablets of Levothyroxine (Thyroid) medication. I am also diagnosed with Atrial Fibrillation. Is there a problem with this?
Dr. Saliba: Atrial fibrillation is one of the exacerbating and predisposing factors for atrial fibrillation. Your doctor should check the adequacy of your thyroid treatment with blood tests. While over replacement of thyroid hormone can exacerbate atrial fibrillation, your thyroid pills should keep your thyroid status at normal levels. If that is the case, then your atrial fibrillation should be treated as a separate entity and no necessarily linked to your thyroid problem.
Richard J: I am being treated with Sotalol for Paroxysmal Atrial Fibrillation for the last two years. I have seen two different Electrophysiologists, one recommends having an ablation and the other recommends staying on the Sotalol until it no longer works. What is the current standard of treatment.
Dr. Pinski: The decision about ablation is personal and based on many things included patient preferences and physician expertise. In general, if a medicine is controlling atrial fibrillation without any side effects, most physicians would agree in postponing ablation.
Pearl S: I have atrial fibrillation and have been given the choice of ablation or Tikosyn therapy. Can you give me your recommendation on these two choices. Thank you.
Dr. Saliba: The choice between Tikosyn therapy ablation depends on how many drugs have you tried before, how symptomatic you are with your atrial fibrillation, and whether you have any underlying associated heart disease. It is not unreasonable to try Tikosyn and if that is effective in suppressing your atrial fibrillation, to continue on such therapy (as long as it is deemed). Ablation would then be considered if you failed medical therapy with Tikosyn. Some patients opt to proceed with ablation as a first line therapy, which is currently becoming an acceptable option. These two treatment modalities have different risk profiles and effectiveness and usually, these have to be discussed between the patient and the physician. In our practice, we tend to give a trial of medical therapy before proceeding with an ablation.
Sandra O: Thank you, My question is, “What are the best hypertension meds to take with atrial fibrillation?” My cardiologist told me Norvasc sometimes puts in an extra heartbeat and when I stopped them, it seemed to lessen the afib. I stopped them before he told me about the Norvasc because the symptoms were less. Part B of the question is, “If you still have high b/p with 50 mg of Toprol XL and 10 mg of Ramipril/day, what else is good to take to lessen b/P but not contribute to afib?” Thank you.
Dr. Pinski: Guidelines suggest that a diuretic such as chorthalidone or spironolactone should be added at this time.
Dr. Van Wagoner:Research suggests that spironolactone may also be helpful to decrease the fibrosis that often accompanies the development of AF.
CarolA: Metoprolol 25 mg taken when I get afib, brings my rate to 100 average for the next 10 hrs. Is this a safe rate for this length of time? I start out at 150 and drop down within half hr. of taking Metoprolol. I have been diagnosed with afib for a yr and half….in what ways does it get worse as time passes? thank you for helping me with my questions.
Dr. Saliba: It is reasonable to take Metoprolol on an as needed basis when you develop atrial fibrillation. However, if you are experiencing frequent episodes of atrial fibrillation, you might want to consider suppressive antiarrhythmic medication to reduce the frequency of the episodes. Usually, the episodes become more frequent with time, but the rate of progression differ among patients. The more frustrated you are with the occurrence of atrial fibrillation, the more likely you are to upgrade to the next level therapy.
Gladys T: I’m 79 years and have high blood pressure, which my primary doctor has under control. I was officially diagnosed with AFIB about 3 years ago, although I think I had it longer. The cardiologist I was working with at the time immediately put me on coumadin (warfarin). When I experienced excessive bruising while traveling and because we traveled so much and I would have difficulty monitoring it, he took me off. At the time I was only experiencing two episodes a year. My present cardiologist has me on a new routine to substitute for the warfarin and I’ve been going through several medicine changes trying to find something that works for me and doesn’t leave me constantly dizzy and tired. I’ve been experiencing light-headedness, tiredness, and on the last change, a fainting spell while exercising. Also the AFIB incidents are becoming more frequent. I started out with Atenolol 25 MG’s twice a day, Lisinopril 5 MG, citalopram 20MG and baby aspirin. Along the way these medicines were changed and my next to last prescriptions consisted of atenolol chlorthal 50, citalopram, and amiodarone hcl 200MG, It was this combination, probably the amiodarone, that dropped my pulse so low that I fainted while exercising. As of two weeks ago I’m on hydrochlorothiazide 25MG, Citalopram hbr 20, and baby aspirin. I’m feeling like I’m getting back to normal, but I’m concerned about how these medicines will control my blood pressure and the number of AFIB incidents in the future. I notice my blood pressure slowly rising. Before all the latest changes it averaged about 120/60/over 60. It’s crept up to 140/60/60. But truthfully, I would rather have AFIB for a few days than the constant dizziness I was experiencing daily with the Amiodorone. Would you have any comments, suggestions for me? I’m anxious to receive your advice.
