"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013


How A-Fib Damages Your Heart, Brain and Other Organs

A-Fib reduces the amount of blood flowing to the rest of your body by about 15%–30% and can have damaging effects.

That’s because the upper parts of your heart (the atria) aren’t pumping enough blood into the lower chambers of your heart (the ventricles). At the same time, your heart is working progressively harder and harder.

Here’s what can happen to your heart if you choose to just ‘live with Atrial Fibrillation”:

Don’t Just Live With Your A-Fib

Don’t listen to doctors who advise you to ‘live with A-Fib’ and who prescribe a lifetime on medication. Get a second opinion, or even a third! Educate yourself.

Seek your A-Fib cure!

Hybrid Surgery/Ablation Topic of the Multidisciplinary Arrhythmia Meeting (MAM)

Background: The Hybrid approach is an unusual team effort and is complementary in nature: the Surgeon works on the outside of the patient’s heart and the Electrophysiologist on the inside of the same patient’s heart.
Hybrid Surgery/Ablation is becoming an increasingly important and effective strategy for highly symptomatic patients with persistent atrial fibrillation or longstanding persistent atrial fibrillation who have failed one or two catheter ablations, and for the patient with a significantly enlarged left atrium. (Read more: Hybrid Surgery/Ablation.)

Multidisciplinary Arrhythmia Meeting (MAM)

Multidisciplinary Arrhythmia Meeting (MAM) GFXThe goal of MAM is to improve interaction between cardiologists and surgeons through multiple examples of cooperation in dealing with Atrial Fibrillation. [Note: In the past, it’s been a rare occurrence for a surgeon to work with a cardiac electrophysiologist.]

Zurich stamp GFX

Reporting for A-Fib.com

Cardiologists and surgeons from leading institutions in Europe, the US and Asia will discuss their experiences with hybrid simultaneous, hybrid stages, and multidisciplinary sequential approaches, and report their results.

Reporting from Zurich in September: I’ve been invited to attend this first Multidisciplinary Arrhythmia Meeting (MAM) by the organizers. I’ll be reporting on the key presentations and writing summary reports for our A-Fib.com readers.

Reduce Your Family’s Risk of Arrhythmia: Don’t Store Food in Plastic

The harmful chemical compound, BPA, may have been removed from many plastic bottles and food packaging, but “BPA-free” products may not be much safer.

The BPA chemical replacements, BPS and BPF, can also leach into food and beverages and may have the same impact on the human body (heart problems, as well as cancer, infertility and other health issues).

BPA Replacement Linked to Arrhythmias in Female Rats

Kinetic GoGreen Glasslock Elements food storage at A-Fib.com

Avoid BPS leaching: Use glass or ceramic containers to store or microwave food

A study published in the Journal Environmental Health Perspectives (Seltenrich) shows that the chemical compound BPS has nearly identical impacts on the cardiovascular system of rats as those previously reported for BPA. Researchers reported a link between BPS and irregular heartbeat. More research is needed.

What to Do: It Doesn’t Hurt To Be Cautious

Water bottle - Got A-Fib-Lets Talk at A-Fib.com

Aluminum water bottle at Spreadshirt.com

To reduce your risk of arrhythmia from BPS/BPF, decrease or eliminate your use of plastic storage containers for food or drink.

Drink from steel or glass containers, not plastic ones.

Don’t microwave your food in plastic containers. The heat from the microwave can separate BPA-like compounds from plastic containers, making them easier to ingest. If you must use plastic containers, avoid the microwave.

Ideally, just store food in ceramic, glass or stainless steel containers in the first place.

To read more, see the April 2015 TIME magazine article by Justin Worland, Why ‘BPA-Free’ May Be Meaningless.
References for this article

Conflicts of Interest—The Hidden Cost of Free Lunch for Doctors

by Steve S. Ryan, PhD, updated September 18, 2016

Few people in the U.S. today are shocked or scandalized that the Drug and Device Industry (DDI) basically bribes doctors and hospitals to prescribe their drugs or use their equipment. It’s so commonly done that we take it for granted.

In the U.S., in general, it isn’t considered unethical or immoral for doctors to accept payments or favors from the Drug and Device Industry (DDI). Nor is it illegal.

