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A-Fib News
A-Fib News items are listed by date,
most recent first. To find an A-Fib News item by topic, go to the
A-Fib News Index.
FEBRUARY 3, 2012
Stem Cells Reverse Heart Damage---(This May
Work to Repair Fibrosis and Scarring in A-Fib)
Dr. M (John Mandrola) in his excellent blog described fascinating research using
stem cells to regenerate damaged heart tissue.
Patients who had suffered a heart attack or who had advanced
heart failure and heart muscle damage received infusions of stem cells grown
from cells taken from a biopsy of their own heart. Dr. Robert Bolli of the
University of Louisville and Dr. Piero Anversa at Brigham and Women's
Hospital/Harvard Medical School took the heart stem cells harvested from
patients during coronary artery bypass surgery and sent them to Boston where
they were purified and allowed to grow. Once there were about 1 million of the
stem cells per patient, Dr. Bolli's team in Louisville reintroduce them
into the region of the patient's heart that had been scarred by a heart attack.
The purified batch of cardiac stem cells was infused into the patient's
hearts approximately 4 months after their bypass surgery, allowing time for the
bypass surgery to heal.
JANUARY 31, 2012
Septum Opening Plugged? You Can Still Have a
Catheter Ablation to Fix your A-Fib.
According to conventional A-Fib
practice, if someone had a closure device installed to plug a hole in the
septum, then they couldn't have a catheter ablation. It would be difficult to
get the catheter through the septum wall since the plug occupied part of the
septum wall. The plugging device would block the trans-septal puncture needed to
get to the left atrium.
But a recent study at the Texas Cardiac Arrhythmia Center in
Austin, Texas by doctors Pasquale Santangeli and Luigi Di Biase demonstrated
that it is feasible and safe to do a catheter ablation on patients with a septal
occlusion device (Amplatzer, CardioSEAL).
in most cases( 35) the doctors were able to puncture the septum in an area
not covered by the closure device. In four cases the doctors were able to
puncture through the closure device itself using normal procedures and
instruments, though this did take longer and involved more fluoroscopy time.
A-Fib
Patients with a Septal Closure Device Often Need Aggressive Treatment
The patients in this study all had A-Fib before the septum
plug was installed. They all progressed to highly symptomatic A-Fib and were not
helped by drugs. Over a period of at least four years 11 patients progressed to
persistent A-Fib. Five with persistent A-Fib progressed to permanent
long-standing A-Fib. These patients obviously needed an aggressive treatment.
(A septum opening between the left and right atria can lead to clot formation
and stroke {see Tedy Bruschi]. Closing
off this septal defect helps prevent stroke and is considered to decrease the
risk of developing A-Fib. But if one already has A-Fib, closing off the septal
defect opening doesn't halt the progression of A-Fib.)
Catheter Ablation
Successful through a Septal Closure Device
After a mean follow-up of around 14 months, 77% were free
of A-Fib and atrial tachycardia (this is a high success rate considering that
67% of the patients had persistent or long-standing persistent A-Fib which is
more difficult to ablate). There were no significant differences in outcome
between those who had transseptal puncture or puncture through the closure
device. No patients at three and six months intervals had "interatrial shunt;"
i.e., the puncture holes all closed up by themselves.
The doctors concluded that catheter ablation in patients with
the septal closure device was "feasible, safe and effective." They added,
"Transseptal puncture can easily be performed in a portion of the native septum
not covered by the device in the majority of patients. Direct access through the
device is also feasible and safe but requires significantly longer time."
eDITOR'S
COMMENTS:
Closing
a septal opening decreases the risk of stroke and possibly also of developing
A-Fib. But if someone already has A-Fib, closing this septal defect doesn't halt
the progression of A-Fib. These patients often need aggressive treatment such as
surgery ( Cox-Maze or Mini Maze).
If you have a closure or plug device installed in your
septum, you now have another option besides surgery to fix your A-Fib. But be
aware that most catheter ablation centers will still be reluctant to do a PVI in
your case and will likely refer you to a surgeon. Even though PVIs in patients
with septal closure devices can be "easily performed," It may take a while
for the techniques and experiences of the Texas Cardiac Arrhythmia Center to
become common practice in other catheter ablation centers. Right now you may
need to go to Texas or to another center with experience doing PVIs on patients
with septal closure devices.
If you have a septal closure device installed, be sure and
ask the doctor(s) you are working with if they have experience in ablating
patients with septal closure devices.
Santangeli,
P, Di Biase, L, et al. "Transseptal access and atrial fibrillation ablation
guided by intracardiac echocardiography in patients with atrial septal closure
devices."
Heart Rhythm. 2011 Nov;8(11):1669-75. Epub 2011 Jun 22.
http://www.ncbi.nlm.nih.gov/pubmed/21703215
DECEMBER 29, 2011
Surgical Versus Catheter Ablation---Flawed Study,
But Important Results for Patients
Not that long ago, surgery was the only way to fix most heart problems including
Atrial Fibrillation (the Cox-Maze operation). But thanks to new techniques and
discoveries like stents and the Bordeaux Group's discovery in 1994 that a
catheter with an electrode at the end can electrically isolate the pulmonary
vein openings making people A-Fib free, electrophysiologists (EPs) became more
involved in fixing heart problems. Surgeons had less to do. The last fifteen
years saw a tremendous growth in the number, training and quality of EPs doing
Pulmonary Vein Isolations (PVIs). The author remembers when he could find
and list only ten centers doing PVIs. Now there are over a thousand in the US alone.
A-Fib is indeed an epidemic, but the medical field has risen to the challenge.
Few medical discoveries have been introduced and received such wide-spread
acceptance in such a short time as catheter ablation (PVI).
FDA
Approves AtriCure Synergy Ablation System
And recently surgeons have gotten back in the game, thanks in
no small part to the work of AtriCure, Inc. whose Synergy Ablation System was
recently approved by the FDA (December 16, 2011). (The FDA approved the AtriCure
system "in patients who have persistent or longstanding persistent Atrial
Fibrillation and are also undergoing surgery for coronary artery bypass grafting
or valve repair or replacement."301
The AtriCure System is and can still be used off-label for paroxysmal A-Fib.
It's probably only a matter of time before the FDA approves AtriCure's System
for paroxysmal, stand-alone operations such as the Wolf Mini-Maze.)
The FDA approval, though limited, is nevertheless a major
medical breakthrough for A-Fib patients. A-Fib patients now officially have
a choice of treatments.
Catheter or Surgical Ablation?
But which is better---catheter or surgical ablation?
Over the years there have been many multi-center studies and data developed about the
efficacy and safety of catheter ablation. But that's not the case for the
AtriCure system which is a relatively new treatment.
For what is probably the first time, a recent small study
compared the two treatments head-to-head. AtriCure, Inc. provided funding for
the study "Atrial Fibrillation Catheter Ablation Versus Surgical Ablation
Treatment (FAST)." 59 patients at St. Antonius Hopital in Nieuwegein, the
Netherlands and 64 patients at the Hopital Clinic in Barcelona, Spain were
randomized to receive either a catheter ablation (CA) or surgical ablation (SA).
Patients were selected who had a prior failed catheter ablation (67%), had a
left atrium diameter of 40 to 44 mm and hypertension (28-40 mm is normal), or a
left atrium diameter greater than 45 (33%). (At first glance this seems like
stacking the deck against a successful catheter ablation. These are more
difficult cases requiring more than a simple Pulmonary Vein Isolation ablation.)
CA Ablation
At St. Antonius Hospital the Pulmonary Veins were
re-isolated. No additional lines or ablation strategies were performed
regardless of the type of A-Fib. A non-irrigated tip RF catheter was used.
At
the Hospital Clinic an irrigated tip RF catheter was used. An additional Left
Atrium roofline could be made at the discretion of the operator. Sometimes a
Mitral Isthmus line was also made.
At either site no mention was made of using current mapping
strategies to find and isolate activation sites, or the use of Complex Fractionated
Atrial Electrograms, or Dominant Frequency, or step-wise ablation protocols
typically used in more complex cases. (See
5-Step Ablation Treatment for Chronic A-Fib.) According to the
study authors "patients in the CA group may have been undertreated compared with
patients in the SA group."302 "More than 40% of (the CA) patients had nonparoxysmal
AF and may have been undertreated by PVI alone...67% had already failed a prior
CA, which may be a more serious predisposition to failure than anticipated."302
SA Ablation
The surgical ablation arm used the AtriCure Synergy Ablation
System which uses an RF clamp to ablate and isolate the pulmonary veins. In
addition, 31% of patients had various additional LA ablation lines at the LA
roof, aortic trigone, mitral isthmus, or box lesion around the PVs. "Part of
these lines were made without verifying that conduction block had indeed been
established."302 (In a somewhat surprising observation, the authors concluded
"efficacy tended to be a little lower in patients with such lines."302)
The Left Atrial Appendage was also removed. And Ganglia areas on the outside of
the heart were also ablated. (Ganglia Ablation is a subject of some
controversy that deserves its own report. There are over 1000 neurons [nerve
signal pathways] in the Ganglia areas. They affect other areas than just A-Fib,
such as the ventricles and the GI tract. See
Merits of GP [Ganglionated Plexi] Ablation.) According to the authors of
this study, "So far, no randomized clinical trials have quantified the added
effect of surgical ganglia ablation to achieve freedom from AF."302
RESULTS
Efficacy
(As one would expect),
the efficacy of catheter ablation was low---44.4%. What was more surprising was
that the efficacy of Surgical Ablation was only 67.2%, far less than the over
90% success rates often reported (in unpublished, self-reported, or
single-center, non-controlled series with short duration and lax follow-up).
This is all the more surprising in that the surgical arm, in addition to
isolating the pulmonary veins, often employed additional extensive lesion sets
and burns in the left atrium and elsewhere on the heart. Whereas the catheter
ablation arm was limited in ablation strategies it used.
Safety
The
procedural adverse event rate for surgery was 23% (approximately 1 out of 4
patients) which was significantly higher than catheter ablation 3.2% (in line
with previously published data). The main procedural complications in surgery
were pneumothorax (collapsed lung), major bleeding, and the need for a
pacemaker. (In surgical ablation the lungs have to be alternately deflated
and re-inflated to fit the clamp around the pulmonary veins. Especially in older
people whose lungs are no longer as elastic, this may be hard on the lungs.)
These complications were caused "mostly from direct mechanical injury during the
procedure. About half required additional intervention and/or prolonged
hospitalization."302
"The events reported with CA seemed more transient and did
not require intervention."302 They seemed to center around anticoagulation,
with bleeding on the one hand and transient ischemic attack, stroke and
hemorrhage stroke on the other. (One of the CA patients died of a hemorrhagic
stroke a month after the ablation.)
CA patients tended to stay in the hospital 2.0 days, versus
5.5 days for surgery.
Unlike catheter ablation, "there are no large registries for
minimally invasive surgical ablation that provide good insight into safety."302
EDITOR'S COMMENTS
Though
not the fault of the study's designers and investigators, the deck was obviously
stacked against catheter ablation. The success rates were far lower than
previously published and documented data. (For example, the Bordeaux Group
reports a 95% success rate after two ablations using their step-wise ablation
protocol for Persistent A-Fib patients. (See
95%
Success Rate in Curing Persistent A-Fib.)
But
what was more surprising was the relatively low success rate for the surgical
arm which seemed to pull out all the stops and use the newest, most advanced
extensive lesion sets and burns to achieve success.
In terms of safety, a 1 in 4 major adverse event rate is huge
when one considers that the surgeons were probably under intense scrutiny to
perform their best and not make any mistakes, since so much was riding on this
study.
What the FAST Study
means for Patients
This
was probably the first study to provide documented, verifiable, non-self
reporting data on the safety of Surgical Ablation (Mini-Maze). The results for
patients were not good. A 1-in-4 chance of a major adverse event is not
acceptable for most patients.
This study did not address simpler cases of
Paroxysmal A-Fib. But the surgical Mini-Maze operations are generally the same
for Paroxysmal as for more complex cases. Until we get verifiable data to the
contrary, anyone going for a Mini-Maze operation should expect a 1-in-4
chance of a major adverse event.
"But what if I've had a failed catheter ablation? Shouldn't I
get one of the more advanced types of Mini-Maze ablations?" A 67% success rate
is certainly acceptable and is better odds than you'd get in Vegas. But one of
the more disturbing findings in this study is that with the more advanced
surgical approaches using ablation lines on the left atrium and burns on other
areas of the heart, "efficacy tended to be a little lower in patients with such
lines."302 The Mini-Maze operations featuring extensive ablation lines and burns
didn't seem to work, at least in this study.
And according to the numbers, you have a better (and much
safer) chance of being A-Fib free if you go to catheter ablation centers
specializing in advanced activation mapping, step-wise protocols, etc.
Unfortunately those centers are relatively few and far between. The Bordeaux
protocol, for example, is currently used in only a few centers around the world.
And catheter ablation strategies for complex cases currently have not been
standardized, though most centers' strategies are very similar (See
Comparison of Dr.
Pappone's, Haïssaguerre's, and Reddy's
Stepwise Approaches in Ablating for Chronic A-Fib)
The FAST study, though probably the first of its kind, was a
relatively small study. A-Fib patients shouldn't rely entirely on the results of
this study for their medical decisions. But it does raise red flags particularly
about the safety, but also about the efficacy, of Mini-Maze operations. The
efficacy results for catheter ablation should probably be discounted, because of
the design bias of the study.
Borsama, L.V.A. et al. "Atrial Fibrillation
Catheter Ablation Versus Surgical Ablation Treatment (FAST)." CIRCULATION.
111.074047 Published online before print November 14, 2011.
http://circ.ahajournals.org/content/early/2011/11/13/CIRCULATIONAHA.111.074047.full.pdf
US Food and Drug Administration. "AtriCure Synergy
Ablation System - P100046" December 15, 2011.
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm284063.htm
NOVEMBER 28, 2011
Dabigatran
(Pradaxa)---Recent
Safety Advisories---Should We Worry?
The Japanese Ministry of Health, Labor, and
Welfare recently issued a safety advisory warning of the potential for adverse
effects following the deaths of five patients. Of the deceased patients, one had
kidney failure and four were over 80 years old. In Japan there were 81 reported
cases of serious side effects, including gastrointestinal bleeding, out of
64,000 people who have used dabigatran since it was first introduced in Japan in
2011.
EDITOR'S COMMENTS
81 out of 64,000 is a very low number of serious side
effects, particularly compared to warfarin. In a recent study warfarin was
implicated in 33% of "adverse drug events (ADEs)" for seniors requiring
emergency hospitalizations.
Of the five patients who died, dabigatran is counter
indicated
(shouldn't be used) in patients with renal failure. Caution is obviously needed
in patients over 80 years old. They should be monitored more closely to
determine if they have risk factors for bleeding. This should be reflected in
the labeling of dabigatran.
The
Australian regulatory authority, the Therapeutic Goods Administration, issued a
"safety advisory" on dabigatran because of an increase in the number of
bleeding-related adverse events reports. The most common site of serious
bleeding for dabigatran was the gastrointestinal track, whereas for warfarin it
is intracranial.
EDITOR'S COMMENTS
The clinical trials of dabigatran revealed that nearly two
out of five patients could not tolerate dabigatran.
The Pradaxa Fact Sheet from Boehringer Ingelheim states under "Adverse Reaction
from RE-LY" (the clinical trial of Pradaxa): Patients on Pradaxa 150mg had an
increased incidence of gastrointestinal adverse reactions (35%/yr) compared to
warfarin (24%/yr).
Dabigatran may not be the perfect substitute for warfarin.
If you're taking dabigatran (Pradaxa), watch out for indigestion, burning,
stomach pain (and weight loss). But which would you rather have---a hemorrhagic
(intracranial bleeding) stroke or indigestion? On the other hand, based on the
clinical trial date there is a danger that dabigatran over time may cause
long-term damage to the gastrointestinal system.
This is a decision you and your doctor have to make depending on how you react
to dabigatran.
Overall, dabigatran, though not perfect and not tolerated by
all A-Fib patients, is nevertheless a welcome addition to the tools doctors have
to prevent A-Fib stroke.
CAVEAT
If you're taking dabigatran and have a major traumatic
accident, emergency doctors have no antidote to stop you from bleeding to death
(with the exception of emergency dialysis which is not easily done on patients
with serious trauma and bleeding). Whereas doctors can rapidly reverse the
anticoagulant effect of warfarin using vitamin K, plasma factor Vlla, and factor
concentrates.
Also, the degree of warfarin anticoagulation can be easily
assessed, whereas no such tests exist for dabigatran.
But the advantages of dabigatran may outweigh the chances of
a traumatic accident like a car crash which may not be survivable any way. How
likely are you to be in a traumatic accident? This is again a decision you need
to consider with your doctor.
Wood, Shelley. "Deaths Prompt Dabigatran Safety
Advisory in Japan." HeartWire, TheHeart.org. 8/17/11
http://www.theheart.org/article/1264365.do
"Dabigatran: Australia issues bleeding warning"
HeartWire, TheHeart.org October 7, 2011
http://www.theheart.org/article/1291757.do
Wood, Shelley "Trauma patients on dabigatran prompt
call for "pragmatic" trials, trauma surveillance." HeartWire,
TheHeart.org. November 24, 2011
http://www.theheart.org/article/1317869.do
Lowes, Robert. "Warfarin tops list for emergency
hospitalizations in seniors." HeartWire. TheHeart.org. November 25, 2011.
http://www.theheart.org/article/1318469.do
NOVEMBER 26, 2011
Dronedarone (Multaq)---Time to Stop
Taking It?
This report is a compilation of several recent
news reports about dronedarone (Multaq) and what they mean for A-Fib patients.
1. "Multaq should not be prescribed for patients with
permanent A-Fib." according to Sanofi-Aventis' warning to doctors. In the PALLAS
study, terminated early, patients on dronedarone were dying at more than twice
the rate of those on a placebo. The ratio of stroke and hospitalization for
heart failure was also more than twice as high.
2. French health authorities concluded that the efficacy of
dronedarone was "insufficient." This could lead to the drug being dropped from
France's drug reimbursement program.