Dr. Pinski: You appear to be at higher risk for stroke from atrial fibrillation and should be on a blood thinner if not contraindicated. Aspirin is not protective. Many antiarrhythmic drugs used to treat atrial fibrillation (especially amiodarone) result in bradycardia (a slow heart rhythm). At times, it is necessary to install a pacemaker to allow safe treatment with an antiarrhythmic agent.
John CZ: Doctor, After many years of AFIB it suddenly stopped. This coincided with the time I started taking Calcium with D. Is this just a coincidence? Thank you for your reply.
Dr. Pinski: Difficult to answer. I know of no controlled studies of calcium/vitamin D for atrial fibrillation. Time will tell if this is a coincidence. For now, I recommend 1000 to 2000 units of vitamin D (without calcium) to everybody, especially if levels are on the low side or not exposed to the sun.
Carol A: I am getting closer and closer to 75, I take Pradaxa. What is the possibility of a blood thinner to be more effective and safer for those of us 75 with afib?
Dr. Saliba: Pradaxa is a good alternative to Coumadin for patients who need anticoagulation for stroke prevention in the setting of atrial fibrillation. When compared to Coumadin, it is slightly more effective for stroke prevention with similar bleeding side effects compared to Coumadin.
RangerJoe: Had single bypass 1996. Have high BP is managed. Had Atrial Fib 2001.Converted in hospital using meds. Taking 325 Aspirin since, ZOCOR, Jestril. Had another episode of atrial fib 2 weeks ago. Hospital 2 days, converted after 2 days with meds. Dr wants me to take coumadin or Pradaxa. I am hesitant to take anything since I had only 2 episodes. Do you think aspirin and maybe Plavix would be a safe alternate?
Dr. Pinski: No, aspirin alone or with Plavix would not be safer or more effective than a blood thinner in your case.
Deb F: I was diagnosed w/ A-Fib 10 years ago in ER as a 54 yr. old obese female, hypothyroid (on Synthroid for 20 year). Since that time I have been under the care of a cardiologist, lost 50 lbs., BP under control, and taking a regime of Metroprolol, Simvistatin, Lisinopril, a water pill and an adult aspirin everyday. I avoid alcohol & caffeine. In this 10 year period I have had only 1 additional A-Fib episode 5 years ago, that resolved spontaneously after 2 hours. I am keenly aware of going into A-Fib and am very confident that I am not slipping into A-Fib unnoticed. My cardiologist would like me to be on a serious blood thinning agent such as Coumadin and I have resisted. Does 2 episodes of A-Fib in a 10 year period warrant the risk of major league blood thinning agents like Coumadin? Isn’t Aspirin sufficient for my needs?
Dr. Pinski: You do not appear to be at high risk for stroke to warrant anticoagulation. On the other hand, you should also know that there is no strong evidence that aspirin is beneficial in a patient like you. If anything, I would consider dropping the aspirin dose to 81 mg daily.
Mark K: I am always in atrial fibrillation and have been on coumadin for 10 years. I have considered having an ablation because of excessive bleeding from minor cuts. Short of that are there any clear medical indications which would suggest that an ablation would be a better treatment than continuing with the coumadin?
Dr. Saliba: If you have been in atrial fibrillation for 10 years, it is less likely that an ablation would lead to long term maintenance and sustainability of normal rhythm. Furthermore, if you need to be on anticoagulation, then an ablation would not necessarily eliminate the need for anticoagulation because it is expected that you might have some intermittent atrial fibrillation that you might not be aware of and would increase your risk of stroke. Therefore, the need for anticoagulation might still be present even following a successful ablation. There are other procedures that would preclude the use of long term anticoagulation. Some of these procedures are awaiting approval by the FDA and include implanting a device in the left atrial appendage to obliterate that pocket that is responsible for most strokes in patients with atrial fibrillation. The Cleveland Clinic is part of that research and I will be more than happy to discuss this with you further.