But soon U.S. patients will be able to simply type in our doctor’s name in the Open Payments Database and see how much they are being paid by the DDI and what conflicts of interest they have.

Open Payments DataThanks to the Sunshine Act (a provision of the U.S. 2010 Patient Protection and Affordable Care Act), the DDI must report when they make a payment to a doctor for meals, promotional speaking or other activities.

This data is available at https://projects.propublica.org/docdollars/ Just type in your doctor’s name. See also, OpenPaymentData.CMS.gov and the ProPublica Dollars for Docs project.

Influencing Doctors’ Prescriptions for the Price of a Meal

In a recent JAMA Internal Medicine report (DeJong, C., June 2016), the authors compared meal payments to doctors with the drugs they prescribed to Medicare patients.

Even doctors who accepted only one free meal were more likely to prescribe the brand name drug.

Not surprisingly, they found that physicians who accept free meals from a drug company are more likely to prescribe that company’s brand name drugs rather than cheaper (and usually more proven) generic drugs. This study only focused on physicians who received meals.

Even doctors who accepted only one free meal were more likely to prescribe the brand name drug. Doctors who accepted four or more meals were far more likely to prescribe brand name drugs than doctors who accepted no meals. Furthermore, doctors who accepted more expensive meals prescribed more brand name drugs.

In another related JAMA Internal Medicine report (Yeh, JS, June 2016), researchers found similar evidence that industry payments to physicians are associated with higher rates of prescribing brand-name statins.

Steer Clear of Conflicts of Interest

The publication, Bottom Line Personal, offered words of wisdom on this subject.

“Studies have found that when there is a conflict of interest, it is almost impossible for even well-meaning people to see things objectively.”

Dr. Dan Ariely of Duke University described how, if a doctor must choose between two procedures, they are likely to pick the one that has the better outcome for their bottom line.

“That doesn’t mean the doctor is unethical…it just means he is human. We truly seem to not realize how corrosive conflicts of interest are to honesty and objectivity.”

He advocates that we steer clear of people and organizations with conflicts of interest “because it does not appear to be possible to overcome conflicts of interest.”

Conflicts of Interest: Be Suspicious of Doctors

Doctors are only human. If a drug rep gets them great tickets to a sporting event, for example, of course they will be inclined to favor that rep’s drug.

Whenever you visit a health/heart website ask yourself: “Who owns this site?” and “What is their agenda?”

But be suspicious if your doctor tells you:

• to take an expensive new drug
• to just “live with your A-Fib”
• insists that catheter ablation is too dangerous or unproven
• that A-Fib can’t be cured
• that you have to take drugs for the rest of your life

If this happens to you, RUN and get a second opinion (and even a third opinion).

Conflicts of Interest: Be Suspicious of Health/Heart Websites

When I attend talks at most A-Fib conferences, the first slide a presenter shows is often a list of their Conflicts of Interest.

But this is not required of websites! Health/Heart websites are not required to be transparent and reveal their conflicts of interest.

Whenever you visit a health/heart website ask yourself: “Who owns this site?” and “What is their agenda?” (Hint: Check their list of “sponsors” and follow the money!)

Drug Industry Owns or Influences Most Heart/Health Web sites

The drug and device industry owns, operates or influences almost every health/heart related web site on the Internet!

The fact is most health/heart web sites are supported by drug companies who donate most of their funding.

For example, did you know that the drug company Ely Lilly partially owns and operates WebMD, the Heart.org, Medscape.com, eMedicine.com and many other health web sites?

The fact is that most health/heart web sites are supported by drug companies who donate most of their funding. Consider how that may affect the information they put on their web sites―they’re not going to bite the hand that feeds them.


About A-Fib.com: Read A-Fib.com disclosures on our website and check
A-Fib.com’s 990s at GuideStar.org.

Be Suspicious of A-Fib Info on the Internet

Steve Ryan video at A-Fib.com

Video: Buyer Beware of Misleading or Inaccurate A-Fib Information.

In our crazy world, you can’t afford to trust anything you read on the Internet.

At one time I tried to keep track of all the mis-information found on various A-Fib web sites. When we’d find something wrong, we would write the site. I don’t think we’ve ever received a reply. Finally, we gave up. (See my video: Buyer Beware of Misleading or Inaccurate A-Fib Information.)