3. The European Medicines Agency stated that, because of the
increased risk of liver. lung and cardiovascular adverse events, dronedarone
"should only be prescribed after alternative treatment options have been
considered."
4. Dr. Steven Nissen of the Cleveland Clinic told the Wall
Street Journal that he thinks the drug is dangerous.
5. Dr. Sanjay Kaul of Cedars-Sinai Medical Center in Los
Angeles added, "It doesn't even appear safe in intermediate-risk patients.
6. Dr. John Mandrola of Louisville stated, "I don't know any
of my colleagues who would start a patient out on Multaq. It just doesn't work."
7. The FDA publishes a list of drugs to monitor after having
identified potential signs of serious risks or new safety information.
Dronedarone appeared on this list for the fifth straight time.
But according to Dr. Stuart Connolly (McMasters Un., Hamilton
Ontario), one of the co-primary investigators of the PALLAS trial, patients with
non-permanent A-Fib benefit from dronedarone, and he doesn't think this type of
patient should be worried. (But is there that much of a difference between
permanent and non-permanent A-Fib patients that we shouldn't be worried or
concerned? For example, by the time liver damage shows up in tests, liver cells
have already been damaged, probably permanently.)
EDITOR'S COMMENTS:
So many red flags have been raised about
dronedarone (Multaq) that anyone taking dronedarone should discuss with your
doctor if you can take another antiarrhythmic med instead. If the worst fears
about dronedarone are true, it may be both ineffective and dangerous. Why take a
drug associated with increased strokes, hospitalizations, heart failure, liver
damage, lung damage and death if it doesn't work? Even if it did work, the side
effects probably wouldn't justify taking it.
No antiarrhythmic drug is 100% safe and effective for all
A-Fib patients. But until we get more favorable research on dronedarone, all
A-Fib patients should probably consider not taking it, not just those in
permanent A-Fib. It's not worth the risk of taking a drug that isn't very
effective any way.
For a spirited,
lengthy defense of dronedarone, read Mellanie True-Hills' article/editorial
http://www.stopafib.org/newsitem.cfm/NEWSID/353/What we have learned about
Multaq/dronedarone
But in her own words, "The maker of Multaq is one of many
organizations that has contributed so that we can do research and writing to
give you the best content."
Wood, Shelley.
"Deaths
doubled with dronedarone in PALLAS: FDA and EMA updates"
HeartWire, July 21, 2011
http://www.theheart.org/article/1255799.do
Nainggolan, Lisa. "EMA Adds CV Events to Review of
Dronedarone" HeartWire,
July 12, 2011
http://www.theheart.org/article/1252319.do
O'Riordan, Michael. "EMA recommends
restricting use of dronedarone" HeartWire, September 20, 2011.
http://www.theheart.org/article/1283205.do
Miller, Reed. "Dronedarone "dear
doctor" letter sums up recent alerts." HeartWire, August 17, 2011.
http://www.theheart.org/article/1264551.do
NOVEMBER 25, 2011
Successful A-Fib Catheter Ablation Improves
Health
It feels so great to be A-Fib free and
in normal sinus rhythm after a successful Pulmonary Vein
Isolation (PVI) procedure that one feels more healthy. But is one's health
actually improved after a successful PVI?
In an observational long-term study of the impact of A-Fib
ablation, over 4,000 patients from the Murray, Utah Intermountain Medical Center
were followed for over three years. Compared to matched controls who had A-Fib
but did not have an ablation, ablated patients had a significantly lower risk of
death, stroke, heart failure, cardiovascular hospitalization and dementia.
(People with A-Fib have an increased risk of developing dementia, because blood
is not being pumped properly to the brain and other organs when in A-Fib.)
Catheter Ablation Superior to Drug Therapy
The article cited previous studies which showed that
antiarrhythmic drugs, which attempt to return the heart to normal sinus rhythm,
don't improve morbidity and mortality compared to leaving patients in A-Fib with
rate control drugs, perhaps because current antiarrhythmic meds aren't highly
effective, recurrence rates during therapy are high (44%-67% at 1 year), and
adverse events and side effects are common.
Catheter ablation was found superior
to drug therapy in suppressing A-Fib and improving symptoms, exercise capacity,
and quality of life.
Successful Ablation Patients More Healthy Than People
Without A-Fib!
The over 4,000 ablated patients were also matched
with controls who did not have A-Fib. Ablated patients were more likely to have
had hypertension, heart failure, and significant valvular disease---were more
likely to be less healthy than the controls. But after three+ years of normal
sinus rhythm, there was a trend towards lower long-term adverse events in the
A-Fib ablation group compared to the "healthier" control group (with the
exception of heart failure).
Editor's
Comments:
We know
that we feel better after a successful Pulmonary Vein Isolation (PVI) procedure.
It makes intuitive sense that our heart and body would function better, that we
would be more healthy after a successful PVI. But it's good to have studies that
document this in no uncertain terms.
But what's even more interesting is that patients A-Fib free
were to some extent healthier than matched controls who never had A-Fib, even
though the patients with A-Fib probably had more health problems going in than
the controls. The authors of this study didn't speculate on why this occurred.
Could it be that those of us made A-Fib free value normal sinus rhythm more and
take more steps to stay healthy and A-Fib free?
T. Jared Bunch, et al. "Patients Treated with Catheter Ablation for
Atrial Fibrillation have Long-Term Rates of Death, Stroke, and Dementia Similar
to Patients without Atrial Fibrillation."
J Cardiovasc Electrophysiol. 2011 Aug;22(8):839-45. doi:
10.1111/j.1540-8167.2011.02035.x. Epub 2011 Mar 15.
http://www.ncbi.nlm.nih.gov/pubmed/21410581
See also: Hunter RJ et al. "Maintenance of sinus rhythm with an ablation
strategy in patients with atrial fibrillation is associated with a lower risk of
stroke and death."
Heart
doi:10.1136/heartjnl-2011-300720
http://heart.bmj.com/content/early/2011/09/19/heartjnl-2011-300720.abstract
SEPTEMBER 15, 2011
Dr. Marcos Daccarett, MD, MSc, FACC, FAHA,
FHRS has moved from the University of Utah Hospital to
St. Luke's
Idaho Cardiology Associates in Boise.
SEPTEMBER 12, 2011
Having Trouble Sleeping?---the Aspirin
(NASIDs) You're Taking May Be the Problem
People
with A-Fib are often prescribed the blood thinner aspirin to
help prevent clots and A-Fib stroke. NSAIDs (aspirin, ibuprofen, etc.)
work by inhibiting prostaglandin synthesis which is involved in pain and
inflammation. But they are also involved in melatonin synthesis and body
temperature regulation.
A recent double blind study found that aspirin and ibuprofen
suppressed melatonin synthesis and attenuated the normal circadian decrease in
body temperature during nighttime hours. This alteration of normal sleep patters
in healthy individuals by the NSAIDs aspirin and ibuprofen was not found,
however, in all study subjects.
(Editor's Comments: if you're taking aspirin, even at the
lowest dosage 81 mg, and are having trouble getting to sleep, try taking the
aspirin in the morning rather than in the evening before bedtime. However, you
may find that even taking aspirin in the morning may still affect your sleep.
NSAIDs are the most frequently prescribed medications
worldwide. But one wonders why when considering the documented side effects to
the gastrointestinal tract, liver, kidneys, central nervous system, endocrine
system, and articular cartilage this article briefly documents.
For example, "researchers estimate that 8-10% of the overall
incidence of end-stage renal (kidney) disease is attributable to acetaminophen
[Tylenol]. The risk is dose dependent with measurable increases of risk
beginning at 105-365 pills per year or greater than 1000 pills per lifetime."
What this means in non-medical language is if you take more than 1000
acetaminophen during your lifetime, you stand a good chance of permanently
destroying your kidneys. For a 50-year-old that's only 20 pills a year. One
wonders why so many doctors and hospitals in the US prescribe or recommend
acetaminophen for pain relief, even for children. [Some researchers do not
consider acetaminophen a NSAID, though it works by the same
mechanism---inhibition of prostaglandin synthesis.] )
Thanks to one of our readers for calling our attention to this
article and to its importance. He had trouble sleeping when taking 81 mg of
aspirin (baby aspirin). ayatingl(at)gmail.com
NSAIDs -- The Unintended Consequences
Dynamic Chiropractic
October 20, 1997, Volume 15, Issue 22 by Alan Cook, DC
http://www.chiroweb.com/archives/15/22/06.html
SEPTEMBER 11, 2011
NSAIDs Associated with A-Fib
NSAIDs (nonsteroidal anti-inflammatory
drugs such as aspirin, ibuprofen [Advil, Motrin], naproxen [Aleve,
Naprosyn) and COX-2 inhibitors are associated with an increased risk of
developing A-Fib and/or Flutter.
A Danish study of 32,602 patients with A-Fib or Flutter found
that the use of NSAIDs was associated with an adjusted 17% increased risk of
developing A-Fib or Flutter. There was a slightly higher risk associated with
the use of COX-2 inhibitors.
New users had the highest risk. For those who filled a
prescription for NSAIDs within the previous two months, they had a 46% chance of
developing A-Fib/Flutter. For COX-2 inhibitors there was a 71% increased risk.
A previous study based on the United Kingdom General Practice
Research Database also found an association between the use of NSAIDs and A-Fib.
But this study found the highest risk among long term users (for more than one
year) rather than first-time users.
But an "association" doesn't necessarily mean that NSAIDs
cause or trigger A-Fib/Flutter. Perhaps an inflammation condition increases the
risk of A-Fib on the one hand or prompts the use of NSAIDs on the other.
According to Dr. Jerry H. Gurwitz (Un. of Massachusetts Medical School,
Worchester), "The risk is unproven. But NSAIDs should be used with caution in
high risk patients anyway."
(Editor's Comments: though inflammation may produce
fibrosis, loss of atrial muscle mass and thereby foster A-Fib, that doesn't
explain how nearly one out of two new users filling prescriptions for NSAIDs
developed A-Fib/Flutter within two months.
Until further research clarifies these points, it's prudent
to consider NSAIDs not just associated with A-Fib but actual triggers or causes
of A-Fib.
These Danish and British studies may be medical
breakthrough research. Avoiding NSAIDs may help prevent the development
and/or triggering of A-Fib/Flutter.)
NSAID use associated with risk of atrial fibrillation or flutter
July 5, 2011
Michael O'Riordan
http://www.theheart.org/article/1249265.do
NSAIDs and atrial fibrillation
BMJ
2011;
343:d2495
doi: 10.1136/bmj.d2495
(Published 4 July 2011)
Cite this as:
BMJ
2011;
343:d2495
SEPTEMBER 11, 2011
Elderly Shouldn't Use NSAIDs
NSAID (nonsteroidal anti-inflammatory
drugs---such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve,
Naprosyn)
use among elderly patients with high blood pressure and coronary artery
disease leads to increased mortality, heart attacks and stroke. Chronic NSAID
users had a 60% increased risk of death, heart attack and stroke. And according
to Dr. Anthony Bavry (Un. of Florida, Gainesville), "This association doesn't
appear to be due to elevated blood pressure, because chronic NSAID users
actually had slightly lower...blood pressure."
Editor's Note: Many A-Fib patients are elderly. It's all
too tempting to turn to NSAIDs to handle pains big and small. But what can we
elderly do? Acetaminophen (Tylenol) is associated with kidney failure. COX-2
inhibitors have their own set of problems. Are there any pharmaceutical pain
killers that are safe to take?
We need to investigate "natural" pain killers. Are there
natural pain relievers that would help us without causing bad side effects? Has
anyone studied natural pain relievers which A-Fib patients might use? Here is a
starting list of natural pain relievers:
- Olive Oil
- Fish Oil
- Tart
Cherries
- White Willow
Bark (like aspirin)
- Boswella
- Tumeric (circumin)
- MSM (Methyl
Sulphonyl Methane
- Feverfew (tanecetum
parthenum)
- Essential
Oils (jasmine, peppermint, juniper, rose, rosemary)
- Ginger
- Skullcap
Tincture
- Yucca
- Cat's Claw
- Eucalyptus
- Aloe Vera
Gels
- Kava Kava
- Valerian Root
NSAID use in elderly with hypertension linked to
increased cardiac risk
By Piriya Mahendra
18 July 2011
Am J Med 2011; 124: 614–620
http://www.medwire-news.md/59/93424/Hypertension/NSAID_use_in_elderly_with_hypertension_linked_to_increased_cardiac_risk_.html
Thanks to Ira David Levin for calling our attention to this article and for
pointing out its importance for A-Fibbers.
SEPTEMBER 3, 2011
Silent Clots from Multielectrode Phased-RF Ablation Catheters
In two small studies of catheter ablation, Magnetic Resonant Imaging (MRI)
revealed "subliminal (silent) intracranial embolic events" (clots, lesions) that
normally would not have been detected if MRI weren't used. These non-randomized
studies raise concerns that catheter ablation may cause small, unnoticeable
clots or lesions in the brain. The studies compared Multielectrode Phased-RF
Ablation Catheters (Medtronic Ablation Frontiers), conventional Irrigated-Tip
Catheters (Navistar Thermocool, Biosense Webster), and CryoBalloon Catheters
Arctic Front, Medtronic).
In one study using the Multielectrode Phased-RF Ablation
Catheter 38.9% of patients (9 out of 27) experienced silent cerebral lesions.
This was significantly more than a conventional Irrigated-Tip RF catheter (2 out
of 27, 7.4%) or the CryoBalloon catheter (1 out of 23, 4.3%). (Some reports
cite only the percentages which can be misleading, since the actual numbers of
patients were so small.)
Why Lesions from
Multielectrode Phased-RF Catheters?
Why would a Multielectrode Phased-RF Catheter produce so many
small clots or lesions?
Possibly because, unlike conventional Irrigated-Tip catheters, it is not
irrigated. What may happen is, when heart tissue is heated, energy is
transferred back to the electrode, which as it heats up can cause char. This
char can break off and cause clots and strokes. Conventional Irrigated-Tip
catheters are cooled by saline solution to reduce or eliminate this heat effect.
MRI-Detected
Lesions may be Insignificant or may Reverse Themselves
A Medtronic spokesperson pointed out that the lesions detected by
MRI have not been clearly linked to neurologic defect or cognitive decline, and
that some studies have shown that the lesions detected have been shown to
reverse on follow-up.
(These MRI-detected lesions may not have any lasting effect or may resolve
themselves much as a more serious TIA (Transient Ischemic Attack) often resolves
itself and doesn't seem to have a lasting effect.)
But A-Fib
Patients Should Still be Concerned
Any kind of lesions in the brain are cause for
concern. In the words of Dr. Vivek Reddy (Mount Sinai School of Medicine, New
York), "It can't be a good thing to have all this stuff in your brain." What do
these silent ischemic lesions mean, how do they affect us? Dr. Jonathan
Steinberg (Columbia College of Physicians & Surgeons, New York) sums up, "We
don't know if some of this is reversible, or if it's such a small volume of
damage that it ultimately is negligible or has no functional impact."
Need for
Further Study
What needs to be done is to follow patients who have had
these MRI-detected lesions to see if they are affected neurologically over time,
to see if these lesions do indeed resolve themselves and disappear.
EDITOR'S COMMENTS:
These studies,
though small, seem to indicate that A-Fib patients should probably avoid
ablations by Multielectrode Phased-RF catheters until these silent cerebral
lesions are proven to be benign.
But what about conventional Irrigated-Tip and CryoBalloon
catheters? The number of silent lesions was so small in both studies that it's
hard to make decisions based on such limited sample sizes. (One would expect the
CryoBalloon catheter to produce less silent lesions. In the clinical trials, it
was safer than conventional Irrigated-Tip catheters and produced less clots. See
CryoBalloon Ablation Safer Than RF)
However, there is a small but real risk of stroke during a RF
catheter ablation procedure even with using an irrigated tip catheter (less than
0.5%34). Stroke is less of a risk
when using CryoBalloon ablation.
"Silent-embolization concerns mount
for RF ablation catheter."
http://www.theheart.org/article/1260023.do
Siklódy CH, Deneke T, Hocini M, et al. Incidence of asymptomatic intracranial
embolic events after pulmonary vein isolation. J Am Coll Cardiol 2011;
58: 681-688.
http://www.theheart.org/article/1237547.do
Gaita F, Leclercq JF, Schumacher B, et al. Incidence of silent cerebral
thromboembolic lesions after atrial fibrillation ablation may change according
to technology used: Comparison of irrigated radiofrequency, multipolar
nonirrigated catheter and cryoballoon. J Cardiovasc Electrophysiol 2011;
DOI:10.1111/j.1540-8167.2011.02050.x.
JULY 20, 2011
Dr. Edward Gerstenfeld has moved from the
Un. of Pennsylvania to the Un. of California San Francisco where he will be
directing the EP program and performing A-Fib ablations.
JULY 19, 2011
Dronedarone
(brand name Multaq) "Risk of Severe Liver Injury."
The FDA notified healthcare professionals and patients about
cases of rare, but severe liver injury, including two cases of acute liver
failure leading to liver transplant in patients treated with the heart
medication dronedarone (Multaq). Information about the potential risk of liver
injury from dronedarone is being added to the WARNINGS AND PRECAUTIONS and
ADVERSE REACTIONS sections of the dronedarone labels.
If you start feeling nausea, vomiting, fever, anorexia,
malaise, fatigue, right upper quadrant pain, jaundice, dark urine, or itching,
it's recommended you stop taking Multaq and get in touch with your doctor ASAP.
Your doctor should be testing you for "hepatic (liver) serum
enzymes" especially during the first 6 months of treatment.
(Editor's Note: It's disappointing that the FDA had to
issue this risk notification about Multaq. The FDA found cases of cellular liver
damage "hepatocellular liver injury."280
We can't help but ask if Multaq may
cause long-term damage to the liver, even though it's tolerated in the short
term. How many people taking Multaq have had their liver serum enzymes tested,
know what their benchmark liver serum enzymes numbers are, and keep track of any
rise (not just whether they are in an acceptable range)?