Joe S: I have a question. I am 82 years old and have Atrial Fibrillation. I have been on Tamsulosin (Coumadin) for 4 to 6 years. Coumadin was prescribed by my cardiologist after an emergency trip to the hospital when my heart rate went from normal approx 60 to 150. Coumadin was prescribed as a blood thinner to reduce the possibility of a stroke. Coumadin causes bruises from the slightest bump and they last for weeks. If blood is drawn and they miss a vein the bruise is usually 2 – 3 inches in diameter. Coumaden also causes me to be much colder in winter especially my hands. In winter I often need gloves when watching TV. Coumadin also caused unprovoked internal bleeding. Recently for no identifiable reason the area above my knee swelled up 3 – 4 inches in diameter and bending my knee was very painful. An MRI showed no problem other than arthritis in the knee. My Orthopedic doctor drew some fluid from the swelling and it was mostly blood. I treated the swelling with ice packs. A month later it swelled again, not as much, and I again used ice packs. Questions: It would be desirable to get off Coumadin and get back to normal. Would you recommend trying to stop the Atrial Fibrillation ? At 82 am I a candidate or would you recommend that I live with it ? Sincerely, Joe
Dr. Pinski: We need more information. Are you in atrial fibrillation permanently? Was the INR in the recommended range when you had your bleeding episodes? Does the INR fluctuate a lot? You may be a candidate for one of the newer anticoagulants.
Devin: If not in atrial fibrillation, is it okay to be on blood thinners?
Dr. Saliba: If your doctor has decided that you need to be on blood thinners for the purpose of atrial fibrillation, then you need to continue such therapy even if you are not in atrial fibrillation. This is because you do not know when you will have atrial fibrillation and you might have atrial fibrillation that you are not aware of. There is obviously an ongoing risk of bleeding, which is relatively small, and the benefit of continuing blood thinner needs to be discussed with your physician.
Dr. Van Wagoner: Yes. The blood thinners are used to prevent clot formation, and are safe for chronic use. Many episodes of AF are “silent” – you cannot easily tell when you are in AF. Clots can form within 24-48 hours of AF.
sidepocket: A large number of us on a forum are puzzled about the use of aspirin for anti-coagulation. I note it is in use at your clinic and others. Controversy exists with other providers as well.
Mellanie: The ESC 2010 guidelines say that for a low CHADS score, in choosing between aspirin and nothing, chose nothing. The ESC 2012 guidelines and the Afib Optimal Treatment Task Force Expert Consensus Recommendations are even more definite about recommending against aspirin for afib stroke prevention. There is an expectation that aspirin will be removed from the ACC/AHA guidelines, eventually.
Dr. Saliba: We agree.
Bob S: Thanks for notice about web chat cancelling. I have 2 questions any answers appreciated. What are pro/con of multiple cardio versions. I am 71 yr with Paroxysmal Atrial Fib/Flutter since 2005 . Have had 2 ablations 4 cardiov with minimum discomfort when in afib or flutter. Cardiov puts me in NSR lasts 5-9 months then I return to flutter whether using either amiodarone or multaq.
Dr. Saliba: There are not specific problems related to multiple cardioversions, especially if done appropriately. It appears that you require one or two cardioversions on a yearly basis to keep you in normal rhythm in addition to antiarrhythmic medications. This might not be an unreasonable approach, especially if you have tried so far, 2 ablations. You mentioned that you returned to flutter, which is a known problem following ablation. In that regard, it is also possible to consider yet another ablation to try and close the circuit of atrial flutter in an attempt to minimize the recurrence of this arrhythmia.
Donald B: I am a 70 year old male. I have had permanent a fib for 12 years treated with rate control and warfarin. None of the rhythm control drugs worked. Had an aortic valve replaced 14 months ago and had Maze procedure performed at the same time. Afib persisted after the surgery though rate control drugs needed diminished by 75%. Key question: given this history, should I pursue an ablation? I am essentially asymptomatic and maintain consisted inr readings.
Dr. Pinski: Was the left atrial appendage closed/ligated with the MAZE? If yes, I would accept atrial fibrillation as permanent.
Tina H: Thanks so much for your e-mail. I would like to ask the following. I am facing a PVI ablation, but am far from comfortable about the idea! My question relates to post -ablation silent AF attacks.
Q: I have read in research reports that the success rate of PVI ablation is grossly overestimated as post ablation, the number of silent AF attacks increase.
Thank-you so much-any info would be very much appreciated. Regards, Tina
Dr. Pinski: Silent atrial fibrillation occurs often, both before and after ablation. I am not sure if it is more frequent AFTER ablation. At times, people after ablation had a regular atrial tachycardia. In that case, the pulse may be rapid but not necessarily irregular.
