Atrial Fibrillation

Here is the current situation:

Newest research suggests that there is little to differentiate longevity between those who have paroxysmal or persistent AF and whether they take medication or have an ablation. IOW, the morbidity is about the same across the entire population of AF patients if they are broken up 'randomly' into two groups, one receiving monitoring and drugs, the other getting an ablation.

But...............................................it's the individual patient who matters. Some do well with cardioversions now and then, with DOAC (Daily Oral Anti-Coagulation medicine), and with rhythm and rate control (rivaroxaban/apixaban and metoprolol/bisoprolol/diltiazem respectively), while others do best with the mechanical 'fix' (it isn't a fix, it's just a way of blocking the spurious electrical impulses) in a procedure called ablation. [Sorry, I tend to write complex sentences that may need a re-read...].

Secondly, the patient is the one who is either really bothered by what he/she feels when in arrhythmia, or they are blissfully unaware and don't lose any sleep or feel pressured to deal with the arrhythmia. I was highly symptomatic, so as soon as I read about catheter ablation, I began to push for that form of relief. I finally got the relief, but not until I got a second ablation (my first one failed. F first ablations have a 75% success rate, 85% for a second attempt).

Thirdly, almost all cases of AF are progressive. At first, they are manageable and infrequent. Then, they begin to come more frequently, and they often last longer, even a couple of days. You want to be treated before you enter the 'persistent' phase, and certainly before you are deemed to be 'permanently' in AF. The reason is that the heart begins to 'remodel' its substrate (underlying structure) with chamber thickening and with fibrosis, neither of which is good for the heart. A heart advanced in remodeling is usually headed for heart failure, or what I would wish they'd rather call it 'cardiac insufficiency', because the heart doesn't really 'fail.'

You are strictly in the paroxysmal phase, where your AF comes and goes. That's good. If you ever feel like you're beginning to lose ground to the disorder (that's what it is, an electrically disordered heart), you must get referred to an electrophysiologist as soon as possible and get either improved medication control or get in line for a catheter ablation. You want it dealt with firmly before you become 'persistently' arrhythmic.

@dao that is a long time between AF episodes! For the last 10 years I have mainly had afib once a year with heart rate around 195. In 2023 I had it twice. I saw an electrophysiologist since my cardiologist thought things were getting worse, and the EP said that if he had done an ablation on me and saw two episodes a year, he would consider it a success!

I recommend the book The Afib Cure by Day and Bunch. two cardiologists. For some patients, they say that progression is not inevitable if triggers are identified and lifestyle changes are made. They even write about getting off meds. That said as responsible physicians, they write about meds in depth as well as cardioversion and ablation.

I declined blood thinners with my first dramatic episode in 2015 and am still not on any. I don't take any medications regularly knock on wood. I am humble and understand things may change. I take magnesium, drink low sodium V-8 for potassium, calcium and D3. I walk and do tai chi and try to keep stress down- not always successfully. I don't eat after 6pm and don't recline after eating, and never lie on my left side. Gas X relieves GI gas and can avert an episode. We are all different and over time these have been helpful things I have learned.

I have had "pill in a pocket" diltiazem for years and have taken it a couple of times but always end up in the ER because low blood pressure makes treatment difficult. Last fall I finally got permission to have Eliquis, a blood thinner, also as a "pill in the pocket," meaning when needed after an episode > 5 hours. This is a new protocol and avoids the side effects of daily blood thinners to cover afib that is so infrequent.

If I make it to April I will have gone a year again. Fingers crossed. But every year that goes by I am ready for a change!

I was just diagnosed with AFib but I don’t really get symptoms. They say it happens approximately 7% of the time. It was diagnosed after a slightly abnormal echo which led to a 8 day holter monitor. They’ve put me on Eliquis 2x/day. Blood clots are the biggest fear. I’ve never heard of taking it as a pocket med. curious what else you take.

How did you know to get tested for Afib?

Other studies have shown that the success rate for ablation increases the sooner it is done.