Many web sites put out biased or mis-information. Be skeptical. You can tell if someone is trying to pull the wool over your eyes. Truth will out. If you feel uncomfortable or that something is wrong with a site, it probably is. When you find a good site, the truth will jump out at you.

In today’s world, you have to do your own due diligence. You know what makes sense and what doesn’t.

For more, see my article: EP’s Million Dollar Club—Are Payments to Doctors Buying Influence?

References for this article


Wearables in Healthcare: You can Help Develop A-Fib App

It’s early days for wearables in healthcare, but there’s a lot of potential.

In the near future, an Apple Watch or Android Wear could detect if the wearer is experiencing Atrial Fibrillation. A preliminary algorithm (app) to detect A-Fib has been developed by researchers at UCSF and engineers at Cardiogram, Inc.

Sample of A-Fib app on Smart Watch

Sample of A-Fib app on Smart Watch

The mRhythm Study: You Can Help Develop the Smart Watch App

The researchers need your help now. If you have an Apple Watch or Android Wear—regardless of whether you have A-Fib—you can contribute your data to help make the algorithm more accurate.

The mRhythm Study is being run with the UCSF Health eHeart Study, using Cardiogram to train a deep learning algorithm to detect atrial fibrillation.

To Participate in the Study: Visit the mRhythm Study website and scroll down the page and look for ‘We Need Your Help.’ At the bottom of the page, you can then read answers to ‘Frequently Asked Questions’.

See How the System Works: To see the graphic displays of how the system works, go to Cardiogram, Inc. or see the Apple Watch graphics in particular.

mrhythm graphic 400 x 175 pix at 300 res

What atrial fibrillation and normal heart rhythm look like when measured on a watch.

What This Means for Patients

Each year, more than 100,000 strokes are caused by A-Fib. But all too often, their A-Fib is “silent” with no obvious or noticeable symptoms. In these cases, their A-Fib is undiagnosed until they have a stroke. Only then do they find out they have A-Fib (…if they survive). About 50% will have a disabling stroke.

Apple Watch owners—regardless of whether you have A-Fib—you can contribute your data to help develop this app. 

If the Smart Watch algorithm app works as intended, anyone with an Apple Watch or Android Wear will be alerted if they are experiencing Atrial Fibrillation.

For the undiagnosed, their A-Fib will be ‘visible’ and no longer be “silent.” They will know if they are at risk of an A-Fib stroke and can get the proper preventive treatment.

Today patients rely on an ECG in a doctor’s office or the use of a Holter monitor to detect A-Fib. Instead, a Smart Watch with the A-Fib app can extend a patient’s monitoring period to a year (between doctor’s visits) or on an on-going basis.

Amazing! Think of all the lives saved and debilitating strokes avoided! The A-Fib Smart Watch app has the potential to revolutionize the field of A-Fib monitoring.

References for this article


New Report: Is Your Stroke A-Fib-Related or Something Else?

Third in my series from the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Read my other reports here.

If you have A-Fib, it’s important to realize that not all strokes are ‘A-Fib related’. You may be perfectly anticoagulated or have a Watchman Device installed and still experience a stroke.

Realize: an A-Fib patient can have a stroke that isn’t caused by A-Fib.

Dr. Jennifer Majersik of the Stroke Center of the Un. of Utah described the case of a man with A-Fib who had an ischemic stroke even though his INR on warfarin was in the correct range.

An A-Fib patient can have a stroke that isn’t caused by A-Fib. There are multiple mechanisms which can cause a stroke. Of the 690,000 strokes in the US/year nearly 1/3 are cryptogenic (of unknown cause) and of those 30% is caused by asymptomatic or Silent A-Fib.

Read my full report in which Dr. Majersik described five subtypes of artery occlusion strokes (as opposed to hemorrhagic [bleeding or vessel rupture] strokes.) <…continue reading…>


65 and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?

In a  recent study, 99% of subjects aged 65 or older had evidence of microbleeds; and closer examination of the cranial MRI images revealed an increased number of detectable microbleeds (i.e., the closer they looked, the more microbleeds they found).

Microbleeds in the brain are thought to be a precursor of hemorrhagic stroke.

Cerebral microbleeds (MBs) are small chronic brain hemorrhages of the small vessels of the brain.

If Microbleeds Cause Hemorrhagic Stroke, Should I be on a Blood Thinner?