Is Multaq destined to be yet another antiarrhythmic med that
causes more problems/side effects than it solves? )
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm240110.htm
JUNE 25, 2011
Michelle Straube is
walking the Alps
to promote A-Fib
Awareness! After being in A-Fib for 30 years she was made A-Fib free in 2009.
Check out her blog Into the Heart of the Alps for Atrial Fibrillation
Awareness: http://bit.ly/hHPG2f.
"We’re
leaving for the first 22 days of our trek this Sunday — still so much to do, but
so excited. Just walking uphill fast is a miracle, but now I can do that and
talk at the same time, or carry a 20-lb backpack and make it up without wheezing
or dizziness. Life is so good!" See
Michelle Straube's
story.
APRIL 24, 2011
Fibrosis
Predicts Stroke Risk
In a study from Dr. Nassir Marrouche at the
Comprehensive Arrhythmia Research and management Center in Utah, Stage IV (over
35% fibrosis) patients were four times more
likely to have a stroke than patients with a low level of atrial fibrosis. And
the level of fibrosis didn't always correlate with standard
CHADS2 risk scores of stroke.
16.5% of patients with a CHADS2 score of 0 (low risk) and 18.5% with
a score of 1 (intermediate risk) had Stage IV atrial fibrosis.
Whether you were in paroxysmal or persistent A-Fib didn't
seem to have an impact on the likelihood of stroke rate.
Women were three times more likely to have a stroke
than men. The researchers hypothesized that, because men tend to get
treatment for A-Fib sooner, women had more extensive remodeling and fibrosis
than men, which led to a higher stroke risk.264
(Editor's Observations: MRIs to measure fibrosis in the
heart should become a routine diagnostic tool for anyone in A-Fib. According to
this study, the CHADS2 method of evaluating risk of stroke doesn't
work in many cases. Should we retire the CHADS2 and replace it with a
more empirical, scientific method such as fibrosis measurement?
Some people have argued that there is less risk of stroke if
one is in continuous A-Fib rather than paroxysmal (occasional), because one
might be more at risk of a clot when the heart stops and starts beating
normally. But this study indicates that whether one is paroxysmal or persistent
doesn't seem to influence the risk of stroke.
The finding that women are three times more likely to have a
stroke than men should be a wake-up call for doctors (and of course for women)!
If women hear from their doctor "It's all in your mind," or Take a valium," it's
time to get a second opinion ASAP. An A-Fib stroke is a fate worse than death,
if you live through it. Doctors should become more aware of the increased danger
A-Fib presents to women.)
APRIL 14, 2011
PVA(I) Improves Ejection Fraction
A successful Pulmonary Vein Ablation (Isolation) (PVA(I) reverses many of the
remodeling effects of A-Fib. For example,
enlargement of the left atrium and the ability of the
atria to contract can be reversed after a successful catheter ablation.58
But there is
some disagreement among researchers as to whether a successful PVA(I) over time
improves Ejection Fraction.258
In
a study from the Bordeaux group, A-Fib patients with Congestive Heart Failure
and an ejection fraction of less than 45% (normal ejection fraction range is
56%-78%), had a PVA(I). After approximately 12 months, 78% were A-Fib free
without meds. They had significant improvement in left ventricular function
including increases in ejection fraction of approximately 21% (as well as
exercise capacity, symptoms, and quality of life). The ejection fraction also
improved significantly (24%) in the control group of A-Fib patients without
Congestive Heart Failure.259
(Editor's Note: It's not all that surprising that A-Fib patients with a low
ejection fraction would improve after a successful PVA(I). But the control group
without Congestive Heart Failure also improved their ejection fractions. In this
study a successful PVA(I) improves ejection fraction even if one has a
relatively normal ejection fraction to begin with.)
259 Hsu, Li-Fern et
al. "Catheter Ablation for Atrial Fibrillation in Congestive Heart Failure."
N Eng J Med 2004; 351:2373-2383 December 2, 2004.
http://www.nejm.org/doi/full/10.1056/NEJMoa041018
APRIL 10, 2011
Dabigatran (Pradaxa) Indigestion,
Burning, Stomach Pain, (Weight Loss) Side Effects
If you've started
taking Pradaxa, watch out for indigestion, burning, stomach pain (and weight
loss). These are listed as common side effects of Pradaxa. As many as 35% of
people taking Pradaxa may experiences these symptoms. There is a fine line
between allowing one's body to get used to a new drug, and deciding this drug
isn't for me because of its bad side effects.
The Pradaxa Fact Sheet from Boehringer Ingelheim states under
"Adverse Reaction from RE-LY" (the clinical trial of Pradaxa):
• Patients on Pradaxa 150mg had an increased incidence of
gastrointestinal adverse reactions (35%/yr) compared to warfarin (24%/yr).
• The discontinuation rate due to drug-related adverse
events was 21% for Pradaxa 150mg and 16% for warfarin.
"In addition to bleeding, Pradaxa can cause stomach upset or
burning, and stomach pain." (Pradaxa Fact Sheet 101910.pdf)
(Editor's Note: In the RE-LY clinical trial nearly 2 out
of 5 people had gastrointestinal adverse reactions. 35% is a very high rate of
adverse reactions. Pradaxa may not be the wonder drug we've all been hoping
would replace warfarin. If
it has such bad side effects, it may be damaging many more people's stomachs
over a longer period of time.)
http://www.drugwatch.com/pradaxa/side-effects.php
APRIL 9, 2011
LARIAT ii SUTURE
DELIVERY DEVICE
Most A-Fib strokes (90-95%) come from
clots which form in the Left Atrial Appendage. One strategy to prevent A-Fib
stroke is to close off the Left Atrial Appendage. In most cases this is as
effective as taking blood thinner medications. Though, as with blood thinners,
it isn't an absolute guarantee you will never have an A-Fib stroke.
A novel noose device to close off the Left Atrial Appendage is inserted from
outside the heart (Lariat II,
SentreHeart, Inc., Palo Alto, CA)
(unlike for example the
Watchman device which
is inserted into the LAA from inside the heart).
It is used in cases where the patient can not
tolerate anticoagulants like Coumadin. (The
Watchman device requires a patient be on
anticoagulants for a couple of months.)
From the inside of the heart a balloon is placed inside the
Left Atrial Appendage to expand it and make it accessible to the noose device
which is inserted from the outside of the heart. The positioning balloon is
withdrawn before the Lariat noose is closed around the base of the Left Atrial
Appendage. The noose completely closes off the Left Atrial Appendage which dies
and is no longer electrically active. The Lariat II snare device has been approved by the FDA.
The Lariat device was invented by Dr. William E. "Billy"
Cohn, Director of Minimally Invasive Surgical Technology at the Texas Heart
Institute at St. Luke's Episcopal Hospital. (Thanks to Beverly Stansfield for
calling our attention to the importance of this device.)
APRIL
8, 2011
Dr. Edward Gerstenfeld from the Un. of
Pennsylvania will be moving to the Un. of California San Francisco in July,
2011.
APRIL
1, 2011
HALF OF ALL A-FIB DUE TO
AVOIDABLE RISK FACTORS
There are factors
somewhat under our control which my influence or trigger A-Fib, such as
hypertension, diabetes, obesity and smoking. One study says that half of all
cases of A-Fib are due to the above cardiovascular risk factors, with
hypertension the strongest predictor of A-Fib.253
(Editor's Comment: One wonders why the study didn't also mention
binge drinking as a cause or trigger of A-Fib. That's certainly something we
have control over.)
Maintaining a healthy diet and life style may help
prevent A-Fib. But don't count on them to make you A-Fib free once you develop
A-Fib. However, anything that makes you more healthy overall might influence the
amount and severity of A-Fib attacks.
The study also found that African Americans have a lower risk
of developing A-Fib, even though they have more risk factors for A-Fib, such as
high blood pressure and obesity.253
MARCH 30, 2011
most
beta-blockers can have a harmful effect, except carvedilol
(Coreg)
A new study
casts doubt on the effectiveness of most beta-blockers which "undermine the
structure and function of the heart...Blocking the beta-receptor alone promotes
cardiac remodeling via growth of cardiac fibroblasts induced by alpha-adrenergic
receptor signaling. The growth of fibroblasts in the heart further damages the
integrity and function of the heart."247
Carvedilol, however, targets both the beta- and
alpha-adrenergic receptors on the heart muscle. Beta-blockers (like carvedilol)
which target both receptors "offer the most benefit to cardiac patients." A
study in 2003 showed that carvedilol produced a greater survival rate than
metoprolol.247 [Thanks to Janet
Brown for calling our attention to this research.]
Nebivolol seems to eliminate most of the common bad side
effects of beta blockers by dilating blood vessels through the release of nitric
oxide. But it also only blocks Beta 1 receptors. See nebivolol.
DECEMBER 20, 2010
FDA APPROVES CRYOBALLOON
ABLATION CATHETER
The
FDA approved the first cryoablation balloon catheter for
A-Fib---the Arctic Front system
(Medtronic,
Minneapolis, MN). This is a major medical breakthrough
in treating A-Fib.
Cryoballoon ablation appears to be
safer, faster and easier than RF. The cryoballoon can isolate a pulmonary vein
opening in as little as one freeze (about 10 minutes per vein), while an RF
ablation requires ablating one spot at a time. Also, the frozen balloon sticks
to the PV opening, which keeps the catheter stable during the ablation. In one
study of the clinical trial (STOP AF),
there
were no strokes, no pulmonary vein stenosis, no esophageal injury, and no
coronary artery injury as sometimes occurs with RF ablation (RF ablations
typically have a major complication rate of around 4%).
(Added 3/7/11: Results from the North American Arctic Front
STOP-AF trial did show a PV stenosis rate of 3.1% which did not show up in the
European trials. This may have come from the use of a smaller 23 mm balloon
which possibly penetrates too far into the Pulmonary Vein opening.242
The STOP-AF trial also showed a Phrenic
Nerve Palsy (paralysis, weakening) of 11.2 %. Some of these cases did not
resolve within 12 months (18 %). This Phrenic Nerve damage may have come from
the use of the smaller 23 mm balloon which gets closer to the Phrenic Nerve. Dr.
Kuck has had good results (no PV stenosis) using only the larger 28 mm balloon.)242 In the clinical trial 69.9% of patients treated with the
Arctic Front Cryoballoon catheter were free from A-Fib at one year, compared to
only 7.3% of patients on meds only. See
Cryoballoon Safer than RF,
CryoBalloon & RF Ablation---the future of
A-Fib treatment, and
Dr. Kerwin's explanation of Cryo Ablation.
(The author predicts that Cryoballoon ablation, perhaps combined with RF,
will become the treatment of choice for Pulmonary Vein Ablations.)
http://www.theheart.org/article/1166735.do?utm_campaign=newsletter&utm_medium=email&utm_source=20101222_EN_Heartwire
DECEMBER 14, 2010
CLEVELAND CLINIC SECOND OPINION PROGRAM
The Cleveland Clinic has developed an online consulting service that A-Fib
patients can use. They will "review your individual situation (including medical
records and test results), answer your questions and provide you with a
comprehensive report - with treatment options or alternatives, as well as
recommendations regarding your future care needs." The cost is less than $600.
There is a caveat, "Availability of online medical second opinion varies by
state of residence."
(If anyone uses this service, could you please tell us what you think of it?
Thanks.)
http://eclevelandclinic.org/myconsult
(Thanks to Jerome Jacobi for calling our attention to this service.)
NOVEMBER 15, 2010
Rivaroxaban
Another Possible Replacement for Warfarin
Rivaroxaban (brand name Xarelto by Bayer/Johnson & Johnson) tested well as a
replacement for the blood thinner warfarin. Both rivaroxaban and warfarin block
the action of vitamin-K dependent proteins called clotting factors, but
rivaroxaban targets a specific clotting factor called Xa. Unlike
dabigatran, rivaroxaban is reversible is cases of serious bleeds.223
http://www.newsroom.heart.org/index.php?s=43&item=1191
NOVEMBER 3, 2010
Dabibatran Now Available In
Pharmacies
Dabigatran (brand name Pradaxa by Boehringer Ingelheim) will be priced at a
"wholesale-acquisition" cost of $6.75/day.
According to Dr. Michael Ezekowitz, switching patients from
Coumadin is relatively easy.
If the INR (international normalized ratio) is 2 or less, you can switch the
patient immediately to dabigatran. It only takes 30 minutes to two hours for it
to become effective. Dabigatran produces a 34% reduction in stroke, a 60%
reduction in intracranial bleeds, and fewer bleeds in general.
The only patients who shouldn't take dabigatran are those
with kidney problems (creatinine clearance of less than 15 which is close to
needing dialysis), and patients with mechanical heart valves
(not part of the original RE-LY trial).
http://www.theheart.org/article/1142899.do
(Added November 29, 2010.)
Dabigatran (brand name Pradaxa) is a direct thrombin inhibitor, a newer type of
medication. Thrombin is an enzyme that converts soluble fibrinogen into
insoluble fibrin. Fibrin is a fibrous protein involved in the clotting of blood.
It forms a mesh or clot over a wound.
Dabigatran is currently irreversible. In case of a serious bleed, there is no
way to stop the bleed short of dialysis. It takes approximately one day for
dabigatran to leave the body.223
INR tests, such as for
warfarin, aren't good tests for monitoring the effectiveness of dabigatran.
Doctors may use other tests such as Thrombin-Antithrombin Complex (TAT) (normal
levels 0.85-3.2 microgram/l)221 or
Prothrombin Fragment 1+2 (normal levels 0.4-1.2 nmol/l)222.
OCTOBER 31, 2010
Anticoagulants and Antiplatelets
Don't Mix
If someone is taking an anticoagulant
like warfarin to prevent A-Fib stroke, wouldn't it be more effective to also
take an antiplatelet like aspirin as
well since they work differently?
That doesn't seem to be the
case.
A Danish study, reported in Hans Larson's October The AFIB
Report,
indicates that combining anticoagulant and antiplatelet meds in the same patient
is associated with a substantially higher risk of fatal or non-fatal internal
bleeding.
And there was no indication that combining warfarin with an antiplatelet
(aspirin, clopidogrel, or both) reduced the risk of
ischemic stroke.
http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Anticoagulation-Dangerous
combinations" Number 103, October, 2010. p. 8.
Hansen, ML, et al. "Risk of bleeding with single, dual, or triple therapy with
warfarin, aspirin, and clopidogrel in patients with atrial fibrillation."
Archives of Internal Medicine, Vol. 170, No. 16, September 13, 2010, pp.
1433-41.
OCTOBER 30, 2010
Flutter
Ablation should be Combined with Left Atrium A-Fib Ablation
Hans Larson, in his October The
AFIB Report, points out that trying to cure A-Fib with only a right
atrium Flutter ablation "is usually fruitless with a success rate somewhere
between 5 and 10%."
But what if someone only has Atrial Flutter and not A-Fib?
Since a Flutter ablation in the right atrium is relatively simple and doesn't
take much time, should an A-Fib ablation in the left atrium be done at the same
time? Some Flutter may originate in the left atrium, or the Flutter may mask
A-Fib which may appear later after a successful Flutter ablation? "As many as
half of all patients ablated for Flutter may later develop A-Fib."
Researchers at Ball Memorial Hospital in a small study of
patients with lone right atrium flutter gave some patients a right atrium
Flutter ablation only, while others received both a Flutter and an A-Fib
ablation at the same time.
After a 16-month follow-up, 87% of the group that had
received both a Flutter and an A-Fib ablation were free of any arrhythmia
without the use of any medication. But only 44% of the Flutter-only group were
so lucky. 36% developed paroxysmal A-Fib and 20% developed persistent A-Fib. The
researchers concluded that adding Pulmonary Vein Isolation ablation to Flutter
ablation for lone atrial flutter provides better long-term freedom from
arrhythmias than just performing a Flutter ablation by itself.
(Editor's Comments: If someone recommends you get a
Flutter-only ablation, you should probably get a second opinion. If you have
A-Fib and A-Flutter, you are probably wasting your time on a right atrium
Flutter-only ablation.
If you only have documented Atrial Flutter, you should still
get a second opinion. Some Flutter does originate in the left atrium, or the
Flutter may mask A-Fib which can often appear later. This Ball Memorial Hospital
study suggests that anyone with only Flutter would be better served by both a
Flutter and an A-Fib ablation at the same time.
http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Flutter ablation may unmask AF" Number 103, October, 2010. p. 6.
Navarrete, A. et al. "Ablation of atrial fibrillation at the time of
cavotricuspid isthmus ablation in patients with atrial flutter without
documented atrial fibrillation derives a better long-term benefit." Journal
of Cardiovascular Electrophysiology, July 19, 2010 (Epub ahead of print)
OCTOBER 29, 2010
Acupuncture
Helps A-Fib---Specific Acupuncture Sites Identified
Hans Larson, in his October The
AFIB Report,
states
that Italian researchers found acupuncture effective in preventing A-Fib in
persistent A-Fib patients who had just undergone successful cardioversion.
The acupuncture points used in the Italian clinical trial
were:
1. Neiguan (PC-6)
2. Shenmen (HT-7)
3. Xinshu (BL-15)
Acupuncture at the Neiguan and Xinshu points help modulate
and stabilize the autonomic nervous system. Stimulation of the Shenmen point has
a calming and sedative effect on cardiac excitability.
Patients received 10 weekly
acupuncture sessions.
The article also includes two stories of patients whose A-Fib
was eliminated primarily by acupuncture:
http://www.afibbers.org/resources/journeys/Craig.pdf
http://www.afibbers.org/resources/journeys/Girskis.pdf
(Editor's Comment: As Hans
Larson points out, now that we know the exact points to be stimulated, why not
use acupuncture for Paroxysmal A-Fib as well?)
http://www.afibbers.org/afib103jh.pdf
Larson, Hans. The AFIB Report. "Acupuncture: An effective
antiarrhythmic?" Number 103, October, 2010. p. 5.