Robert W: what can you tell me about Dr. Sanjiv Narayan and his focal beat and rotor [FIRM] ablation? where can I get it, and where can I sign up? I live near Ann Arbor Michigan. thank you
Dr. Saliba: The rotor theory by Dr. Narayan is an attractive one, but as all theories that pertain to atrial fibrillation, it needs to be proven and validated. So far, it is a single center experience. There is an ongoing study using such approach for patients with paroxysmal atrial fibrillation. To my knowledge, you will need to get in touch with the group in San Diego where Dr. Narayan practices to get more information regarding signing up.
Joefive: The question I was going to pose is the advisability of the standard Atrial Fibrillation ablation procedure relative to the relatively new “Focal Impulse and Rotor Modulation” procedure. I am scheduled to have the standard procedure in January.
Dr. Pinski: I have no personal experience with the so-called FIRM procedure. I would recommend that people who undergo this procedure do it under a registered research study, so we learn something about it.
John P: What is your opinion of the FIRM guided ablation technique and results? Have you started using FIRM ablation at the Weston clinic and if not, when do you expect to see it incorporated into the Weston Clinic?
Dr. Pinski: Answered above. We are not planning to incorporate this at Cleveland Clinic Florida in the near future.
David O: Just wondering what the success rates for cardiac ablation for long distance runners. I have tried two medications, but still have a fib once or twice a month, and feel more tired when running Thank you
Dr. Saliba: If you are in good health and have only paroxysmal atrial fibrillation, the success rate for an ablation is in the order of 75-85% from the first time around.
Madelene S: After 16years of afib, controlled by medication, when does one think about ablation? What are the guidelines that warrant this procedure and what are the risks. I am 78 and in good health.
Dr. Pinski: Generally, ablation is a decision taken by the doctor and a patient, when the impact on well-being and quality of life of atrial fibrillation and its treatment outweigh the small, but certainly present, risks of the procedure.
Lynn H: I am a 68 year-old female recently diagnosed with ‘symptomatic persistent AF’. My general health is very good & I have no other underlying cardiac problems. A pulmonary vein antral isolation is recommended. Can you tell me which is the best ablation method- radiofrequency or cryotherapy. Thank you
Dr. Saliba: If you have persistent atrial fibrillation, I will not recommend cryo therapy and would be more tempted to consider radiofrequency ablation.
colindo : what are the main differences between cyroablation and rf ablations, is one procedure better than the other? what are the advantages of one over the other.
Dr. Pinski: Most of the experience with atrial fibrillation ablation has been gathered with radiofrequency, which should be considered the gold standard at this time. Balloon cryoablation was approved by the FDA on the basis of relatively small studies that showed good success and safety in patients with paroxysmal atrial fibrillation. Cryoablation has the putative advantage of less risk of very rare but serious complication of RF such as pulmonary vein stenosis or atrial-esophageal fistula, maybe at the expense of a less durable pulmonary vein isolation and higher incidence of recurrence. There are no large head-to-head comparisons of these ablation techniques in similar patients and by similarly experienced physicians.
cz8kxq: Does waiting to have an ablation cause the odds of success to decrease if the AF runs are short in duration and the disease is still classified as paroxysmal? I am being treated with warfarin and propafenone and have been able to stay in the therapeutic range for my INR reading. I have had AF, confirmed by Holter studies, for 4 years.
Dr. Saliba: As long as you are satisfied with the frequency pattern of the atrial fibrillation, then continuation of treatment with Propafenone and Coumadin is reasonable. Consideration to proceed with an ablation can be done down the road if antiarrhythmic medication becomes less effective. We do not know that waiting to have an ablation decreases the success rate. However, atrial fibrillation is a progressive disease and the chances of recurrence of atrial fibrillation down the road might be higher than what they are today by virtue of the progressive nature of the problem.
grammarhodes: I had a mini-maze operation on 5/23/12. The a-fib was successfully ablated, but exactly 4 months later I developed SVT’s. I’m scheduled to see an EP in December to determine if it’s possible to ablate the new problem. I chose surgery because I had an ASD that was repaired with an Amplatzer device. The SVT’s are coming from the left atrium. For now, I’ve had an electrocardioversion and am taking Sotalol to stay in rhythm. My question is this, is it better to hold off on the ablation (which is challenging given my “hardware”) or to go for it and hope that this solves the problem? Could the ablation cause new arrythmias?