The fact that almost everyone 65 or older has microbleeds is astonishing and worrisome, particularly if you have A-Fib and have to take anticoagulants. Anticoagulants cause bleeding. That’s how they work.

In plain language, this study indicates that cerebral microbleeds lead to or cause hemorrhagic stroke. It’s not surprising then that some doctors are reluctant to prescribe heavy-duty anticoagulants to older A-Fib patients.

Being older and already having microbleeds only makes taking anticoagulants all the more worrisome.

Risks of Taking Anticoagulants (Blood Thinners)

Taking most any prescription medication has trade-offs. Older A-Fib patients find themselves between a rock and a hard place.

In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding.

For those over 65 who already have microbleeds, … Continue reading this report…->

Brush & Floss! Is Oral Hygiene Linked to A-Fib?

Warren Welsh, from Australia, answers ‘Yes’ to that oral hygiene question. He wrote me about how he developed bleeding gums and felt it contributed to his Atrial Fibrillation diagnosis. (A 2010 catheter ablation made him A-Fib free. Read Warren’s story.)

Brush and floss regularly we were taught as kids, but who knew that oral hygiene is linked with A-Fib?

Dental Cleanings and New-Onset A-Fib

A study in Taiwan compared a group without A-Fib who received dental cleaning at least once a year to a similar group who didn’t. Both groups were followed for five years. The regular dental cleanings group had a lower occurrence rate of new-onset A-Fib.

More frequent dental visits (2-3 times a year) further reduced the risk.

Graphic of tooth A-fib.com

Good Oral Hygiene Reduces Inflammation

Studies have shown that inflammation is an independent risk factor both for the initiation of A-Fib and its continuation once you have it.

Good oral hygiene prevents A-Fib, probably by reducing the amount of inflammation of the gums and periodontitis (gum disease).

Take Away

Good oral hygiene reduces the risk of new-onset A-Fib and of sustaining it once you’ve got it.

For more about A-Fib and dental health, read my FAQ question about Local Anesthesia Used in Dentistry May Trigger Your A-Fib.

References for this article

Your Records: Will You be Charged for Copies?

Before meeting with a new electrophysiologist (or surgeon), you’ll want to send (or take along) a packet with your medical records, test results and any images/X-rays, but you may be missing some medical records.

HIPAA stands for the U.S. Health Insurance Portability and Accountability Act of 1996.

What They Can and Can’t Charge You

When requesting copies of your medical records, expect to pay duplication costs for hard copies. In the U.S., HIPAA regulations allows doctors/practices to charge a “reasonable, cost-based fee.”  They can charge for supplies, staff time for copying and processing, and mailing costs, if applicable.

However, they may not charge for the time a staff member spends searching for the record. In addition, they should not adopt a policy of charging a flat fee or charging a patient to view a record.

Pill-shaped USB flash drive

Copy digital files to a USB flash drive

No-Cost Copies?

To save money, ask your doctors or medical center if they will copy electronic files to your USB Flash drive or to a disc/CD you supply.

“But I Live Outside the U.S.”

If you live outside the US, know that over 89 countries have adopted Data Privacy Laws that apply to patient records. For example, Canada has the Personal Information Protection and Electronic Documents Act (PIPEDA) and in Europe there’s the EU Data Protection Reform. To learn more, research your country’s data privacy laws.

Continued Reading: 3 Ways to Request Copies of Your Medical Records.

Blizzard of 2016 Increases Risk of A-Fib Stroke

We’ve all heard of someone dropping dead from a heart attack while shoveling snow. But along with record snowfall and subfreezing temperatures comes a warning for those with Atrial Fibrillation. Winter increases stroke risk in people with A-Fib.

Winter and increased risk of stoke at A-Fib.com

Winter: increased stroke risk

Do You Live in a Cold Climate?

In a study from Taiwan, nearly 300,000 people with new-onset A-Fib were followed for eleven years. Almost 35,000 suffered an ischemic (A-Fib) stroke.

The risk for an ischemic stroke was nearly 20% higher in winter than in summer.

“When the average temperature was below 68⁰ F (20⁰C), the risk of ischemic stroke significantly increased compared to days with an average temperature of 86⁰F (30⁰C).”

Why More Ischemic Strokes During Winter?