Lomuscio, A et al. "Efficacy of acupuncture in preventing atrial fibrillation
recurrences after electrical cardioversion." Journal of Cardiovascular
Electrophysiology, August 30, 2010 (Epub ahead of print)
OCTOBER 28, 2010
Vigorous Exercise and A-Fib
Some commentators have cited recent
research on vigorous exercise to say it is associated with the development of
A-Fib. "Vigorous exercise increases the risk of atrial fibrillation."218
But a close examination of the
observational study used to support this statement shows that A-Fib is
associated only with men under 50 years of age who jogged/ran over four miles a
day 5-7 times a week. This is a level of running usually associated only with
elite athletes. Other types of vigorous exercise such as cycling, swimming or
racquet sports were not associated with an increased risk of A-Fib.
Why only elite male runners under 50? The authors of this
study hypothesized that several factors might explain the increased risk of
A-Fib in elite male runners under 50 years old.
- left atrial enlargement
- left ventricular hypertrophy
- left ventricular dilation
- an increase in
parasympathetic tone
(the most commonly cited factor)
"Jogging in particular results in greater enhancement of the parasympathetic
nervous system compared to other exercise types."
"Heightened parasympathetic tone has
been associated with A-Fib onset in patients with structurally normal hearts;
and in animal and human studies, parasympathetic stimulation frequently induces
and maintains A-Fib, whereas vagal denervation prevents A-Fib."
People over 50 years old have decreased parasympathetic
activity and usually exercise less vigorously as they age.
The authors of this study recognize the benefits of vigorous
exercise for most people. "Exercise has multiple beneficial effects on
cardiovascular health that may lower A-Fib risk." In particular, exercise lowers
blood pressure, improves lipid profile and glucose control, and decreases risk
of cardiovascular disease.
(Editor's Comments: With the exception of elite male runners under 50 who run
over four miles a day 5-7 times a week, vigorous exercise does
not increase the risk of A-Fib,
according to this study. Rather, vigorous exercise may lower A-Fib risk.)
Aizer, A. et al. "Relation of Vigorous Exercise to Risk of Atrial
Fibrillation." The American Journal of Cardiology, Volume 103, Issue 11,
Pages 1572-1577, June 1, 2009
http://www.ajconline.org/article/S0002-9149(09)00549-9/fulltext
OCTOBER 27, 2010
Steroids Reduce A-Fib Recurrence after an Ablation
For A-Fib
patients (as well as for EPs and Mini-Maze surgeons), the biggest frustration
after an ablation or surgery is the recurrence of A-Fib. Even the most
experienced A-Fib centers have unacceptably high rates of recurrence. This
recurrence is often due to regrowth/re-connection of previously ablated areas
(see
Marchlinski "Regrowth/Reconnection of Ablated Areas").
http://www.a-fib.com/BostonA-FibSymposium2007.htm#ThirdandFourthPVIsolation/AblationProcedures
Japanese researchers administered intravenous hydrocortisone
to Paroxysmal A-Fib patients the day of their ablation, followed by oral
prednisolone for three days after the ablation. (The hydrocortisone dosage was
2mg/kg which translates to approximately 750 mg for a 170 lb. person. The oral
prednisolone dosage was 0.5mg/kg which translates to approximately 190 mg for a
170 lb person.)
Within the first three days, 31% of individuals treated with
a placebo had a recurrence of A-Fib, compared with only 7% of those treated with
corticosteroids. Corticosteroid treatment did not decrease A-Fib recurrences
between 4 and 30 days after ablation (A-Fib patients were not given
corticosteroid treatment during these days). The A-Fib-free rate at 14
months post-ablation was greater in the corticosteroid group---85% versus 71%
for the placebo group (a statistically significant difference [p=0.032), but not
nearly as large as the first days' results).
(Editor's Note: One wonders what would have happened if
the oral prednisolone was continued for more than three days.)
The researchers found that inflammation, highest
body temperature, largest change in body temperature, maximum C-reactive-protein
(CRP) levels, and change in CRP were lowest among patients with steroid therapy.
(Editor's Note: All of the above are markers or signs of
inflammation which some research links to A-Fib.84
Steroids may work to reduce recurrence of A-Fib by lowering inflammation after a
procedure. Steroid therapy, by reducing inflammation, may be a safe and
effective method of reducing recurrence of A-Fib after an ablation. Steroid
therapy after ablation may be a medical breakthrough
in the treatment of A-Fib..
Even though this study is small (125 patients) and limited,
A-Fib patients undergoing ablation and/or Mini-Maze surgery should receive
steroid therapy, unless counter indicated. The steroid therapy should probably
be continued for more than three days. Steroid therapy certainly seems to reduce
the recurrence rate of A-Fib after ablation.)
(Thanks to David Holzman to calling our attention to this article.)
http://www.theheart.org/article/1139047.do
Koyama, T. et al. "Prevention of Atrial Fibrillation Recurrence With
Corticosteroids After Radiofrequency Catheter Ablation." Journal of the
American College of Cardiology, 2010; 56:1463-1472.
OCTOBER 26, 2010
Increased PR Interval a Red Flag for developing
A-Fib
In the well-known Framingham Heart Study, people who had
PR Intervals longer than 200 ms had twice the risk of developing A-Fib (as well
as three times the risk of requiring a pacemaker and a 40% increased risk of
death from all causes).
("PR Interval" is the time it
takes for an electrical signal to spread from the upper chambers of the heart
(the atria) to the lower chambers (the ventricles). A PR Interval of less than
200 microseconds (ms) is considered normal. A prolonged or increased PR Interval
is known as "first-degree atrioventricular block (AVB)" when the PR interval
exceeds 200 ms.)
(Editor's Note: A prolonged PR Interval may be a sign or
marker for fibrosis, scarring, or other heart conduction problems that may lead
to A-Fib. A routine EKG would show whether you have a prolonged PR Interval. If
so, your doctor should check you periodically to make sure you aren't
developing any progressive conduction block.)
http://www.theheart.org/article/981659.do
Cheng S. et al. "Long-term outcomes
in individuals with prolonged PR interval or first-degree atrioventricular
block."
JAMA 2009;301:2571-2577.
OCTOBER 26, 2010
Pot May Lead To or Trigger A-Fib
This year voters in California will vote to legalize and
tax cannabis (pot) which is already approved for medical use. Pot is widely used
in the US and internationally.
In this article from Israel
where pot is the most widely used illegal drug, the author observed that a
20-year-old male admitted to the hospital for A-Fib had no other apparent
pathological cause of his A-Fib except "cannabis abuse." He recommends that
young people admitted to the hospital for A-Fib be tested for cannabis abuse,
and be counseled to stop cannabis drug abuse.
"Cannabis abuse is responsible
for a wide range of pathologies, including atrial and ventricular arrhythmias,
cognitive impairment, a rise in the prevalence of lung, head, and neck tumors,
and an increase in the risk of ischemic cardiovascular events (strokes).
Cannabis abuse can induce A-Fib in predisposed patients."
(Editor's Note: Please be advised that this is an observational study based on
the author's experience and observations, rather than a clinical study of
cannabis. Also, the term "cannabis abuse" is not defined. How much cannabis use
would be considered "abuse?" Would any use of cannabis be considered "abuse?"
In spite of
the above reservations, this article may be an important warning, particularly
for young people. If you use pot and develop A-Fib [whatever your age], you may
need to cut your use or stop using pot all together.
Research
Question: Are there types of pot less likely to trigger A-Fib?)
HAREFUAH. 2005 Jan; 144(1):2-3,72.
Cited in
http://www.raysahelian.com/atrialfibrillation.html
OCTOBER 26, 2010
Watchman Device Encouraging Results
The
original clinical trial for the Watchman device (PROTECT AF) was completed in
2009. However, doctors in the trial continue to insert the Watchman device and
follow up on patients who have received it.
In new
studies and updates, procedure time to insert the Watchman device was reduced,
implant success was greater, and the proportion of patients who discontinued
warfarin at 45 days was significantly increased. Device safety improved. Major
bleeds, pericardial effusion, and device embolization dropped from a hazard
ratio of 2.85 to 1.57. According to a study to be published by Dr. Vivek Reddy
(Mount Sinai Medical Center), pericardial effusions for the most part occurred
very early on, and rates tend to go down with more operator experience.
Dr. Joseph
Rodes-Cabau (Quebec Heart and Lung Institute) called the results "really
encouraging." He was particularly impressed by the reduction in ischemic
strokes. "Most of the ischemic strokes in the device group occurred in the first
7 days." The rate of ischemic stroke over follow-up was "pretty low...The
concept seems to be right---that thrombus (clot) formation in the left atrium is
mostly in the Left Atrial Appendage, and that closing it will significantly
reduce ischemic stroke."
An FDA
advisory panel approved the Watchman device in a close 7-5 vote (PROTECT AF
trial presented April, 2009). But the FDA has mandated a new trial of the
Watchman device dubbed PREVAIL that will randomize 475 patients 2:1. In order to
address several of the concerns raised during the advisory panel hearing, the
trial will focus on enrolling patients with a CHADS2 score of 2 or higher or
CHADS2 1 patients with existing heart disease. The last follow-up visit will be
in September 2013, with the data to be submitted to the FDA one month later.
One problem
not addressed in current US trials is whether the Watchman device can be used in
patients who can not tolerate warfarin at all. (In the original PROTECT AF
study, patients who received the Watchman device also took warfarin for several
weeks.) There is a higher risk of thrombus (clotting) in the first week after
device implementation. A current study in Europe gives patients six months of
Clopidogrel plus aspirin instead of warfarin. Though this study is ongoing, so
far out of 64 patients there has been one serious pericardial effusion and no
strokes or transient ischemic attacks.
A surgical device for LAA occlusion, known as the AtriClip, has been FDA
approved. It is usually used during a Mini-Maze or other heart operation rather
than as a stand-alone operation. (Surgical
devices tend to be more readily approved by the FDA than catheter devices.)
(Editor's Note: The Watchman device is considered a low risk procedure with an
even lower risk than a typical catheter ablation, since there is no ablation
involved.
"Pericardial effusion" refers to blood leaking from the heart
into the pericardium, the sac surrounding the heart. This may occur when the
Watchman device is inserted into the Left Atrial Appendage, and is less likely
to happen with operator experience.
"Device embolism" refers to clots that form on or are possibly stirred up by
inserting the Watchman device. (There is a similar risk during catheter
ablations.) However. after seven days this risk is eliminated. To prevent device
embolisms, anticoagulants are administered during and after the Watchman is
inserted. In the Editor's opinion, the payoff of a 90-95% reduction in A-Fib
strokes certainly justifies the small risk of a device embolism.
The
Watchman device not only reduces the risk of an ischemic stroke, but also the
risk of a hemorrhagic stroke by reducing or eliminating the need to
take warfarin or other anticoagulants.
Though
the FDA won't approve the Watchman device till 2013, it is still available for
most people in the US at selected sites. See
http://www.a-fib.com/Facilities.htm#DOCTORSINSTALLINGTHEWATCHMANDEVICE)
http://www.theheart.org/article/1124905.do
OCTOBER 19, 2010
FDA
Approves Dabigatran!
The FDA has approved dabigatran! A-Fib patients now have an alternative
to warfarin (Coumadin)! See Dabigatran to
Replace Warfarin.
http://www.theheart.org/article/1138703.do
SEPTEMBER 20, 2010
FDA Advisory Panel Unanimously
Approves Dabigatran
An FDA advisory panel unanimously recommended approval of the anticoagulant
dabigatran---an oral thrombin inhibitor (brand name Pradaxa by Boehringer
Ingelheim). The 18,000 patient RE-LY trial (Randomized Evaluation of Long-Term
Anticoagulant Therapy) showed low dose dabigatran was as good as
warfarin, while the high dose was better at preventing stroke and systemic
embolism. It doesn't require anticoagulant
monitoring or major diet changes.
(Author's Note: Warfarin is one of the most widely used and effective
anticoagulants. But it's also one of the most disliked. Dabigatran's recommended
approval is a
major medical breakthrough and most welcome news for A-Fib patients who will
no longer have to cope with measuring INR levels, worrying about diet, vitamin K
deficiency, side effects, etc. It's also welcome news for doctors who won't have
to wrestle with keeping patients at the right INR levels. They will have an oral
anticoagulant that is very effective, has fewer side effects, and can be
administered to a broader range of patients.
Upon FDA approval [almost assured] will dabigatran
(and/or
ticagrelor)
replace warfarin?
Probably not right away. A-Fib patients doing well on warfarin and maintaining
their INR between 2-3, might be advised not to switch. Dabigatran (and
ticagrelor) do not use INR to measure their anticoagulant effectiveness. This
can be somewhat disconcerting to A-Fib patients who measure their INR and know
they are being protected from an A-Fib stroke.
Doctors would risk malpractice suites if they would switch
someone from warfarin and that person had a stroke. [A small number of people on
warfarin at the proper INR levels do still have strokes. Warfarin reduces but
doesn't totally eliminate the threat of an A-Fib stroke.] These new
anticoagulants are very effective, but they are not full proof and most likely
will not totally eliminate the threat of an A-Fib stroke.)
http://www.theheart.org/article/1123797.do
SEPTEMBER 18, 2010
FDA Advisory Panel Approves the
Blood Thinner Ticagrelor
An FDA advisory panel recommended the approval of the antiplatelet drug
ticagrelor (brand name Brilinta by AstraZeneca). (Clinical trial
PLATO---Platelet Inhibition and Patient Outcomes.) Ticagrelor reduced the rate
of MI (heart attack), stroke, and cardiovascular death compared with Plavix
(clopidogrel).
http://www.theheart.org/article/1106859.do
September 15, 2010
Calcium Supplements Danger
Calcium supplements (at least
500mg/day) without vitamin D were associated with a 30% increase in heart
attacks. (Vitamin D is necessary for calcium absorption.)
This increase in heart attacks may occur because "calcium
supplements speed vascular calcification and...increase cardiovascular events
and MI (Myocardial Infarction---heart attacks) in women." Dr. Ian Reid in
an article in Bottom Line Health adds, "Calcium from supplements,
including antacids such as Tums and Rolaids, elevates blood calcium quickly,
which may contribute to artery disease." Whereas "calcium in foods is absorbed
slowly."217
However, an article in Bottom Line Health points out
that the researchers in this study did not analyze what happens when calcium is
taken with Vitamin D. The study excluded people who were taking vitamin D. But
according to Dr. John Schindler "Vitamin D is protective from a cardiovascular
standpoint."215
The Bottom Line Health article somewhat disputes the
calcium danger findings. "The
majority of existing studies have shown no link between calcium supplements and
heart attack risk," and further suggests that eating calcium-rich foods is a safe way
for most people to boost their intake of calcium.216
(Author's Note: Calcium supplements may also trigger or make
the heart more susceptible to A-Fib attacks. See
WARNING: DANGER OF TOO
MUCH CALCIUM !.)
http://theheart.org/article/1108009.do
SEPTEMBER 3, 2010
Anticoagulant (Coumadin) can be Stopped 3-6 Months after a Pulmonary Vein
Ablation (Isolation)
In a study of 3,355 patients who had a
successful PVI, some stopped taking anticoagulants after 3-6 months, while the
second group kept on taking anticoagulants. Only two of the 3-6 month group and
three of the second group had an ischemic
stroke. Whereas 13 (2%) of the second group had a major
hemorrhagic stroke.
(Author's Note: From this study there doesn't seem to be a
need or benefit for anticoagulation for more than 3-6 months after a successful
PVI.) "The risk/benefit ratio favored the suspension of oral anticoagulants
after successful A-Fib ablation even in cases of patients at moderate-high risk
of TE (thromboembolic events---strokes)."
Themistoclakis S. et al. "The risk of thromboembolism and
need for oral anticoagulation after successful atrial fibrillation ablation."
J Am Coll Cardiol. 2010 Feb 23;55(8):735-43.
http://www.ncbi.nlm.nih.gov/pubmed/20170810?dopt=Abstract
SEPTEMBER 2, 2010
A-Fib Patients at Risk of Dementia
In a study of 37,025 aging patients,
27% developed A-Fib, and 4.1% of these developed dementia during the five year
follow-up. A-Fib was significantly associated with all types of dementia,
particularly in the younger group (under 70 years of age). And dementia combined
with A-Fib put patients at a high risk of death.
(Author's
Note:
Treatment strategies to keep people in A-Fib while controlling the heart rate
(rate control meds) may lead to dementia and early death.)
Bunch TJ, et al. "Atrial fibrillation
is independently associated with senile, vascular, and Alzheimer's dementia."
Heart Rhythm. 2010 Apr;7(4):433-7. Epub 2009 Dec 11.
http://www.ncbi.nlm.nih.gov/pubmed/20122875?dopt=Abstract
AUGUST 31, 2010
Magnesium Importance for A-Fib
In a letter to the editor of BMJ (British Medical
Journal) Drs. Dietch, Wilson and Thomas point out that magnesium is important in
regulating the electrical activity of the heart and can help cases of acute
A-Fib. "Treatment with magnesium may correct rhythm disturbances in patients
with both low and normal magnesium concentrations." Magnesium is "superior to
amiodarone in treating atrial tachycardias in critically ill patients."
"It is our impression that magnesium is underused;
should we not use it more widely?"
(Author's Note: Magnesium is a naturally occurring
element that we should be getting from the food we eat. However, almost everyone
today is magnesium deficient, due to the lack of magnesium and other trace
elements in today's over-farmed soil (some magnesium can be obtained from fish).
Because it is a naturally occurring element, magnesium is considered safe to
take in normal doses. "Magnesium is a relatively safe drug." It is certainly
safer than amiodarone or other antiarrhythmic meds.
In addition to cases of acute A-Fib, all A-Fib
patients may want to discuss with their doctor whether magnesium supplements
might help their A-Fib.)
http://www.bmj.com/cgi/content/full/312/7038/1101/b
BMJ Letters "Magnesium is underused in acute atrial
fibrillation." 1996;312:1101 (27 April)
AUGUST 29, 2010
Effects of a Successful Catheter
Ablation
In an
analysis of 17 different studies enrolling 869 patients, a successful catheter
ablation significantly decreased (improved) left atrial diameter and volume,
but had no significant difference in
ejection fraction and actual
emptying fraction.