Dr. Pinski: As you said, transseptal ablation of a left atrial tachycardia in the presence of an Amplatzer occluder for ASD is technically challenging. It is my impression that if sotalol is working without a lot of side effects, most EPs would recommend to continue medical treatment.
Joanne R: As a way of introduction, I was diagnosed with an ASD when I was a teenager. At the age of 52 I had the holes closed with 2 Amplatzer Occluders. In 2010 I was diagnosed with A-fib and was told that a normal catheter ablation would be difficult because of the hardware already in my septal wall. After a 10 month reprieve from A-fib with electro-cardioversion and Beta Blockers, I was placed on Rythmol for a few months. When that failed, I opted to have a mini-maze surgery at Ohio State University. I was told that the success rate for fixing A-fib was in the mid 90% range. I had the operation on May 23, 2012. Exactly 4 months later, I began experiencing a-flutter and SVT’s. A local EP was able to stop the signal coming from the right atrium, but didn’t want to cross the septum where he’d discovered 2 signals that he described as SVT’s, not flutter. I have an appointment on 12/07/12 with an EP at Ohio State U who claims to have done successful ablations on people with occluder devices in their hearts. At the moment, I’m in normal rhythm, although I needed another electro cardioversion less than two weeks ago. I’m taking Sotalol and Lisinopril as well as Warfarin. My question is, is it wise for me to have another catheter ablation? Should I have it while I’m in rhythm, or wait till my heart goes crazy again. (Not sure how long that will be, maybe only days.) Could the ablation create a new place for flutter or SVT? I’m just trying to decide what options are still open for me to fix my heart’s speeding rhythm. Thanks!
Dr. Saliba: The decision whether to proceed with catheter ablation depends on the recurrence pattern of your atrial flutter. Furthermore, you are still taking Sotalol for your arrhythmia. If you are frustrated with recurrence of atrial flutter, then obviously, consideration is reasonable. We have done several ablations in patients with ASD occlusion devices. That is usually somehow more difficult, but definitely possible. It would be better if you undergo the ablation while you are in atrial flutter. If not, your doctor might be able to induce the rhythm at the time of the procedure. Obviously, ablation can create new places for flutter and ablation of certain flutters, might allow other flutters to be possible. Your doctor will try to eliminate as many circuits as possible. I think the consideration for an ablation is very reasonable at this point provided it is done in an experienced hospital.
Jeff I: 75 yr old white male w/ afib since 2006. Pacemaker implanted 1.26.12 for CHF. I have a good heart why 3 wires instead of two? I want cure not control. Recently had a stress tread mill test scored mets 10. Now scheduled for a pharmacological cardiac stress agent test using Lexiscan & technetium. Is this necessary? Seems redundant & risky particularly when literature says this drug is to be used when patient is unable to undergo adequate stress. I’m 6’3 195 lbs in very good physical condition with regular exercise/long power walks of 5 miles. Does Cleveland Clinic collaborate w/UCLA for ablation? If so what is the surg. teams first time ablation success %. Can they beat 78%? Thx. Jeff
Dr. Saliba: I am not sure why you had a pacemaker with 3 wires placed, but probably because the heart muscle is weak. We will need more information to comment on that. I agree that a stress test might be possible with treadmill and the choice of the test is obviously left up to the discretion of your physician. We do not have any specific collaboration with UCLA for ablation. Quoting a specific success rate is artifactual because atrial fibrillation is different in different individuals and the number quoted is just an average and does not reflect the spread of the success rate that is seen in common practice. I believe that the patient has to be comfortable with the physician performing the procedure, which is the most important factor in decision making.
John N: a) I have read that ablation success rates are 80% to 90+%, though the criteria for these levels is only one year post-procedure without symptoms. Have there been any studies of long-term outcomes? Do these success rates carry over for longer time periods (e.g., 3 to 5 years)? b) The “headlines” in various newsletters (including Cleveland Clinic’s Heart Advisor) suggest that ablations are now as safe as anti-arrhythmic medications. However, early enthusiasm for catheter ablation as a “cure” for A-Fib now seems somewhat more tempered. Given the limited efficacy of medications over time, and the safety record of ablations, might one expect that multiple procedures and “touch-ups” will be necessary over the long term (10 to 20 years)?