Cold weather may make blood more prone to coagulate.

Cooler temperatures may produce greater plasm fibrinogen levels and factor VII clotting activity and may lead to “increased coagulability and plasma viscosity,” according to the author of this study, Dr. Tze-Fan Chao. 

Ischemic stroke was nearly 20% higher in winter than in summer.

What Patients Need To Know

The cold temperatures can put you more at risk for an A-Fib (Ischemic) stroke. So act accordingly. Bundle up during winter. Keep the thermostat set to keep you warm enough.
If you’re on a blood thinner, discuss this research with your doctor. You need to keep your anticoagulant levels up during winter.
References for this article

My 2015 Top Five List: Advancements in the Treatment of A-Fib

Looking back over 2015, I found five significant developments for those ‘living’ with A-Fib and those seeking their ‘cure’. My ‘Top Five List’ focuses on the Watchman device, a Pradaxa antidote and research findings about lifestyle choices, and reducing fibrosis.

1. FDA Approves the Watchman Device

The Watchman occlusion device

The Watchman is positioned via catheter

Anticoagulant Alternative: Because A-Fib patients are at high risk of stroke and clots, a blood thinner (anticoagulant) like warfarin is often prescribed. If you can’t or don’t want to be on blood thinners, you had few options.

That was until March 2015 when the US Food and Drug Administration (FDA) approved the Watchman device. There’s now an option to blood thinners! The Watchman device (Boston Scientific) is inserted to close off the Left Atrial Appendage (LAA), the origin of 90%-95% of A-Fib clots.

To read my complete Top Five List…go to My 2015 Top Five List: A Review of Advancements in the Treatment of A-Fib->.

My 2015 Top Five List: A Review of Advancements in the Treatment of A-Fib

2015 in Review at A-Fib.comWith the beginning of a new year, we often look back and measure how far we’ve come. In 2015, I found five significant advancements in the treatment of Atrial Fibrillation.

1. FDA Approves the Watchman Device

The Watchman occlusion device

The Watchman is positioned via catheter

Anticoagulant Alternative: Because A-Fib patients are at high risk of stroke and clots, a blood thinner (anticoagulant) like warfarin is often prescribed. If you can’t or don’t want to be on blood thinners, you had few options.

That was until March 2015 when the US Food and Drug Administration (FDA) approved the Watchman device. There’s now an option to blood thinners! The Watchman device (Boston Scientific) is inserted to close off the Left Atrial Appendage (LAA), the origin of 90%-95% of A-Fib clots.

It’s not an absolute guarantee you will never have a stroke―but neither is taking warfarin or the newer anticoagulants. For more, see Watchman Device: An Alternative to Blood Thinners.

2. Research: Watchman Better Than a Lifetime on Warfarin

Warfarin - Coumadin tablets various dosages

Warfarin (Coumadin)

The Watchman device isn’t simply an alternative to taking warfarin, clinical trials show it’s actually better. Patients with the Watchman had fewer hemorrhagic strokes and less bleeding compared to patients on warfarin. (Warfarin and other anticoagulants work by causing bleeding and are inherently dangerous.)

It’s too early to say the same about the newer anticoagulants like Pradaxa, Xarelto, Eliquis and Savaysa/Lixiana with their short history but one would expect the same general principles to apply. For more, see Watchman Better Than Warfarin.

3. Antidote for Pradaxa

Praxbind - antidote to Pradaxa

Praxbind: Pradaxa antidote

Up to now, patients on Pradaxa have been bleeding to death in the emergency room while doctors were powerless to stop their bleeding and could only stand by and watch them die. See Stop Prescribing or Taking Pradaxa.

In October 2015, the FDA granted “accelerated approval” to Praxbind, the reversal agent (antidote) to Pradaxa (Boehringer Ingelheim). Praxbind (idarucizumab) is given intravenously to patients and reverses the anticoagulant effect of Pradaxa within minutes.

Note: The reversal agent, Andexanet Alfa, is on FDA fast track and is expected to be approved by mid-2016 as an antidote for Xarelto and Eliquis (Factor Xa inhibitors).

4. Life Style Changes Can Make Some People A-Fib Free



Weight Loss: A weight loss program and counseling in Australia has worked so well that some patients have become A-Fib free.