(Author's Note: It's certainly reason for hope for A-Fib
patients, that a successful A-Fib ablation will not only stop but reverse some
of the remodeling effects of A-Fib.
If before an ablation one's ejection fraction is low, one
would expect an improvement over time as the heart becomes stronger. But for
someone with a normal ejection fraction before ablation, there may not be much
of an improvement. "Ejection Fraction"
just measures what the ventricle does with the blood it receives, not whether it
receives more or less blood from the left atrium.)
Jeevanantham, V et al. "Meta-analysis of the effect of radiofrequency catheter
ablation on left atrial size, volumes and function in patients with atrial
fibrillation." Am J Cardiol. 2010 May 1;105(9):1317-26.
http://www.ncbi.nlm.nih.gov/pubmed/20403486?dopt+Abstract
AUGUST 29, 2010
Carotid Sinus Stimulus or Massage by
manual pressure for A-Flutter/A-Fib
Carotid Sinus Stimulation or Massage is a technique used by doctors to partially
block or slow down the flow of blood through the carotid sinus. It is used to
tell the difference between different types of arrhythmias, and "rarely, may
also terminate the arrhythmias and reestablish sinus rhythm." It is used in
patients "in whom a rapid decrease in heart rate is desirable."
Dr. Nayab Ali describes why carotid sinus massage may work.
"Vagal Stimulation, by altering the atrial refractory period, may break the
circus movement, atrial reentry, and atrial response to ectopic focus, thus
allowing the sinus node to take over control."212
Nayab Ali, "Conversion of Atrial Flutter to sinus rhythm by carotid sinus
pressure." Journal of the National Medical Association, Vol. 74, NO. 8,
1982.
WARNING: Carotid Sinus Stimulus or Massage should
be done only by doctors and not by individual patients on themselves.
AUGUST 28, 2010
"Radioactivity in Low Doses is Good
for Us."
In 1983 180
apartment building were built in Taiwan. But somehow highly radioactive
Cobalt-60 was mixed into the concrete. The 10,000 people who lived in these
apartments for 9-20 years received an average of 74 millisieverts (mSv) of
radiation a year (a typical catheter ablation using fluoroscopy produces around
15 mSv176---non-x-ray
imaging systems much less).
But cancer rates of people living in these highly radioactive
buildings were
3.6% of prevailing Taiwanese rates. This is a reduction in cancer
rates of 96.4%. This phenomena is perhaps explained by the theory of
hormesis which holds that intermediate levels of radioactivity actually
stimulate life and improve health.
http://www.jpands.org/vol9no1/chen.pdf
http://www.ecolo.org/documents/documents_in_english/taiwan-cobalt-60-apartmt-04.htm
New Scientist, "Radiation
thresholds." October 30, 2004
(Author's Note:
The nuclear theory that any level of radiation is cumulatively damaging may not
be valid [the "Linear No Threshold [LNT}" theory.] The levels of radiation
received during a typical catheter ablation may not be dangerous, but may even
be healthful.)
AUGUST 28, 2010
CryoBalloon & RF Ablation---the future of A-Fib treatment
CryoBalloon ablation is safe and effective in Pulmonary
Vein Isolation, but is limited in treating persistent A-Fib (because it only
isolates the pulmonary veins and not other parts of the heart). Doctors at
Mass General used a combined CryoBalloon and RF ablation to treat patients with
persistent A-Fib.
(Added December 20, 2010:
The FDA approves the
CryoBalloon Catheter.)
First a PVI was done using the CryoBalloon catheter.
It took approximately 10 minutes to isolate each vein (a considerable
savings in time compared to a typical RF ablation). 6% of patients
required additional RF ablations to completely isolate the pulmonary veins.
Then an RF catheter was used to ablate
complex
fractionated electrograms (CFAEs). Finally linear ablations were performed
with the RF catheter to terminate the persistent A-Fib.
After a single procedure 86.4% of patients were A-Fib
free without antiarrhythmic drugs (a high success rate for persistent A-Fib
after only one procedure).
(Author's Note: The above study only dealt with cases of
persistent A-Fib. But this combination of CryoBalloon {or possibly Laser
Balloon] and RF will probably become the standard treatment for all cases of
A-Fib.
Because the CryoBalloon is safe, effective, and fast, it will
probably become the normal method of isolating the pulmonary vein openings. If
A-Fib remains after the CryoBalloon ablation, then RF can be used to ablate
other areas of the heart that produce A-Fib signals. This combination of
CryoBalloon and RF ablation is a major medical breakthrough in
the treatment of A-Fib.)
Heart Rhythm. 2010 Apr;7(4):452-8. Epub 2009 Dec 24
http://www.ncbi.nlm.nih.gov/pubmed/20188229?dopt=Abstract
AUGUST 27, 2010
Bypass Surgery and A-Fib
It is estimated that one out of three bypass surgery patients will suffer at
least one episode of A-Fib after surgery. 40% of these will have more than one
A-Fib attack.
Beta-blockers and ACE inhibitors, as well as potassium
and non-steroidal anti-inflammatory drugs (NSAIDS) appear to reduce the risk of
developing A-Fib after bypass surgery.
The risk factors most associated with developing A-Fib after bypass surgery are:
- Advancing age,
- Past history of A-Fib,
- Chronic obstructive pulmonary
disease,
- The discontinuation of
beta-blockers and ACE inhibitors after bypass surgery.
(It was assumed that patients were too sick after surgery to continue to take
beta-blockers or ACE inhibitors. But according to this study, "the
discontinuation of beta-blockers and ACE inhibitors would be unwise, and their
use appears to be protective.")
(Author's Note: It wasn't clear whether this study
included antiarrhythmic drugs. The author questions whether administering
antiarrhythmic meds after bypass surgery [similar to what is often done after an
A-Fib ablation] might prevent the development of A-Fib after bypass surgery.)
http://www.scienceblog.com/community/older/2004/3/20042692.shtml
AUGUST 26, 2010
Fibrosis in A-Fib: Chicken or the Egg?
In a study
indirectly related to A-Fib, it was found that fibrosis leads to or is the cause
of the development of
cardiomyopathy,
rather than being caused by or a result of the disease. (People with
cardiomyopathy often have A-Fib as well.) According to Dr. Carolyn Y Ho of
Brigham and Women's Hospital in Boston, MA, "...the development of fibrosis
might play a role in actually driving the development of the disease, rather
than being a reaction to the development of overt disease."
http://www.theheart.org/article/1109291.do
(Author's Note:
Since fibrosis also occurs in A-Fib, strategies to prevent fibrosis or to
identify factors such as genetics, diet, life style, chemical/biological
markers, etc. which influence the development of fibrosis may help prevent the
future development of A-Fib. "...targeting fibrosis...may help to forestall the
development of clinical disease."209)
AUGUST 18, 2010
Five-Box Thorascopic (Mini-)Maze
Surgery
Dr. John Sirak of the Ohio State University has developed a type of Mini-Maze
surgery for A-Fib---the "Five-Box Thorascopic Maze Surgery" or Total Thorascopic
Maze (TTM) which, according to his web site, has a "cure rate in excess of 95%."
(Author's Note: This
Mini-Maze surgery may be an alternative to the full
Cox (Radial) Maze surgery
for A-Fib.) http://www.ohioafib.com/maze-surgery/
(Added 9/25/10: See Sirak et al. "The
Five-Box Thoracoscopic Maze Procedure" Ann Thorac Surg 2010;90:986-989.
http://ats.ctsnetjournals.org/cgi/content/full/90/3/986. It is not
explained in the study what happened to the missing patients. 48 started, 36
made the 3-month interval, while only 4 completed the 13-month interval.)
AUGUST 9, 2010
Chicago Cubs Pitcher
Carlos Silva has Catheter Ablation
Chicago Cubs pitcher Carlos Silva had a catheter ablation procedure to correct a
problem with his heart rate (paroxysmal supraventricular tachycardia). Dr.
Bradley Knight performed the two-hour procedure at Northwestern Memorial
Hospital. He is expected to begin light physical activity in a week, and start a
throwing program early the next week. Silva had the same procedure as former Cubs player Mark
DeRosa, now with the Giants. DeRosa had the heart work done during spring
training 2008 and was able to play in 149 games that season.
http://www.washingtonexaminer.com/breaking/cubs-silva-undergoes-heart-procedure-100310124.html
August 8, 2010
40% Recurrence/Reconnection
in Mini-Maze Surgery
In a study of 50 patients who
underwent Mini-Maze surgery, 40% had
recurrences of arrhythmias during the healing process, in a follow-up study of
12 months. PV reconnection accounted for most recurrences. Most patients' A-Fib
was terminated by catheter ablation, often combined with antiarrhythmic and rate
control meds.208 (Catheter
Ablation procedures also have significant recurrence rates.)
(Author's Note: This article may be very important to
A-Fib doctors and researchers, because it identifies specific areas of the heart
where re-growth/recurrence is likely to occur. "The relative thickness of
human myocardium, particularly in areas with endocardial ridges, as well as the
presence of blood flow, may explain the discrepant results between patient
outcomes..."
Catheter ablation does follow the contours and ridges of
the heart. Can the catheter be programmed to produce deeper burns in areas of
greater heart thickness like endocardial ridges? This might be a solution to a
very troublesome problem for both A-Fib doctors and patients.)
The author questions whether other energy sources like Cryo
or Laser might help both surgery and catheter ablation overcome this problem of
re-growth/re-connection after surgery and ablation for A-Fib.)
JUNE 18, 2010
FDA Approves AtriClip
to Close Off Left Atrial Appendage
The AtriClip LAA Exclusion System
with Preloaded Gillinov-Cosgrove Clip is made by AtriCure, Inc. (West Chester,
OH). The surgeon positions the rectangular-shaped device around the LAA. The
frame assembly of the device consists of two springs connecting two opposing
tubes which are covered with pressure pads. The springs close the device like a
clamp, leaving behind a Woven Dacon Fabric which eventually becomes part of the
heart. Blood no longer flows into and out of the Left Atrial Appendage.
The FDA approved the AtriClip on the basis of one trial with
70 patients. It was determined to be "substantially equivalent" to other devices
such as staplers and sutures already FDA approved.291,292
MAY 22, 2010
Vernakalant Successful in Stopping
A-Fib
For A-Fib patients with underlying
heart disease, the intravenous med Vernakalant converted 51.7% of A-Fib patients
to sinus rhythm after only around 11 minutes. It was shown to be safe, well
tolerated, and associated with greater improvements in quality of life (the AVRO
trial). An FDA advisory panel voted in favor of vernakalant, but the FDA still
has not approved it in the US.183
http://www.theheart.org/article/1079027.do
(Vernakalant
is a medical breakthrough for A-Fib patients with structural heart
disease who cannot use other antiarrhythmic drugs, if the FDA approves
it.)
MAY 21, 2010
Ablation of A-Fib
Reduces Risk of Alzheimer's and Dementia
In a large population study
(37,908) at the Intermountain Medical Center in Utah, some patients with A-Fib
received catheter ablation treatment, while others received drug therapy. After
three years of follow-up, the rate of Alzheimer's disease and all forms of
dementia was significantly lower among patients who underwent catheter ablation.
According to Dr. John Day, "In fact, the rates we saw were similar to those that
you'd see in patients who never had A-Fib to begin with." Catheter ablation also
reduced the risk of mortality and stroke at three years.182*
(Catheter ablation may reduce Alzheimer's and dementia:
1. By improving and/or normalizing blood flow to the brain.
2. By reducing inflammation. There may also be an
inflammatory connection, "with both A-Fib and Alzheimer's disease associated
with high levels of C-reactive protein."
3. By reducing and eliminating
TIAs and subclinical strokes caused by A-Fib. These mini-strokes produce
amyloid plaque found in Alzheimer's disease patients.)
Catheter ablation reduces the risk of mortality and stroke,
and reduces the risk of Alzheimer's and dementia. Then why leave A-Fib patients
on medications? As Dr. Day suggested, "...if you have A-Fib and medication
isn't working, maybe we should move toward a potentially curative procedure
earlier, rather than spinning our wheels for years with medication."181
http://www.theheart.org/article/1079365.do
*The title of reference
182 is confusing. I have written
the author for a clarification.
MAY 17, 2010
High Dose Steroids May Cause A-Fib
In a case-control study in the
Netherlands involving 7,983 men and women, high-dose corticosteroid use
significantly increased the risk of developing A-Fib. (Corticosteroids include
meds such as prednisone, cortisone, hydrocortisone, budesonide, betamethasone,
dexamethasone, Advair. High-dose refers to a daily dose greater than 7.5 mg of
prednisone equivalents.)
But it's dangerous to suddenly stop
taking steroids. Sudden withdrawal can lead to serious side effects and, in some
cases, be life threatening.180
http://www.theheart.org/article/696423.do
May 15, 2010
Dr. Andrea Natale Joins Scripps
Dr. Andrea Natale has been named the
Director of Interventional Electrophysiology at Scripps Clinic in La Jolla, CA
(April 5, 2010). Here is his address info:
Scripps Clinic 10666 N. Torrey Pines Rd SW 206 La Jolla, CA 92037
(858) 554-5049
Dr. Andrea Natale, Director of Interventional
Electrophysiology Dr. Douglas N. Gibson (858) 554-8730
Dr. Natale is also available to help A-Fib patients in other
areas of the US: see ---Austin, Texas Dr. Natale is the Executive Director of the
Texas Cardiac Arrhythmia
Institute ---Akron, Ohio
Akron General Medical Center ---Cleveland, Ohio
MetroHealth Medical Center
---San Francisco, CA
Northern
California Heart Center
APRIL 15, 2010
Women with A-Fib Have Higher Risk of
Stroke
Women
with A-Fib had a higher stroke risk, more stroke-related disability, and were
less often prescribed blood thinners, according to researchers analyzing past
A-Fib studies comparing how A-Fib affects men and women. Doctors may be more
reluctant to prescribe warfarin (Coumadin) to women, because some evidence shows
that women have a significantly higher risk of bleeding from blood-thinning
medication.177
(If you are a women with A-Fib, make sure you consult with
your doctor about the risk-benefit of taking blood thinners. An A-Fib stroke is
often a fate worse than death. See
Anticoagulants.)
december 22, 2009
Catheter Ablation Survey Good
Results
The latest worldwide survey of A-Fib ablations includes data
on 20,825 catheter ablation procedures performed on 16,309 patients over a
four-year period from 2003 to 2006 (some patients had more than one
ablation). This is almost twice the number of patients treated compared to
the first survey from 1995 to 2002.
The success rate was 70% (A-Fib symptom-free without
having to take antiarrhythmic drugs), which was a major improvement over the 52%
reported in the first survey. The "overall success rate"---defined as
freedom from A-Fib with or without the use of antiarrhythmic drugs---was similar
in both surveys, at 80%.
More patients with persistent and long-lasting A-Fib were
treated than in the previous survey. Of the 1,108 patients with long-standing
A-Fib, the success rate was 63.1%, while the overall success rate was 72.3%.
The overall complication rate was 4.5%, down slightly from
the previous survey. But Transient Ischemic Attacks were cut in half, and
Pulmonary Vein Stenosis was reduced by two thirds. (Pulmonary Vein Ablation
is a relatively new procedure. More experience, improved techniques and
equipment, and the sharing of knowledge have definitely improved the outlook for
A-Fib patients.)
There were 25 procedure-related deaths and 37 strokes,
similar to the previous survey. Atypical Atrial Flutter doubled. Atrioesophageal
Fistula, not reported previously, occurred in 0.04% of patients, of whom 71%
died. (The author is not sure about these figures. 0.04% of 16,309 is only
around 7 patients.) (Atrioesophageal Fistula is less of a problem today. Most
centers now take precautions to prevent Atrioesophageal Fistula.)
http://www.theheart.org/article/1035905.do
Author's Conclusions
Limitations of the survey
85 electrophysiology centers in North
America, Europe, Asia, and Australia provided data for this survey. But in the
US alone there are currently around 200 centers performing A-Fib ablations. The
85 centers providing data may be the most experienced, larger centers. Are the
newer, smaller centers achieving similar success and complication rates? We
simply don't know. (From the author's limited experience, the newer, smaller
practices seem to be achieving similar success and complication rates, at least
in the US.)
Insufficient
doctors and medical centers for A-Fib
Though 16,000+ patients seems
like a huge number, it's very small compared to the number of people developing
A-Fib. Though there has been a tremendous growth in medical centers and doctors
doing A-Fib ablations, they can not possibly handle all the cases of A-Fib which
some are calling an epidemic.114
Nearly three million people
in the U.S. have A-Fib. By the year 2050, the number will be 5.6 million.71
In the US people
over 40 have a one in four chance of developing A-Fib.82
A-Fib needs to become a national and worldwide health issue.
Remarkable progress in a short time
A-Fib patients should be encouraged
by the remarkable progress doctors have made in A-Fib catheter ablation within a
relatively short period of time. The first Pulmonary Vein Ablation was done a
little more than a decade ago. A worldwide improvement from 52% to 70% success
rate is a notable achievement and a testament to the hard work of A-Fib doctors
everywhere.)
december 19, 2009
Warfarin to be Taken for
Two Months after
a PVA(I), but Aspirin Option for Low Risk
Following a Pulmonary Vein Ablation
procedure, patients should be given warfarin for at least 2 months regardless of
their stroke risk factors (HRS/EHRA/ECAS AF Ablation Consensus Statement).125
But a recent study found that "low-risk patients with a low
CHADS2 (0-1) score... can safely be discharged
on aspirin alone."171 (Thanks to
William Pfeifer for calling our attention to this research.)