Dr. Saliba: There are data about long term success rates. Usually the recurrence following the first 2 years is 3-5% per year. There is data up to 5 years where success rate has dropped down to 50%. Obviously, this depends heavily on the definition of success. We should not talk about cure for atrial fibrillation, because we do not understand the definite mechanism. Any treatment, be it suppressive antiarrhythmic medication or ablation is only an attempt at decreasing the recurrence of atrial fibrillation to a level that would be satisfactory to the patient. It is difficult to speculate the kind of therapy that would be available 10-20 years down the road as our understanding of atrial fibrillation might be better and would allow to better treatment modalities than currently available.
jerryf5878 If a person has had two unsuccessful ablations, what are the chances of a third ablation correcting their AF?
Dr. Pinski: It depends on many factors, mainly the proficiency and expertise of the previous operators. For example, I would be reluctant to recommend a third ablation to a patient who has had two ablations with Dr. Saliba. On the other hand, I often do a third ablation in patients who had 2 ablations with other doctors, only to find that the pulmonary veins are “virgin”.
Robert H: I was recently diagnosed with a-fib and have been hospitalized twice in the last 5 months for it. In each case, I was given medications only and converted back to NSR within 12-16 hours. I’ve been considering catheter ablation as the medicines I’ve been taking are making me feel terrible. I was given Amiodarone when I was released from the hospital but I’m now I’m on Multaq and Xarelto. I’m only 45 and have had numerous tests ECG, Nuclear Stress Test, Halter Monitor and I’m told that outside of the Paroxysmal A-FIB my heart is healthy. I’m trying to figure out whether I should try and see if the medications will work longer term and if the side effects will hopefully go away or to just have the ablation procedure. What are your current success rates for treating A-Fib with catheter ablation? One a side note… I have found an EP here in Southern California that says he received his training at the Cleveland Clinic under Dr. Natale and I was wondering if you could confirm this? His website actually mentions your name as someone he worked with and I was hoping you would remember; His name is Dr. Carlos Alves. Thanks for your time. Robert
Dr. Saliba: The current success rate for treating paroxysmal atrial fibrillation with no underlying heart disease is between 75-85%. Dr. Carlos Alves did train with us at the Cleveland Clinic and I believe he is quite versatile in this.
Annettemc: I have never had AF until recently. I have had 2 short episodes of AF with RVR and near syncope. First on 10/03/2012 and then documented with event monitor on 10/16/2012. I have controlled HTN with valsartan/hct and MetoprololER 100mg. I am willing to take anticoag (rivaroxaban) but am fearful of the antiarrythmics. My stress echo was read as normal. At what point would I be a candidate for ablation? Thank you for your consideration
Dr. Saliba: If you are having recurrent episodes of atrial fibrillation and do not want to be on antiarrhythmic medication , then you are a candidate for atrial fibrillation ablation. We are seeing more patients moving to first line therapy with ablation treatment. However, this decision depends on discussion between and your physician as to the various risks and advantages of each one of these modalities.
Dr. Pinski: Correctly prescribed and monitored antiarrhythmic agents are safe. If you are still not willing to take one, one could consider ablation.
GTO: I am a 63 year old female and I went into A-fib last March and my heart rate was 176 when I arrived at the emergency room. After being on IV meds for eight hours, I came out of A-fib. I am now on 120mg of Diltiazem, 25 mg of Atenolol and coumadin. Prior to this incident I was only taking a low dose of Norvasc to control slightly high blood pressure. I have talked to doctors about an ablation but am reluctant to proceed with that as I have had no more incidences since I’ve been on the medication. However, I am not sure I want to be on all this medication for the rest of my life. I have had events over the past twenty years that appeared similar to what I felt during the March incident but was never able to document what the episodes were. Therefore, I cannot be sure whether or not I have had past A-fib events. I am following up with an arrhythmia specialist but am really not sure what my next step should be. Do you think some type of long term monitor would be beneficial to see how my heart is actually beating before I consider surgery? Or do I need to continue considering an ablation if I’ve been doing well on the meds? However, as I stated previously, I would rather not be on all these meds forever. Thank you
Dr. Saliba: Treatment of atrial fibrillation is mainly a symptomatic one apart from risk reduction with blood thinning if needed. If you are not experiencing frequent episodes of atrial fibrillation, then continuation with the current approach is not unreasonable. Should you start experiencing more frequent episodes, then consideration for either antiarrhythmic medication or ablation would be reasonable. If you are satisfied with the way things are at this point in time, I would not do anything different.