In his Adelaide clinic, Dr. Prashanthan Sanders convinces his overweight A-Fib patients to buy into the program, lose weight, and keep it off.  This holistic approach to health has also been successfully applied to other A-Fib contributing factors such as diabetes, sleep apnea, hypertension, binge drinking and smoking. See Weight Loss Key to Reverse Atrial Fibrillation, Improve Ablation Success.



Exercise: But not everyone can lose weight and keep it off. And other risk factors like hypertension and diabetes are more difficult to permanently change.

The same Australian researchers found that exercise improves A-Fib (even obese A-Fib patients benefit from exercise). Supervised aerobic and strength exercises reduced A-Fib by 84%.

Combine for Best Results: Exercise and weight loss together produced the best results. An astounding 94% of obese patients who both lost weight and exercised regularly were A-Fib free after rhythm control therapy (i.e., antiarrhythmic drugs and/or catheter ablation).

Couch Potato Warning: If you don’t exercise regularly, you’re almost guaranteed to stay in A-Fib. Even with rhythm control (antiarrhythmic drugs and/or ablation), 83% of the low-fitness obese patients had A-Fib.

5. Research Studies: Preventing Fibrosis

Fibrotic cells - 2008 Boston A-Fib Symposium Kottkamp

Fibrotic cells

A-Fib produces fibrosis, and up to now, was considered permanent and irreversible. Fibrosis is fiber-like scar tissue that stiffens and weakens the heart muscle which reduces pumping efficiency and leads to other heart problems.  (See Fibrosis and A-Fib).

Dr. Jose Jalife’s experimental studies with sheep found that a Gal-3 inhibitor (GM-CT-01) actually reduced or prevented fibrosis. Better yet, instead of having to wait years for possible FDA approval, a natural supplement, Pecta-Sol C (Modified Citrus Pectin) works like a Galectin-3 inhibitor.

For A-Fib patients, this may provide the means to avoid fibrosis or repair fibrotic heart tissue. (See Galectin-3 Inhibitor Prevents A-Fib).

A Personal Prediction

WATCHMAN device at A-Fib.com


On a personal note, I’m excited about the great potential of the Watchman device to significantly reduce or eliminate the threat of strokes—especially in the elderly―even if they don’t have A-Fib.

Imagine a world where stroke risk could be eliminated by a simple 20-30 minute procedure. The Watchman device (and other occlusion devices) may change the way elderly medicine is practiced.

If you find any errors on this page, email us. Y Last updated: Thursday, January 21, 2016

Report: FIRM Mapping System—Should Ablation Patients Avoid It?

The FIRM mapping system was a hot topic at the last annual AF Symposium. In his presentation Dr. Ravi Mandapati compared data from his study of FIRM ablations performed at UCLA Medical Center to the CONFIRM clinical trial data published by Dr. Sanjiv Narayan, one of the inventors of the FIRM mapping system.

Topera-FIRMap catheter - three sizes

Topera-FIRMap catheter (three sizes)

Up to this point in time, everyone seemed to be jumping on the FIRM/Topera ‘bandwagon’ with very little critical analysis or understanding of how it worked.

As patients, we should now be skeptical of the FIRM system:

• It doesn’t map nearly ½ of the left atrium
• The FIRM mapping algorithms finds stable rotors that other research finds are not stable, and electrophysical characteristics that other research doesn’t confirm
• Results of ablating FIRM-identified rotor sites are relatively poor. (This is what should most concern us as patients.)

So, as an A-Fib patient, you may ask: “Should I now stay away from doctors or centers using the FIRM system?” Read my answer and my full 2015 AF Symposium report at Critical Analysis of the FIRM Mapping System.

For more background also see my 2014 AF Symposium report: ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping.

Is Cryoballoon as Effective and Safe as RF Ablation? A Clinical Study

There have been few randomization trials directly comparing CryoBalloon ablation to RF ablation.

That’s why Dr. Armin Luik and his colleagues developed the FreezeAF clinical trial―to directly compare CryoBalloon ablation to RF ablation for treating patients with paroxysmal atrial fibrillation. Dr. Luik (U. of Freiburg, Karlsruhe, Germany) presented the study results at the May 2015 meeting of the Heart Rhythm Society.