(Author's Note: For safety's sake [and to avoid legal
liability problems], your doctor will probably still want you to be on warfarin
after an ablation.)
december 7, 2009
Fibrosis Measured by MRI
Recent research indicates that
A-Fib Fibrosis can be measured by an MRI.169,
170
november 23, 2009
Medifocus Free
Abstracts of Latest A-Fib Journal Articles
Medifocus provides a listing of the latest medical journal
articles published in MEDLINE, with direct links to the specific article
summaries (abstracts). To subscribe to the free Medifocus Digest Alert on
Atrial Fibrillation, click on this link:
http://www.medifocus.com/zcr004.php?assoc=afib
NOVEMBER 19, 2009
Dabigatran to Replace Warfarin (Coumadin)
The above title is presumptuous, because the FDA hasn't yet approved the oral
anticoagulant dabigatran. But the recent RE-LY trial
comparing dabigatran etexilate (by Boehringer Ingelheim) to warfarin at 951
centers in 44 countries with 18,113 A-Fib patients produced results that are
hard to ignore. Low dose dabigatran was as good as warfarin, while the high dose
was better at preventing stroke and systemic embolism.
To paraphrase the lead investigator Dr. Wallentin, dabigatran
does not need frequent blood-test monitoring for INR levels, isn't affected by
possible food-drug or drug-drug interactions, can be used in many more patients
than warfarin, has few side effects, and is more effective and safer than
warfarin.
(The author predicts that dabigatran will be approved by
the FDA and will quickly replace warfarin as a treatment to prevent A-Fib
stroke. [It is already approved in the European Union and Canada.]} This is a
major medical breakthrough and most welcome news for A-Fib patients who will
no longer have to cope with measuring INR levels, worrying about diet, vitamin K
deficiency, side effects, etc. It's also welcome news for doctors who won't have
to wrestle with keeping patients at the right INR levels. They will have an oral
anticoagulant that is very effective, has fewer side effects, and can be
administered to a broader range of patients.
http://www.theheart.org/article/1024935.do (Thanks to Ira
David Levin for calling our attention to this article.)
NOVEMBER 17, 2009
Rhythm (Antiarrhythmic) Meds
Better Than Rate Control
In a study of 5604 patients with A-Fib
who were treated with either antiarrhythmic or rate control meds, "81% of
patients treated with rhythm control, compared with 33% of patients in the
rate-control arm were in sinus rhythm, after one year... 13% progressed to
permanent A-Fib in the rhythm-control arm, whereas 54% in the rate-control arm
had permanent A-Fib after one year." This finding disagrees with the AFFIRM
trial which indicated there was no advantage of rhythm control vs. rate control
for the prevention of cardiovascular events.
Author's Note: Though the study found no significant
difference in clinical outcomes, from this patient's perspective it's certainly
better to have a normally beating heart than to be in A-Fib---from a clinical as
well as from a quality of life aspect. If the study were longer than one year,
one would expect to see more heart problems develop in those still in A-Fib. And
why isn't progressing to permanent A-Fib not considered a clinical outcome?
Anyone who suffers from A-Fib dreads and fears going into permanent A-Fib.
A disturbing point mentioned in passing in this study is the
high percentage of patients (54%) in the rate-control arm who progressed to
permanent A-Fib within one year! This should be a wake-up call to all A-Fib
patients. If you don't aggressively try to stop your A-Fib (as with
antiarrhythmic meds or a Pulmonary Vein Ablation. etc.), you can expect your
A-Fib to become permanent within one year (54% chance).
This RECORD AF Registry data was presented at the
American Heart Association 2009 Scientific Sessions by Dr. John Camm.
http://www.theheart.org/article/1023939.do (Thanks to Ira David Levin for
calling our attention to this article.)
OCTOBER 1, 2009
Dr. Wharton Audio Presentation
on A-Fib Ablation
Dr. j.
Marcus Wharton of the Medical Un. of
South Carolina has a very informative 18 minute audio presentation on A-Fib
Ablation
http://www.muschealth.com/multimedia/Podcasts/displayPod.aspx?podid=252&autostart=true
August
14, 2009
A-Fib Support Volunteers Started
We are very excited about
starting a new way of helping people with A-Fib. Many people who've had A-Fib
have generously committed to serve as A-Fib Support Volunteers, to help people cope with and be cured of A-Fib.
They've listed their Email addresses and are there for anyone who needs advice,
emotional support, and hope in getting through the A-Fib ordeal.
JULY 30, 2009
Dronedarone (brand name Multaq)
Now Available in Pharmacies
Dronedarone (brand name Multaq) is now available in pharmacies in the U.S.
http://www.reuters.com/article/rbssHealthcareNews/idUSLS59493520090728
JULY 2, 2009
Dronedarone (Multaq) Approved by FDA
Dronedarone (brand name Multaq by Sanofi-Aventis) was approved by the FDA. This
is a major medical breakthrough for many A-Fib patients. See
Dronedarone.
http://www.theheart.org/article/983519.do.
But there is a caveat. "Dronedarone is
not indicated in patients with severe heart failure or those with NYHA (New York
Heart Association) class 2 or 3 heart failure with a recent decompensation
requiring hospitalization." (Class 2 refers to patients with slight, mild
limitation of activity, class 3 refers to patients with marked limitation of
activity. "Decompensation" refers to rapid accumulation of fluid in the lungs
due to heart problems.) "The ANDROMEDA trial showed that dronedarone increased
the risk of mortality twofold among those treated by the drug." This is a major
difference from amiodarone which dronedarone is similar to but with less toxic
effects. Amiodarone is
considered safer for patients with structural heart disease, while dronedarone
is not indicated for patients with severe heart failure.
June
20, 2009
RF &
CryoBalloon Produce Parallel Double Vein Lesions to Reduce Recurrence
Dr. Richard Schilling of the London AF
Center is doing preliminary research to help eliminate regrowth/reconnection of
ablated areas in a Pulmonary Vein Ablation and the recurrence of A-Fib after
ablation. He uses both RF (Radio Frequency burns) and Cryo (Freezing)
ablation. He first performs a wide encirclement RF ablation
of the left atrium pulmonary
vein ostia. Then he supplements this with Cryo
balloon ablation, which tends to freeze
the veins a little bit closer to the origins of the veins. In effect he produces
two parallel lines of electrical block, which reduces the chances of recovery of
electrical connection between the pulmonary veins and the left atrium.
This reduces the
recurrence of A-Fib after ablation.
Though this procedure
has only been performed in 15 patients with reasonable follow-up, he has seen a
dramatic improvement in the first time success rate for ablation of paroxysmal
A-Fib. This technique is now being tested in a randomized control trial to see
if the additional cost of using two technologies (RF and Cryo) is justified by a
significant improvement in first time success rates.
(Editor's Note: Dr. Shilling's
innovative technique of using both RF and Cryo balloon may be a major
medical breakthrough for A-Fib patients. Eliminating
regrowth/reconnection and the recurrence of A-Fib after ablation may
significantly reduce the need for a second ablation and improve the success rate
of
Pulmonary Vein Ablations.)
JUNE 9, 2009
A-Fib Patients at Greater
Risk of Developing Alzheimer's
Researchers have made a
medical breakthrough connection showing a
strong relationship between A-Fib and the development of Alzheimer's. This
finding was presented at the May 15, 2009 Heart Rhythm Society Scientific
Sessions. In the Intermountain Heart Collaborative Study in Murray, UT
37,025 people were followed for five years: 1. Patients with A-Fib were 44
percent more likely to develop dementia than others. 2. Younger patients with A-Fib were
at a higher risk of developing all types of dementia, particularly Alzheimer's.
A-Fib patients under age 70 were 130% more likely to develop Alzheimer's. 3. Patients who had both A-Fib and
dementia were 61 percent more likely to die during the study than dementia
patients without A-Fib. 4. Younger A-Fib patients with
dementia may be at higher risk of death than older A-Fib patients with dementia. Alzheimer's is the most common form of dementia (a general
term for life-altering loss of memory and other cognitive abilities), and
accounts for 60-80 percent of all dementia cases today. Today Alzheimer's is the
sixth leading cause of death in the US. "Previous studies have shown that patients with A-Fib are at
higher risk for some types of dementia, including vascular dementia. But to our
knowledge, this is the first large-population study to clearly show that having
A-Fib puts patients at greater risk for developing Alzheimer's," according to
Dr. T. Jared Bunch, the study's lead researcher.154
(Editor's Note: The study only states there is a strong
connection or relationship between A-Fib and Alzheimer's, because there may be
other factors influencing both the development of A-Fib and Alzheimer's. But as
A-Fib patients we have to assume until proven otherwise, that A-Fib causes or leads to Alzheimer's and dementia.
This conclusion
makes intuitive sense. In A-Fib, blood is not being pumped properly to the brain
and other organs. Another conclusion to be drawn from this study is: therapies
which leave patients in A-Fib while controlling the ventricular rate should be
avoided (rate control meds like Metoprolol or Digoxin), because they may lead to
Alzheimer's and dementia.)
May 22, 2009
Dr.
Reddy to Mount Sinai
Dr. Vivek Y. Reddy will join the Mount
Sinai Medical Center July 1, 2009. He previously was affiliated with the Un. of
Miami, Miller School of Medicine.151
Dr. Andre d'Avila
and Dr. Srinivas R. Dukkipati will also transfer to Mount Sinai in December.
(Thanks to contributor Ray for this info.)
Their address will be: Cardiac Electrophysiology Laboratories 1468 Madison Av. @ 100th. St. New York, NY 10029 (212) 241-7911
MAY 11, 2009
Coffee and
Caffeine May Not Trigger A-Fib and May Be Antiarrhythmic
Some research suggests that coffee and caffeine
in moderate to heavy doses may be antiarrhythmic and may reduce propensity and inducibility
of A-Fib both in normal hearts and in those with focal forms of A-Fib.143
MAY 8, 2009
Predicting A-Fib Using ECGs(EKGs)
(For people with occasional or
silent A-Fib, it is sometimes difficult to get an
ECG or documentation of
the A-Fib. By the time one gets to the Doctor's office or the ER, the A-Fib
attack has stopped. It may now be possible to predict A-Fib simply by examining
an ECG of the heart in sinus rhythm. Doctors can predict A-Fib by looking at the
P wave which is formed when the atria contract. See EKG
Signal.)
The measures used to predict A-Fib are: "P-wave terminal
force, P-wave duration, P-wave area, and PR duration."139
For example, a P-wave duration of greater than 140 milliseconds is predictive of
A-Fib.138
The study found that African Americans "seem to
have more of these ECG predictors than whites, which might explain why
they are at higher risk of ischemic stroke than whites, despite apparently
having a lower prevalence of A-Fib." They may have intermittent or silent
A-Fib which is not always detected.139
(Editor's Notes: The authors of the above study did not
draw the following conclusions.
Why not use the above A-Fib predictors to develop a
nation-wide program to screen for A-Fib? For example, anyone over 50 could be
screened by a Cardiologist looking at the patient's ECG. Anyone with A-Fib
predictors, even though in sinus rhythm, could be given a Holter or other
monitoring system to document if the patient has A-Fib. The A-Fib, even though
it may be asymptomatic ("silent"), could then be treated. This would save many people from an A-Fib stroke or deteriorating
heart health due to progressive A-Fib.)
MAY 5, 2009
FDA Advisory Panel Approves
Watchman Device
An FDA advisory panel on April 24,
2009 approved the
Watchman device (Atritech, Plymouth, MN) with conditions: centers implanting
the device must have surgical backup, and a physician certification program must
be created. The panel also recommended the creation of a registry, and extended
follow-up of current trials. The FDA usually follows its advisory panel's
recommendations.
Though the vote was split 7-5, "most panel members felt
the sponsor showed the device to be effective." Some panel members were
uncomfortable with the size of the 800-patient study, the duration of follow-up
(two or three years) and the long-term safety of the device. Some felt a
decision on effectiveness was difficult when there were so few strokes in either
arm. (Six patients in the control Warfarin arm had a hemorrhagic stroke, four of
whom died. No one died who received the Watchman device.)
The PROTECT-AF study on which the FDA advisory panel based
its approval was a prospective randomized trial comparing closure of the Left
Atrial Appendage by the
Watchman occluder with long-term warfarin therapy (90% of strokes come from
the Left Atrial Appendage). This was a "noninferiority" study---"the Watchman
device was associated with a reduction in hemorrhagic stroke risk vs. warfarin,
and all-cause stroke and all-cause mortality outcomes were noninferior to
warfarin."
Of the patients receiving the Watchman
device, 87% were able to stop taking warfarin after day 45. By 12 months, 93%
were off warfarin permanently.
There were problems such as pericardial effusion in the first
implantings of the Watchman device. But these decreased with experience and
improved devices, training, and procedural modifications. According to Dr. David
R. Holmes, Jr., current effusion rates are now around 1% and "are going to be
much more what we will see as the device rolls out." Dr. Gary Abrams added, "I
think that once the early morbidity from this gets worked out as people get
experience with it, I think it offers an option for people who need to stay on
warfarin for many, many years."
http://www.theheart.org/article/962955/print.do and
http://www.theheart.org/article/951777.do
Editors
Comments: This advisory panel's approval of the
Watchman device is a major medical breakthrough
for A-Fib patients.
It is estimated that only 50% of patients who need
anticoagulation protection are receiving warfarin, because it's so hard to get
the right dosage or because people can't tolerate it. But most A-Fib patients
can receive the Watchman device. Dr. Holmes speculated that the Watchman device
might be an option for up to 70% of patients with nonvalvular A-Fib.
Most of the panel were of the opinion that warfarin can have
"devastating" effects over time. Dr. Jeffrey Brinker said, "the risk of Coumadin
is high, especially in an older population who fall or who are more fragile,"
and who are more at risk of a hemorrhagic stroke. The Watchman device is a most
welcome alternative to warfarin/Coumadin and other blood thinners.
Practical Consequences of the FDA
Advisory Panel's Approval:
Coumadin reduces but does not totally eliminate the risk of
stroke. Even with the proper INR levels of Coumadin, a small number of people
with A-Fib have had strokes. The Watchman device also reduces but does not
totally eliminate the risk of stroke. Like Coumadin, the Watchman is not an
absolute guarantee one will never have a stroke. It basically reduces the risk
of stroke similar to that of a person with a normal heart.
Those of us who hate having to take Coumadin or other
blood thinners will be
able to go in for a low risk procedure that takes as little as 20 minutes,
and never have to take Coumadin again! This is incredibly good news for many of
us.
Even while we are waiting for or trying to decide on having a
Pulmonary Vein Ablation, we can have the Watchman inserted and then not have to
worry about an A-Fib stroke.
The Watchman device may become part of most catheter ablation
procedures. If the catheter ablation procedure were unsuccessful or in case of
silent A-Fib attacks after ablation, we patients would still be protected from
an A-Fib stroke by the closing
off of the Left Atrial Appendage.
march 28, 2009
Digoxin May Harm A-Fib Patients
The AFIB REPORT
by Hans Larson has the following
caution about digoxin. "Recent research has clearly shown that digoxin should
not be used
on a continuous basis in patients with
paroxysmal lone A-Fib, since it is likely to worsen their condition and result
in it eventually becoming permanent." No References Cited)
And, "Digoxin poisoning is a leading
cause of hospital admissions with anywhere between 10 and 30% of patients on the
drug being hospitalized for digoxin intoxication."(No References Cited)131
March 21, 2009
Dronedarone Approved by FDA
Advisory Committee
Dronedarone
(brand name Multaq) was recommended for approval by an FDA advisory committee
(March 18, 2009). It isn't guaranteed that the FDA will approve dronedarone, but
it usually doesn't disagree with its committee's recommendations.
(This is a major medical breakthrough for A-Fib-ers,
especially for older patients, for those who can't have a Pulmonary Vein
Ablation or a Mini-Maze surgery, or for those who have failed these
procedures/surgeries. Dronedarone may allow many of these A-Fib-ers to lead a
relatively A-Fib free life.
Dronedarone is similar to amiodarone which is considered the
most effective anti-arrhythmic drug, but without its toxic side effects. In the
ATHENA clinical trial, Multaq (by Sanofi-aventis) was the only anti-arrhythmic
drug "to have shown a significant reduction in morbidity and mortality in
patients with A-Fib/A-Flutter..." )
http://news.prnewswire.com/ViewContent.aspx?ACCT=109&STORY=/www/story/03-18-2009/0004991096&EDATE
March 4, 2009
WorldOne research
is an independent market research organization based in London. We would like to
invite patients with ATRIAL FIBRILLATION for a 15-20minutes
research study. This can be completed via telephone or online.
The Study aims at gaining an understanding of the following
areas:
- Satisfaction with the treatment for Atrial
Fibrillation.
-
Sources
patients utilise in finding information on Atrial Fibrillation related
topics.
- Their experiences with their condition.
In appreciation of a patient’s time and contribution we would
like to offer a honorarium of $25 on completion of the study.
We would like to remind you that the results of the study are for analytical
purposes only and patients confidentiality will be strictly maintained. Our
research is treated in accordance with Esomar and MRS Code of Conduct.
Should you require further
clarification, please contact me or my colleague Dino Lista at World One
Research on: +44 (0) 207 252 1118 (ext: 1140), or drop me an email to:
anthony.menkiti@w1-research.com.
February 16, 2009
A-Fib.com Receives HONcode
Certification
A-Fib.com complies with the
HONcode standard of trustworthy
health information on the internet.
(The Health on the Net Foundation
in Switzerland tries to guide lay users and medical professionals to reliable
sources of health-care information online. This HONcode accreditation indicates
that A-Fib.com has been deemed a reliable source of health information and meets
standards, including those related to the qualification of the authorities
cited, privacy of personal data submitted by a visitor to A-Fib.com, and
financial disclosure of funding sources. It does not guarantee that all the
health information on A-Fib.com is infallible.)
February 15, 2009
Ablation Frontiers' Multi Electrode Catheters Positive Preliminary Tests
Preliminary tests results of
Ablation Frontiers'
multi electrode catheters is very positive, with an 83% success rate for
Paroxysmal A-Fib patients. See
http://download.journals.elsevierhealth.com/pdfs/journals/1547-5271/PIIS1547527108008679.pdf
February 14, 2009
Insertable
Cardiac Monitor by Medtronic Detects A-Fib Signals
Medtronic has developed an insertable cardiac
monitor to detect A-Fib signals. The Reveal XT is placed just under the skin
of the chest in a short outpatient procedure. It captures an electrogram (ECG)
during an actual A-Fib episode. To store the ECG the patient places a hand-held,
pager-sized assistant over the Reveal XT and presses a button. Later, a
physician analyzes the stored information, transmitted via the Medtronic
CareLink Network or during an in-office patient visit. For further info, go to
http://www.medtronic.com.