But, do not misunderstand…success in this case does not mean cure…..it means the episodes stop for some extended period of time, often years.

I have heart failure probably from afib. But, once the remodeling of the heart begins, even without Afib it will continue. Watch out, because kidney failure is very often a part of that package too. The feed back loop between the heart becoming misshapen (remodeling) and the kidneys failing is unstoppable. My own situation is to stop the Afib episodes and slow down the progression of the rest.

There is a body of evidence from various studies that the risk of blood clot comes a few days after the Afib episode. I felt that any risk of a stroke was too much, so I had a watchman as soon as I could. The best thing in 2024 for me was stopping Eliquis. The huge cost was killing my budget.

@katiekateny I believe the PIP approach with Eliquis is to take it for a month. My doctor seemed to indicate a week might be enough for a shorter episode.

I have never heard or been told of the connection between heart and kidney. Can you share a link?

I have a family history of Afib. Two of my brothers and I all had/have irregular heart rhythm, my sister gets occasional elevated heart rate. One of my brothers and I both feel Afib when it is occurring, so we went to cardiologists to get it sorted out on our own, but as has been stated in a previous comment, some people don't feel it. My other brother never felt his Afib (even when he felt horrible); his primary care physician diagnosed it during a routine physical exam.

So, if you feel something is off, at least see your PCP.

The brain, the liver, and the kidneys need a constant and robust blood supply, and not only that...the blood itself must be well oxygenated, at least to 88% long term. Much below 85% and you will increase mortality over a few months to a couple of years.

A heart that is fibrillating is not moving blood through it properly, and this reduced flow is what causes the risk of stroke to rise (blood not getting circulated enough in the left atrial appendage or LAA). The risk of stroke rises six-fold in patients with AF from what their previous assessed risk was prior to diagnosis of AF. Further, the strokes don't happen right away, not even in the first 24 hours according to the literature. They can happen as long as six months post the last AF episode. !!! So, while AF is not going to kill you, the stroke that happens as a result could do so, and it might wait for a long time to spring the surprise on you. That is why patients with AF, even infrequent AF, should be on a DOAC (Daily Oral Anti-Coagulant). Your cardiologist will tell you that you'll have to take it for the rest of your life, but if you are deemed free of AF after a Watchman being implanted in the LAA, and if a subsequent TEE (Trans-esophageal Echocardiogram) shows that the LAA is closed off to blood intrusion (usually six months after implantation), some cardiologists will allow you to cease taking a DOAC. However, if you have other risk factors for stroke, your cardiologist might insist that you keep taking the DOAC. If you're interested, look up 'CHA2DS2-VASc calculator' and input your numbers....no, your REAL numbers, not the ones you hope/wish you have. If your score adds up to 1.5, you should probably be taking a DOAC. If it's 2.0 and higher, your cardiologist will emphatically ask you to keep taking the DOAC.

So, to summarize, organ perfusion of blood oxygen is key for the liver and kidneys, but also for the brain which uses close to half the 4 grams of serum glucose extant in your blood at any one time every half-hour. A fibrillating heart does a poor job of this, but only while fibrillating; during normal sinus rhythm, it does a normal job. Secondly, the risk of stroke during prolonged AF, but also weeks after an episode has paroxysmally stopped, is exceedingly high, and no ethical physician/cardiologist would agree that you can opt out of taking a DOAC except that you accept the full risk by declining to take it.

@gloaming I have probably seen 4 cardiologists and one well-known EP for my once a year episodes (and my CHADS2DS2-VASc score is 2) and except for the first one (after ONE episode) not a single one has put me on an anti-coagulant. Ditto the ER MD's and hospitalists I have seen. I think this is very individual.

My mother was on Coumadin and a GI doctor took her off for an endoscopy without a bridging med. She had a stroke 5 days later. So it's not like I am cavalier. But I am also not cavalier about the side effects of Coumadin for her, including dementia from micro bleeds in her brain.