Mary W: As an a-fibber who has probably had 20 cardioversions since 2004, including seven this year alone, I finally broke down and scheduled an ablation on Dec. 12. I’m in a-fib right now, and wondered if there would be any harm in not having a cardioversion prior to my ablation date. Thanks for offering this service.
Dr. Pinski: I would perform ablation under uninterrupted anticoagulation without prior repeat cardioversion.
Jeannette I: Is a pacemaker the best way to control A-Fib vs. medicine? Thank You for the help in understanding A-Fib.
Dr. Saliba: A pacemaker does not help in controlling atrial fibrillation. The benefit of the pacemaker is that it allows us to give you more medication that would potentially slow your heart beat down without being concerned about very slow heart beat as the pacemaker would kick in to prevent that. However, it does not have any known suppressive properties for your atrial fibrillation per se.
Dr. Van Wagoner: Pacemakers can be helpful for patients with bradycardia (a slow heart rate), but are otherwise not a very effective tool for controlling AF.
Elliott G: if you have a new implant since august 23rd and have had in excess of 200 episodes of atrial fibrillation to date, should ablation be considered? if yes, then why? there’s different invasive procedures for ablation, which has the least risk and best results? why wouldn’t ablation be successful? any risk continuing and not having ablation? Thanks
Dr. Pinski: Many variables need to be taken into account. Often times, pacemakers call atrial fibrillation things that are not (especially when short lived). The first step here would be actual review of the pacemaker interrogation by an experienced physician. Only once the diagnosis of atrial fibrillation has been substantiated one starts to talk about potential treatments.
Bob C: Age 83 My questions for the physicians regarding AFIB:
I appreciate your help, and thanks.
Dr. Saliba: The decision to proceed with AV node ablation and pacemaker placement has the advantages of simplifying the medication regimen and alleviating the symptoms. However, this is done at the expense of pacemaker dependency as well as continuation of atrial fibrillation, which might still be associated with some symptoms. However, if medications have failed to maintain normal rhythm or have failed to control the heart rate adequately and the patient is not willing to consider afib ablation, then an AV node ablation with pacemaker placement is the next best choice.
AV node ablation does not cure atrial fibrillation and there is a continuation of risk of stroke, which would still require treatment with appropriate anticoagulation/blood thinners. The risk of stroke is not reduced by AV node ablation.
RhondaS: I have a pacemaker, implanted in 2010, due to bradycardia. Since 2010, I have had irregular heartbeats as well as afib. This happens on a daily basis. I am very intolerant of medicines due to side-effects. I was tried on Sectral 400mg twice a day, but it had to be lowered to 200mg twice a day, but it is not really helping. My cardiologist is now recommending ablation. Can you please explain how this works when you have a pacemaker? Any other information you can provide will be most appreciated. Thank you.
Dr. Saliba: The presence of a pacemaker does not preclude performing the ablation. The pacemaker is usually placed on the right side of the heart. The ablation is done on the left side of the heart. Therefore, the ablation is done in the usual fashion in patients who have pacemaker with special care not to dislodge the already existing wires. We will be more than happy to answer more of your questions if you have any.
Sparassis: Would you recommend a mini-maze procedure over pulmonary vein ablation for a 72-year old in terms of risk vs. resolution of afib.
Dr. Pinski: No, I would not.
SFC Bill: I have not yet had my first appointment with an EP (am going to see Hugh Calkins at Johns Hopkins next week), but from my first impression, he does not favor surgery as a first line option. I understand that many, including myself, are concerned when discussing an operation on the heart…however, I am currently 3 years away from a military retirement, and have a great fear that with this condition (2 trips to the emergency room in the last 2 months with heart rates exceeding 150 beats per minute) will preclude me from finishing my military career. Could this be a determining factor for the EP in a decision about what course of action to take? It seems from everything that I have read that drug therapy does not “cure” this condition, just keeps it at bay for a while. And, if surgery is an option, does the Mini Maze provide a higher chance of success without a higher chance of risk?
Dr. Saliba: The decision whether to proceed with suppressive medical therapy — vs.— an ablation procedure or even a mini-MAZE surgery, will need to be discussed specifically with your physician. Since you have had only 2 episodes of atrial fibrillation so far, I would definitely not suggest a very aggressive approach. None of these approaches cure atrial fibrillation, they just suppress it to a variable degree. It is your frustration with your rhythm as well as your current social situation that determines the aggressiveness of your therapy for atrial fibrillation. This is obviously open for discussion with your physician and I am sure Dr. Calkins will be very open to such discussion.