February 10, 2009
FDA Approves First Ablation
Catheter for A-Fib
The
FDA approved the first ablation
catheters for the treatment of A-Fib. The two radiofrequency catheters, the
NaviStar ThermoCool and EZ Steer ThermoCool Nav
(BioSense Webster), were
approved February 6, 2009.
http://www.theheart.org/article/939929.dohttp://www.theheart.org/
article/939929.do See also:
http://www.fda.gov/bbs/topics/NEWS/2009/NEW01953.html
November 25, 2008
FDA
Advisory Panel Unanimously Approves First A-Fib Ablation Catheter
An FDA panel unanimously
recommended approval of an A-Fib Ablation Catheter, the first to be so
recommended. (Up to this point doctors had been using ablation catheters
off-label.)
http://www.theheart.org/viewArticle.do?primary Key=923617
(As a consequence of this FDA panel decision, Pulmonary
Vein Ablation (Isolation) procedures have officially entered mainstream medicine
and can no longer be considered "experimental.")
August 11, 2008
Death of Dr.
Carolyn Kimme-Smith
A-Fib-ers in Southern California were sadden to learn of the death of Dr.
Carolyn Kimme-Smith who hosted and supported the local A-Fib support Group in
her Newport Beach home.
Dr. Kimme-Smith was a breast cancer survivor who tirelessly
devoted her time and energy to many issues, primarily focused on early detection
of breast cancer. She had a distinguished career as a full Professor at UCLA's
School of Medicine, Dept. of Radiological Sciences.
Her husband Hal and her three children hosted a memorial
celebration of her life August 9 which filled their home. We all learned a great
deal about this wonderful woman who touched so many lives.
August 4, 2008
Osteoporosis Drug
Alendronate (Fosamax) Linked to A-Fib
The osteoporosis drug alendronate (brand name Fosamax) is linked to A-Fib. Women
who have used alendronate at any time in their lives have an 86% greater risk of
developing A-Fib than women who have not used the drug.128
July 17, 2008
Nebivolol (Bystolic) New Beta Blocker Approved by FDA
The FDA recently approved the new beta blocker drug
nebivolol (brand name Bystolic by Forest/Mylan, a selective
beta-1-blocker).126This
is a minor medical breakthrough for A-Fib-ers taking traditional beta
blockers like atenolol or metoprolol who may feel tired or fatigued due to
slower blood flow. (Traditional beta blockers reduce the effect of excitement
and physical exercise on heart rate and force of heart contraction.) Nebivolol
is an effective beta blocker that also produces vasodilation (an expansion of
the blood vessels) and reduces peripheral resistance by increasing nitric-oxide
release. Instead of slowing blood flow, nebivolol maintains blood flow and
lowers vascular resistance.
Nebivolol is similar to the newer beta blocker
carvedilol
(Coreg), though they act differently. (Carvedilol is a non-cardioselective beta
1, beta 2 and alpha-receptor blocker, whereas nebivolol is highly
cardioselective [blocking beta 1 receptors only] and produces vasodilation by
nitric-oxide release.)
June 30, 2008
Procanbid No
Longer Available
The anitarrhythmic drug Procanbid
will no longer be available for A-Fib patients. There doesn't seem to be any
generic substitute. King Pharmaceuticals, Inc. which makes Procanbid issued this
statement about its decision. It was "based upon many factors, including our
understanding of current medical therapy and the general availability of
alternative antiarrhythmics."
June 28, 2008
CryoBalloon
Ablation Safer Than RF
"Cryoablation (with the CryoCath Arctic Front
cryoballoon): Safer than RF..." Dr. Burghard Schumacher of Germany described
a study involving 346 patients with Paroxysmal (293) or Persistent (53) A-Fib.
Following one Cryoballoon ablation, 74% of Paroxysmal patients were free of
A-Fib and in permanent sinus rhythm. But this figure was much lower for those
with persistent A-Fib---just 38%. There were no strokes, no pulmonary vein
stenosis, no esophageal injury, and no coronary artery injury as sometimes
occurs with RF ablation (RF ablations typically have a major complication rate
of around 4%). The main complication reported was a temporary palsy of the
phrenic nerve.
According to Dr. Philippe Ritter, president of Cardiostim,
"Cryoablation (with the Cryoballoon catheter) appears to have a lower
complication rate than RF ablation and is easier to perform...but we need some
more years to look at it and compare it with RF ablation." (See:
http://www.theheart.org/article/877315.do)
(Editor's Comments: A 74% cure rate for the CryoCath
balloon catheter is similar to current cure rates for RF ablations for
Paroxysmal A-Fib. The low 38% cure rate for Persistent A-Fib might be due to
only having one ablation. Most RF ablation procedures for Persistent A-Fib now
require two or more ablations. [See:
95%
Success Rate in Curing Persistent A-Fib.] Also, in this study only the
Pulmonary Vein openings were treated with the CryoCath balloon catheter. They
did not attempt any other lines or lesions as is commonly done with current RF
ablations for Persistent A-Fib. Persistent A-Fib is more complex and difficult
to cure. As doctors get more experienced with Cryo, they may well be able to achieve similar success rates as RF for Persistent A-Fib.
In the future we may see centers first use Cryoballoon
catheters to isolate the Pulmonary Veins because it is safer, easier, and uses
less fluoroscopic exposure; and
secondly use RF or non-balloon Cryo catheters for linear lesions and to target
other areas of the heart in more complex cases of Persistent A-Fib. Cryo will
probably also be used to ablate near the esophagus to prevent Atrial-Esophageal
Fistula [see
Morady: Boston A-Fib Symposium 2008].
Cryoballoon catheter ablation may also be the answer to the
problem of re-do's. [See
Dr. Marchlinski's presentation on Ablation re-do's.] All too often RF ablation patients have to return for a
second ablation, because of re-growth and reconduction of the RF ablated areas,
and because PV isolation with RF is difficult to achieve in a uniform fashion, even with
experienced operators. Circumferential ablation with small-tipped catheters
often results in gaps in the lesions lines and uneven scar formation. The Cryo
balloon catheter ablation may solve the problem of re-do's, because of its
ability to easily and quickly produce uniform pulmonary vein isolation. [See:
Dr. Kerwin's explanation of Cryo
Ablation.])
June 27, 2008
Dronedarone Safe in ATHENA Clinical Trials
"Dronedarone safety, efficacy
standings bolstered in huge A-Fib trial." Dronedarone (brand name Multaq by
Sanofi-Aventis) is a drug in clinical trials to replace amiodarone which often
has serious toxic side effects. Both drugs have similar molecular structures and
seem to work in a similar way. But dronedarone (a benzofuran analog of
amiodarone) doesn't have the iodine component that is largely responsible for
amiodarone' s toxic effects on the lungs, thyroid, eyes and other organs.
In the randomized ATHENA trial over 4,500 A-Fib
patients in 37 countries took either dronedarone or a placebo in "the largest
antiarrhythmic drug trial ever conducted." Patients who took dronedarone
experienced a 24% drop in risk of Cardiovascular (CV) hospitalizations or death
over almost two years. Unlike other antiarrhythmic drugs, dronedarone seems to
carry a low risk of adverse events. Secondary clinical end points also improved,
such as less hospital admissions for A-Fib and acute coronary syndromes.
According to Dr. Bramah N. Singh of UCLA, "...in terms of safety, it
(dronedarone) is the best drug we have for atrial fibrillation." See
http://www.theheart.org/article/867591.do.
The trial did not compare the efficacy of dronedarone to
amiodarone, which is the subject of another ongoing randomized clinical trial
called DIONYSUS.
June 16, 2008
A new advancement in mapping techniques may significantly improve ablation
treatments. A specialized multielectrode mapping catheter with a 20-pole penta-array
produces rapid, high-density atrial mapping. The whole atrium can be
mapped in less than 8 minutes. It is used with an Ensite NavX mapping system.
See:
http://circep.ahajournals.org/cgi/content/abstract/1/1/14 (Thanks to Dick
Inglis for calling our attention to this article.)
June 8, 2008
Preliminary results very positive for
Chronic A-Fib Clinical Trials. See:
http://ablationfrontiers.com/webdocuments/
poster-heart-rhythm-society-2008.pdf
April 9, 2008
(Good news for A-Fib patients with Chronic [constant] A-Fib.)
Multi Electrode
Catheter for Chronic A-Fib Clinical Trials Begin
The
first clinical trials focusing on
ablation of Chronic A-Fib have begun in the
US. The study, known as the
Tailored Treatment of Permanent Atrial Fibrillation
(TTOP AF) is sponsored by Ablation Frontiers (http://www.AblationFrontiers.com).
It uses three innovative catheters with multiple electrodes to produce a variety
of different ablations depending on the needs of the patient. Preliminary data
show an 80% success rate after two ablations with relatively short ablation
times. The purpose of this study is to make effective ablation for Chronic A-Fib
available and feasible to all EPs in all clinics. 25 centers will be
participating in these Chronic A-Fib trials. For a more detailed, technical
description of this study, go to
http://www.ablationfrontiers.com/webdocuments/acc-poster-march-20-2008.pdf. Patients will be randomly selected into two treatment groups:
for every three patients who apply, two will receive ablation therapy, the third
drug treatments. The trial allows patients in the control (drug treatment) arm
to receive an ablation if they do not respond to drug therapy (a likely
occurrence). (This may be a major medical breakthrough
for patients with Chronic A-Fib. In the past, medical centers were often
reluctant to ablate patients with Chronic A-Fib, because they were more
difficult to cure. Some centers, for example, had rules excluding patients who
had Chronic A-Fib for more than one year. But with the progress of these Chronic
A-Fib clinical trials, most centers will be able to ablate Chronic A-Fib
patients with a success rate similar to Paroxysmal (occasional) A-Fib patients.) If you wish to participate in this Chronic A-Fib clinical
trial, a full listing of Medical Centers, Locations, Doctors, and Contact
Information is available at
TTOPAFTrialsContacts.
December 20, 2007
Vice-President Dick Cheney Successfully Electrical Cardioverted from A-Fib
Vice-President Dick Cheney was diagnosed with A-Fib and successfully
Electrical Cardioverted back to
normal sinus rhythm at George Washington University Hospital November 27, 2007.113
October 19, 2007
The A-Fib community is shocked to learn that the Cleveland Clinic did not renew
Dr. Andrea Natale's contract. There is no word yet where Dr. Natale will work,
or where A-Fib patients can be treated by him. For more information see
http://www.cleveland.com/news/plaindealer/index.ssf?/base/news/119131405528890.xml&coll=2
. You can leave messages for Dr. Natale at his E-mail address
andreanatalemd(at)gmail(dot) com.
September 1, 2007
Dr. Peng-Sheng Chen is moving from Cedars-Sinai in Los Angeles to become the new
director of the Krannert Institute of Cardiology at Indiana University.
August 19, 2007
FDA Approves Genetic
Testing Labeling for Warfarin (Coumadin)
The FDA's new labeling for Coumadin will explain that
people's genetic makeup may influence how they respond to the drug. In the
Precautions section, "Periodic determination of PT/INR is essential. (See
DOSAGE AND ADMINISTRATION: Laboratory control.) Numerous factors, alone or
in combination including changes in diet, medications, botanicals, and genetic
variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY,
Pharmacogenomics) may influence the response of the patient to warfarin."105
Genetic variants of the CYP2C9 and VKORC1 genes are
individually responsible for anywhere from 35% to 50% of the variable dose
response to warfarin, FDA officials say. But the agency stopped short of
requiring physicians to use the test: there are no adequate clinical trials
proving that genetic testing improves warfarin's safety profile; testing is also
not universally available. The CYP2C9 gene is involved in drug metabolism such
that certain variations permit the drug to remain active in the blood for
longer. The VKORC1 gene represents the site of action of warfarin such that gene
variants could affect patient sensitivity to the drug.
The FDA estimates that 2 million persons start taking
warfarin (the generic of Coumadin) in the U.S. every year to prevent blood
clots, heart attacks and stroke. Warfarin is the second most common drug--after
insulin--implicated in emergency room visits for adverse drug events.
The FDA's "personalized medicine" initiative may further the
study and application of pharmacogenomics---the science that predicts a response
to drugs based upon a person's genetic makeup. Healthcare providers may use
genetic tests to improve their estimate of what is a reasonable warfarin dose
for individual patients. Warfarin is only the second drug in which specific
pharmacogenetic details have been used in the label relating to drug dosing.
However, this is the first time a widely used agent like warfarin has included
these types of genetic details.
(Author's Note: If your doctor puts you on warfarin
(Coumadin) and does not test you for the above gene variations, you
should probably get a second opinion. The tests cost between $125 and $500 and
are fairly widely available. These tests could save you heart problems related
to under- or over-dosing of warfarin.)
(See
http://www.sciencedaily.com/releases/2007/
08/070817113120.htm) (Thanks to
Larry Kushman for calling our attention to this article.)
July 18, 2007
Bordeaux Five-Step
Ablation Protocol for Chronic A-Fib
The French Bordeaux group now uses a five-step process to
treat Chronic A-Fib.
1. They start by isolating the Pulmonary Vein openings.
They
also eliminate potentials at the base of the Left Atrial Appendage, but do not
isolate or electrically disconnect the whole of the LAA which could possibly
lead to clots forming in the LAA and A-Fib stroke. (Ablating at the base of
the LAA as part of the first step in treating A-Fib is a new approach and
may become a very important first step in the ablation treatment of A-Fib.)
2. Next they make a roof line linear ablation linking the Right Superior
Pulmonary Vein with the Left Superior Pulmonary vein opening to create complete
electrical block
3. They then work in the Inferior Left Atrium and the Coronary Sinus. They
make an incomplete blocking line between the Right Inferior and Left Inferior
PVs in order to slow down the rapid atrial electrical activity.
They treat the Coronary Sinus as though it were another heart structure or
Left Atrium, rather than just another vein opening. They disconnect the CS from
the Left Atrium and ablate potentials along the Mitral Annulus. They also slow
down Coronary Sinus electrical activity by ablating both inside and outside the
CS with a lower wattage power, usually 25 Watts. (Treating the Coronary Sinus
as another Left Atrium is a new approach. Most current A-Fib ablation
procedures tend to stay away from the Coronary Sinus because of the risk of
Stenosis (swelling). The French Bordeaux group, by using a low wattage,
irrigated tip catheter, ablates within the Coronary Sinus without
damaging it.)
4. The fourth step is eliminating organized atrial activity in areas such
as:
Anterior Left Atrium & Left Atrial Appendage
Septum
Posterior Left Atrium
Superior Vena Cava
Right Atrial Septum
5. The fifth step is to create a Mitral Isthmus blocking linear ablation line
from the Mitral Annulus to the Left Inferior PV. The goal is to eliminate all
potentials along this line.
In practice, even after these five steps, rapid atrial activity often
remains. It has to be mapped, traced to its source and ablated. Often the top of
the Left Atrial Appendage has to be ablated.
This whole procedure requires a great deal more time, effort, persistence,
skill and experience than normal left ablation procedures.
(Author’s note:
Please be advised that this five-step process for treating Chronic A-Fib is
relatively new and isn’t available today at most A-Fib medical centers.)
June 20, 2007
President George Bush may have Chronic A-Fib
An interesting article from the Houston Independent Media Center suggests that
President George Bush may have Chronic A-Fib
http://houston.indymedia.org/news/2004/
12/35839_comment.php#45166.
June 1, 2007
Warfarin Bests Aspirin for
Stroke Prevention in Elderly A-Fib Patients
Results of the
Birmingham Atrial Fibrillation Treatment of the Aged trial show that even among
A-Fib patients older than 75 years, warfarin was superior to aspirin for primary
stroke prevention without a significant increase in hemorrhage risk. (16th
European Stroke Conference.) [31 May]
May 25, 2007
LOCAL A-FIB SUPPORT GROUPS FORMING.
Are you interested in forming or participating in a local
A-Fib support group? Our goals would be to share our experiences with A-Fib, get
advice, learn about new developments, and form friendships with others who
understand what A-Fib is like. Those who have been cured of A-Fib are also
encouraged to join (and perhaps volunteer to mentor a new A-Fib-er). We'd meet
for informal lunch or dinner, or an evening mixer with a speaker.
We are trying to set up the first local A-Fib support group
in the greater Los Angeles/ Southern California area. If you are interested in
participating in this local A-Fib support group or in forming an A-Fib support
group where you live, contact Joyce at jarintime(at)yahoo.com (the @ is written
as "at" to prevent access by spam mailing lists).
May 25, 2007
A-Fib Decreases Mental Abilities
Men with A-Fib had lower levels of
cognitive performance compared to men in normal sinus rhythm in the
Framingham Offspring Study. This may be due to the reduced cardiac output and
decreased blood flow to the brain in persons with A-Fib. Multiple cognitive
abilities were tested over a wide age range (37-89 years).
"...A-Fib may be one of a number of risk factors for
conversion from mild cognitive deficit to dementia."98
In a previous study persons with chronic A-Fib had a 3-fold risk of cognitive
deficit compared with persons in normal sinus rhythm.99
There were too few women with A-Fib for analysis in this
study. However, in a previous study women with A-Fib had a higher prevalence of
dementia and cognitive impairment.100
(Thanks to Darrel Seife for calling our attention to this study.)
(Author's Note: This is an important study, especially for
those in Chronic A-Fib. The option of simply staying in A-Fib while controlling
the rate and taking blood thinners to prevent stroke may no longer be
acceptable, because of the risk of mental impairment and dementia from A-Fib.)