Bob: What are determining factors to one should consider when deciding on mini-maze or another ablation?
Dr. Pinski: Careful weighting of risks and benefits.
Helen SS: I am a 75-year-old female who had open-heart surgery and a mitral valve repair October, 2006. March 2012, I began an in and out A-Fib. Since August 2012, I am in permanent A-Fib and have some tricuspid valve leakage and enlarged atrium. If A-Fib does not respond to medication, what procedure does Cleveland Clinic recommend for patients with persistent A-Fib and enlarged atrium? Would the mini-maze or maze procedure be recommended? Has Cleveland Clinic performed the new hybrid procedure on patients with dilated atrium whose A-Fib is persistent? THANKS.
Dr. Saliba: Since you have already had one open heart surgery, another surgery, including mini-MAZE or MAZE procedure is usually difficult unless you need another valve surgery. The hybrid procedure is also not straight forward because of your previous surgery, you have a fair amount of adhesions and fibrosis around the heart. You might want to consider an ablation approach, keeping in mind the limitations of the success, especially if you have an enlarged atrium. This can be determined further at the time of your visit to your physician.
Linda W: Thanks for organizing this forum and hope all are safe from Hurricane Sandy. I am posing these questions on behalf of my mother — age 80, great health other than Afib, which she has had for about 4-yrs. Recently hospitalized due to very low blood pressure (passed out and fell).
Q. Due to extreme low blood pressure, my mother was taken off Toprol. What alternative medications should be considered that would not have the effects of lowering blood pressure?
Q. She has been referred to (University of Iowa) for potential new medical procedure. What are the latest surgical treatments for Afib? And what kind of success rate are you seeing?
Thanks very much for your insights!
Dr. Pinski: It depends, is the atrial fibrillation permanent or paroxysmal? What is the rate during atrial fibrillation? I doubt she would be a candidate for catheter ablation before trying medical treatment. If heart rate too slow, she may also need a pacemaker.
Margaret G: How much red wine is safe to drink a day with A-Fib?
Dr. Saliba: Some patients clearly have triggers of atrial fibrillation with wine. Those patients try to avoid this as much as possible. However, if your atrial fibrillation is not specifically triggered by alcohol or red wine, then occasional drinks are not prohibited. If you are in a persistent atrial fibrillation, then obviously, this is not an issue. If you are on anticoagulation with Coumadin, bear in mind that alcohol can affect the level of your blood thinning.
ElizabethN: What are the pros and cons of drinking alcohol or smoking marijuana when on Warfarin? Is one better than the other or are both taboo? Can they be used in moderation?
Dr. Pinski: I believe that for a woman, up to one alcoholic beverage a day is not harmful and maybe beneficial. You need to make sure that the INR remains in range and avoid binge drinking. Far much safer one glass of wine daily than seven on Saturday nite! I cannot opine regarding MJ.
sueann60: comment on AFIB risk as related to pulse rate and entreme exercise
Dr. Saliba: When you are in atrial fibrillation, your heart rate tends to go faster. Obviously, with exercise, sometimes the heart rate can be dangerously fast.
BruceD: Good afternoon- I am a 56 year old male, 5’10, 180 lbs. I have been very athletically active all my life, running track and cross country in high school and college and playing tennis and other sports since then. Several years ago I started to get tachycardia when I played in a paddle tennis league. It gradually got worse. Tests have determined that I have A-fib, atrial flutter and hypertrophic cardiomyopathy. Prior to beginning drug therapy, I was able to exercise hard on a Stairmaster for an hour with no problems; it was the very short bursts of tennis and paddle tennis that would trigger my A-fib. Also, too much alcohol is a trigger. I now am taking 25MG of Metoprolol daily and 1 81MG aspirin. I have no problems if I don’t exercise too intensely or don’t drink to excess. It seems, however, that my heart feels like it always has the potential to go into A-fib, which is highly uncomfortable for me. Questions: In addition to potentially curing my A-fib, would ablation generally make my heart healthier allowing my heart to beat more normally and allow me to resume more strenuous exercise?
Dr. Saliba: Ablation does not make your heart healthier. However, by suppressing atrial fibrillation, you are less likely to have potential damage from fast heart rate related to atrial fibrillation.
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.
Please note that the comments above are the opinions of the Cleveland Clinic doctors, and if you quote these opinions elsewhere, please reference the specific doctor whose opinion you are quoting.
Reprinted with the permission of the Cleveland Clinic.
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November 12, 2012