May 13, 2007
Cox Maze Operation for
Patients with Chronic A-Fib
People with Chronic long-standing
A-Fib and large left atria were generally thought not to benefit from a Maze
operation. This Cox maze operation, which also utilizes supplemental RF
ablation, cuts out sections of the atria to reduce atrial size and improve
ejection fraction.97
May 6, 2007
First Ablation Using Visually Guided Endoscopic Catheter by Dr. Shephal Doshi
Dr. Shephal Doshi of St. John's Health Center in Santa Monica, CA performed
what may be the first visually guided catheter ablation for A-Fib, using
the investigational "Visually Guided Endoscopic Ablation System." A steerable
catheter with fiber optics and a transparent dome at the end works as a video
camera using infrared signals to see through the blood in the heart The
system was developed by CardioFocus, Inc. of Marlborough, MA. For more info call
(508) 658-7200 or visit
http://www.cardiofocus.com.96
For a list of the 20 medical centers participating in the clinical trials of
this system, go to:
http://www.cardiofocus.com/afib_trial_enable.htm
April 26, 2007
Additional centers participating in the CryoCath balloon catheter trials are:
Bay Heart Group,
Iowa Heart Center,
Massachusetts
General Hospital,
Mayo
Clinic,
Virginia Commonwealth Medical Center
Baylor Heart and Vascular Hospital,
Arrhythmia
Associates/Inova Research Center,
Stanford Hospital,
Quebec Heart Institute/Laval Hospital. See
Cryo Cath balloon catheter
trials.
April 16, 2007
The University of
Chicago Hospitals announces new developments in their treatment of A-Fib.
Joining their staff are: Drs. John F. Beshai, Martin Burke, Bradley P. Knight,
and Al Lin.
March 21, 2007
A gentleman from India with A-Fib needs financial help in getting a Pulmonary
Vein Ablation (Isolation) procedure. If you have the financial means to help him
(or if you have any contacts in India), his E-mail address is:
alexander_john123@yahoo.com.
February 8, 2007
The A-Fib ablation doctors formerly associated with Riverside Methodist
Hospital/MidOhio Cardiology have moved to the Ohio State University. Their new
address is:
The Ohio State University
DHLRI, Suite 200
473 W. 12th Avenue
Columbus, OH 43210-1252
(877) 478-2478 Dr. Emile G. Daoud, Dr. Ralph S. Augostini, Dr. John D.
Hummel, Dr. Steven J. Kalbfleisch, Dr. Raul Weiss
January 19, 2007
Cryo Balloon Catheter Ablation Trials to
Begin
Dr. Walter Kerwin of Cedars-Sinai Medical Center in Los
Angeles and Dr. Christopher Cole of Colorado Springs Cardiologists will begin
clinical randomized FDA trials of the Arctic Front-TM balloon CryoAblation
catheter made by CryoCath Technologies Inc. Patients receiving Cryo (freezing)
balloon ablation will be compared to patients taking antiarrhythmic drug therapy
(Sotalol, Rhythmol or Flecainide).
For every three patients, two will be randomly assigned to
receive a CryoCath balloon ablation, while the third will take drug therapy (a 2:1
randomized ratio). After 90 days, patients in the drug therapy group who are
still in A-Fib (a likely occurrence) can cross over and receive a CryoCath
balloon ablation. Patients will be followed carefully during a one year
follow-up.
(To this author, Cryo ablation seems to be significantly
safer for patients than standard RF ablation. However, Cryo ablations currently
take more time to perform than RF ablations. The Cryo balloon catheter will
likely allow a doctor to perform a Cryo ablation and isolation of the Pulmonary
Vein openings more easily and much faster than current methods. The Cryo balloon
catheter may become a major improvement in the treatment of A-Fib. It has
already been approved in Europe, with close to 100% success rate in isolating
the PVs, and 75-80% success in keeping patients free of A-Fib without
anti-arrhythmic drugs.)
The trial will be covered by most good insurance policies
that provide for clinical research participation. Patients will not be paid or
separately charged by the clinical trial for participation. If you're interested
in participating in this Cryo balloon catheter ablation trial for A-Fib, here is
the contact info:
Cedars-Sinai Medical
Center 8631 W. 3rd. St., Suite 1017-E Los Angeles, CA 90048
(310)-289-5901
Dr. Walter Kerwin
Colorado Springs Cardiologists 2222 N. Nevada Ave., Ste 4007 Colorado Springs, CO 80907 (719) 634-6671
Dr. Christopher Cole
The Ohio State University
DHLRI, Suite 200
473 W. 12th Avenue
Columbus, OH 43210-1252
(877) 478-2478 Dr. Emile G. Daoud, Dr. Ralph S. Augostini, Dr. John D.
Hummel, Dr. Steven J. Kalbfleisch, Dr. Raul Weiss
(There will be twenty different centers in the US
participating in these cryo balloon ablation randomized trials. That info will
be published here as it becomes available.)
(Added April 26, 2007: Other centers participating in the
CryoCath
balloon trials are:
Bay Heart Group,
Iowa Heart Center,
Massachusetts
General Hospital,
Mayo
Clinic,
Virginia Commonwealth Medical Center,
Baylor Heart and Vascular Hospital,
Arrhythmia
Associates/Inova Research Center,
Stanford Hospital,
Quebec Heart Institute/Laval Hospital.)
November 1, 2006
Stereotaxis
Starts Computerized Magnetic Ablation Niobe R System
Stereotaxis announces Initial U.S. Clinical Usages of Cardiac Ablation Catheter
with Company's Niobe R) System. The Niobe system utilizes a computer-controlled
magnetic field to remotely steer a magnetic ablation catheter that applies a
consistent, "soft-touch" contact with the heart which may reduce the risk of
perforation during ablation procedures.94
October 21, 2006
A study comparing the
Pappone Circumferential Anatomical PV Isolation procedure with an integrated
approach using both the Pappone method followed by a
Segmental ablation
(with electrophysiological confirmation of PV disconnection) was found to be
more effective than the Pappone method alone. "Electrophysiological confirmation
of PV disconnection could be a useful marker of successful RF treatment of
A-Fib."93
October 14, 2006
Bordeaux Group Reports 95% Success Rate in Curing Persistent/Chronic A-Fib after
Two Ablations
In a major medical breakthrough the French Bordeaux group reported
a 95% success rate in curing Persistent/Chronic A-Fib.92
See
Jaïs
Chronic A-Fib.
August 5, 2006
Four Patients Die
after AtriCure (Wolf) Mini-Maze Surgery
According to a Wall Street Journal article by David Armstrong, four patients are
known to have died after having the AtriCure (Wolf) Mini-Maze surgical operation
to cure A-Fib.91
August 5, 2006
Cleveland
Clinic Surgeons' Financial Ties to Equipment Manufacturers
According to a Wall Street Journal article by David Armstrong, surgeons at the
Cleveland Clinic may have or may have had extensive financial ties to
manufacturers of medical equipment these surgeons use to treat A-Fib patients.91
June 11, 2006
Dr. Andrea Natale and the Cleveland Clinic now call their catheter ablation
procedure to cure A-Fib "Pulmonary Vein Antrum Isolation (PVAI)." This procedure
still involves making circumferential lesions around the outside of the PV
openings.
June 11, 2006
Low-Dose Steroids
Prevent Recurrence of A-Fib after Ablation
Low-dose steroids have been reported to prevent recurrence of A-Fib, possibly
because they suppress systemic inflammation.85
June 10, 2006
Dr. Wolf
Admonished for Not Revealing Financial Ties to AtriCure
"The Journal of Thoracic and Cardiovascular Surgery has admonished a Un. of
Cincinnati surgeon (Dr. Randall K. Wolf who developed the Wolf Mini Maze
operation for A-Fib) for failing to disclose financial ties to AtriCure, the
West Chester, (Ohio) maker of heart-surgery equipment he and other researchers
evaluated in a published study." Cincinnati Business Courier and The
Wall Street Journal December 28, 2005.
81 "An AtriCure
filing with the SEC in August, (2005) reports Dr. Wolf owns 18,402 shares of
company stock (approximate current value $140,000) and has warrants or options
to purchase 13,913 additional shares of stock. (ArtiCure's recent stock price
was $7.60.) In November, AtriCure reported a four-year royalty agreement with
Dr. Wolf that will pay him a minimum of $200,000 a year up to a total of $2
million over the entire length of the agreement."81
June 6, 2006
"Pill-In-The-Pocket" Strategy using Flecainide or Propafenone is Effective
Flecainide
or propafenone can be safely self-administered by outpatients for control of
recurrent atrial fibrillation. This "pill-in-the-pocket" approach resulted in
fewer emergency room visits.
http://www.medscape.com/viewarticle/495111?rss, New England Journal of
Medicine 2004;351:2384-2391.
(There is some disagreement about this strategy. Some say
it might be better to keep patients out of A-Fib by taking antiarrhythmic meds
daily [keeping a fire from starting], rather than waiting for an A-Fib attack to
start [having to put the fire out once it starts].)
May 27, 2006
Obesity,
Smoking, but not Age Affect Recurrence Rates after A-Fib Ablation
Obesity (BMI over 30) and
Smoking, but not Age, affect reoccurrence rates of A-Fib after ablation. Dr.
Dimpi Patel of the Cleveland Clinic hypothesized that obese patients have larger
left ventricles, often due to hypertension or diabetes, and left atrial
dilation, resulting in an increased substrate (structure of the heart). These
conditions may lead to reoccurrence of A-Fib after ablation.
In a Mayo Clinic study by Dr. Jared Bunch reoccurrence rates
were basically the same for patients under 50, between 50 and 65 years old, and
over 65. (Studies presented at the Heart Rhythm Society 2006 Scientific Sessions
in Boston, MA.
http://www.theheart.org/article/706883.do
May 24, 2006
Long-term Warfarin
Use Increases Risk of Bone Fracture in Men
The long-term use of warfarin
appears to increase the risk of bone fractures in men (not women). Warfarin
prevents coagulation by blocking the vitamin K-dependent activation of certain
clotting factors. Because vitamin K is also used to activate osteocalcin and
other bone matrix proteins, "vitamin K antagonists might increase the risk of
osteoporotic fractures." The study also found that taking beta-blockers
decreased the risk of fractures, perhaps because they increase bone mass. (Archives
of Internal Medicine, Jan. 23, 2006.)
http://www.medscape.com/viewarticle/522264
April 23, 2006
"Bottom Line Health," Vol. 20, number 5, May, 2006. "Aspirin vs. stroke.
Because aspirin can cause bleeding, it is typically avoided by people who have
had a hemorrhagic stroke, which occurs when a blood vessel bursts in the brain.
New Finding: In a study of 207 hemorrhagic stroke survivors, those who
took an antiplatelet drug, such as aspirin, were not at increased risk
for another hemorrhage. Implication: Aspirin therapy may be
appropriate for hemorrhagic stroke survivors who are at high risk for heart
attack or ischemic stroke, in which a blood clot blocks blood flow to the brain.
April 15, 2006
The Cleveland Clinic has an
E-Clinic Consult program that allows patients to receive a second opinion and
start the registration process at the Cleveland Clinic. In cooperation with your
cardiologist, all records pertaining to your A-Fib are sent to the C.C. for
evaluation. An extensive medical questioner is also completed. Then all the data
are evaluated by the C.C. cardiology staff. If deemed a candidate for ablation,
the pre-registration process is then completed, and a procedure date is given
for the ablation. The current fee is $565.
November,
2005
Veterinary
Antibiotic Lasalocid Found in Eggs and Poultry Meat May Trigger A-Fib
A recent report from England suggests that the veterinary
antibiotic "Lasalocid" found in eggs and poultry meat may cause or trigger
A-Fib.
Lasalocid is given as a feed supplement to certain farm
animals particularly poultry as a preventative treatment against "coccidiosis"---an
infectious disease caused by a parasite which damages the birds' intestines and
causes illness and sometimes death. Outbreaks of coccidiosis are likely to occur
when large numbers of animals are crowded together in warm and moist conditions.
Lasalocid is considered a "highly toxic heart poison. ...It belongs to a group
known as the ionophores, all of which are potent heart poisons many of which are
in regular use in animal feed."65
(Thanks to Richard Gee of the UK for providing this info.)
June, 2005 Dr. Moussa
Mansour of Massachusetts General Hospital reports that MGH now uses a mapping
system called Carto-Merge to do PVIs. This system incorporates an MRI (or
a CT) of the pulmonary veins with real-time electroanatomical mapping. This
image integration provides the operator with significantly better navigation of
the left atrium and thus a safer and more effective procedure.
January, 2004
Australia and New Zealand now have a doctor from the French Bordeaux group
practicing in Australia. Here is his address:
AUSTRALIA
Royal Perth Hospital
Wellington St., Perth 6000
Perth, Australia
(+618) 9224 2388
Fax: (+618) 9389 5261
E-mail: ruk(at)ziplip.com (the @ is written out as "at" to prevent it
from being accessed by spam mailing lists)
Dr. Rukshen Weerasooriya
April 25, 2003
Massachusetts General Hospital Tribute
to Dr. Brian McGovern
Brian McGovern, MD: Remembering a physician, colleague and friend
Every
seat in the O'Keeffe Auditorium was taken April 19. Two overflow rooms were
filled beyond capacity. The aisles of the auditorium were crowded with people
craning to see the podium and hear the words of remembrance for a beloved and
world-renowned cardiologist, Brian McGovern, MD (right), who was killed
April 8 in a senseless tragedy that stunned and saddened the hospital community.
The memorial service, which was designed for McGovern's patients, also included
colleagues, family, friends and MGH employees who came to hear eloquent words
and heartfelt messages about the man who touched so many lives in his
extraordinary 23-year career at the MGH.
"We can't put a good face on this terrible tragedy, but every time I think of
Brian –
which will be often –
I will aspire in that moment to be a little more patient, a little nicer, a
little more like the ideal that he personified," said David Torchiana, MD,
chairman and CEO of the Massachusetts General Physicians Organization. "If that
can happen a thousand times to all of us, maybe a million times over the years,
I believe this world might be a better place."
With McGovern's widow, Anne Jennings, MD, and one of their daughters, Caitriona,
in the audience, Torchiana introduced the service, which also included tributes
from physicians, colleagues, patients, friends and family members of McGovern.
While each shared personal anecdotes, tearful remembrances and even a few
light-hearted memories, a common theme surfaced: McGovern was a brilliant
physician who possessed the precious gift of genuine compassion and empathy for
all he came into contact with –
patients, friends and colleagues alike.
"When you met him, he made you feel like you were so important to him and that
he was so happy to see you," said Guillermo Sosa-Suarez, MD, a colleague of
McGovern's at St. Peter's Hospital in Albany, NY. "He drew people to him. They
liked him because of his skills as a physician and because of his personal
warmth."
During his tenure at the MGH, McGovern grew into a master clinician and was well
known as a doctor's doctor –
a physician who many colleagues confided in, consulted with and looked to for
advice and wisdom. He built one of the largest referral practices in New England
and was widely known as an expert in cardiac arrhythmia.
He was a sought-after lecturer, a highly respected teacher and, in addition to
his commitment to patient care, he devoted much time to important clinical
research. For many years, he served as medical director for the Ellison 10
Cardiac Step-Down Unit. Every Wednesday, McGovern traveled to Albany, NY, to see
patients at the highly successful outreach arrhythmia program that he had
founded and built. But beyond the impressive credentials and the lauded
achievements, McGovern was what Torchiana described as a "good man" who was
highly accomplished yet humble and self-effacing.
"Despite his incredible accomplishments, Brian never took himself too seriously,
which is what we loved most deeply about him," said Jeremy Ruskin, MD, a
colleague of McGovern's in MGH Cardiology and a close friend. "Everyone knew him
for his sense of humor, which was kind-hearted and borne of intelligence and
generosity. He was always funny, but his humor was never at anyone's expense. He
was able to defuse countless difficult situations with his humor."
For
Ruskin, this memorial tribute was a deeply personal one. Ruskin first met
McGovern in 1981 when the young medical school graduate came to the MGH from
Ireland to interview for a fellowship. During McGovern's training at the MGH and
his subsequent career, Ruskin grew to rely on him for his insightful medical
expertise and thoughtful advice. "Brian was my student, but he became my
teacher," said Ruskin. "I'll always be grateful for his friendship, his loyalty
and everything that he taught me. A piece of each of us is lost with Brian, but
a part of him is alive in all of us. As we try to take care of each other –
as he did so often for us –
we must continue the extraordinary work he did with such grace, skill and
generosity."
It is that extraordinary work of providing the highest quality patient care that
was honored by McGovern's patients, who also spoke of his compassion, caring and
commitment to the many people who walked into his exam room.
Bud Mueller, MD, was one of those patients. Mueller credited McGovern for saving
his life and saving the lives of thousands of other cardiac patients. "His
expertise and kindness gave and continue to give individuals and families the
ultimate gift –
the gift of time," he said. "His work improved beyond measure the quality of
time for patients by decreasing the anxiety that is part of the condition that
patients and their families must endure. Brian delved into his life's work in a
way that showed compassion, caring, respect, empathy and love. We should try to
do the same. If we can try to make the world a better place, we can honor Brian,
his wife, his children, his MGH team, and then Brian can live on in an important
way through each of us whose lives he enriched."
While McGovern touched the lives of many of his patients and his physician
colleagues, the staff of the Arrhythmia Service, Electrophysiology Laboratory,
the Ellison 10 Cardiac Step-Down Unit and the entire Cardiology Division also
are particularly feeling the void left by the loss of a cherished colleague and
friend.
Katie Lynch, RN, a nurse from Ellison 10, spoke of the profound impact McGovern
had made on the step-down unit staff, both professionally and personally. "He
cared for his patients with the utmost respect and compassion," she said. "He
elevated our practice to do our very best work. Personally, he made us better
because his happiness and love of life were evident and contagious. His presence
in our lives was a gift from God, and we will try to honor his memory by caring
for patients as he had taught us."
A tribute from a
friend and colleague
"The good physician
knows his patients through and through, and his knowledge is bought dearly.
Time, sympathy and understanding must be lavishly dispensed, but the reward
is to be found in that personal bond, which forms the greatest satisfaction
of the practice of medicine. One of the essential qualities of the clinician
is interest in humanity, for the secret of the caring of the patient is in
the caring for the patient."
- Francis Weld Peabody, MD, (1881-1927) renowned physician and teacher at
Harvard Medical School
"No
one I've met in my professional
life embodied these words more than Brian did."
- Jeremy Ruskin, MD
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