CryoBalloon catheter

CryoBalloon catheter

FREEZEAF Trial: Patients and Method

In the FREEZEAF study, 315 paroxysmal A-Fib patients with a mean age of 60 years were randomized to either a CryoBalloon ablation (n=156) or a RF ablation (n=159) of the pulmonary veins. Clinical follow up was at three, six, nine and 12 months.

The FREEZEAF Study Results

The FreezeAF trial researchers noted that a number of CryoBalloon ablation studies have demonstrated its efficacy and safety for treatment of A-Fib, but few studies have compared the two techniques head-to-head.

How did Cryoballoon compare to RF Ablation? … Continue reading this report…->

The Risk of Dementia Caused by A-Fib―20 year Study Results

Atrial Fibrillation (A-Fib) has been suggested as a risk factor for dementia since A-Fib can lead to a decrease of blood supply to the brain independent of stroke.

Other long-term studies evaluating the link between A-Fib and dementia have shown inconsistent results.

Study Patients and Method

In a 20-year observational study of participants in the long-term Rotterdam Study, researchers tracked 6,514 dementia-free people. Researchers were monitoring participants for dementia and Atrial Fibrillation (A-Fib). 

“The Rotterdam Study” is a long-term study started in 1990 in Rotterdam, The Netherlands. Cardiovascular disease is just one of several targeted diseases. Since 2008 it has 14,926 participants.

At the start of the study (baseline), 318 participants (4.9%) already had A-Fib.


During the course of the 20-year study, among 6,196 people without established A-Fib:

• 723 participants (11.7%) developed A-Fib, and
• 932 participants (15.0%) developed incident dementia.
• Development of A-Fib was associated with an increased risk of dementia in younger people (<67 years old).
• Dementia risk was strongly associated with younger people (<67 years old) who developed A-Fib but not strongly associated in the elder participants who developed A-Fib.

The authors concluded… Continue reading

Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin

by Steve S. Ryan, PHD, October 2015, Updated January 26, 2016

According to recent studies, you are better off having a Watchman device installed than spending a lifetime on warfarin.


WATCHMAN device for Left Atrial Appendage Closure

In two randomized clinical trials comparing Left Atrial Appendage Closure (LACC-Watchman Device) to warfarin, 1,261 patients from the PROTECT AF and PREVAIL trials were studied. The follow-up period was around 3.3 years. Patients receiving the Watchman compared to patients on warfarin had significantly fewer:

• Hemorrhagic strokes
• Cardiovascular/unexplained death
• Non-procedural bleeding
• All-cause stroke or systemic embolism was similar between both strategies.

There were more ischemic strokes in the Watchman device group, but this was balanced by a greater number of hemorrhagic strokes in the Warfarin group.

Warfarin - Coumadin tablets various dosages

Warfarin (Coumadin) various dosages

However, the patients in the control group of the PREVIAL trial were considered “unusual” in that, given their risk profile, they had a much lower ischemic stroke rate than ever observed in any clinical trial. See Getting FDA Approval for the Watchman Device.

What Patients Need to Know: Watchman Actually Better Than Warfarin

The Watchman device provides similar protection against having an A-Fib (ischemic) stroke as being on warfarin.

But the Watchman device isn’t simply an “alternative” to warfarin, but rather an improvement or advance or progression. One would intuitively expect that people receiving the Watchman device would also have less hemorrhagic strokes and bleeding compared to those on warfarin, which these studies do demonstrate.

Welcome Alternative to a Lifetime on Warfarin

Warfarin and other anticoagulants work by causing bleeding and are inherently dangerous. The Watchman device is not only a welcome alternative to a lifetime on warfarin, but is actually better than warfarin.

Long-term use of anticoagulants such as warfarin have been known to not only cause hemorrhagic strokes but also microbleeds in the brain which lead to dementia.

Among other bad side effects, long-term use of anticoagulants such as warfarin have been known to not only cause hemorrhagic strokes but also microbleeds in the brain which lead to dementia. See Patient on Anticoagulation Therapy for 10 Years Develops Microbleeds and Dementia.

A 2015 study found evidence of microbleeds in 99% of subjects aged 65 or older, and that increasing the imaging strength increased the number of detectable microbleeds. Microbleeds have been suggested to be predictive of hemorrhagic stroke.

According to current research, you are better off having a Watchman device installed than spending a lifetime on warfarin. (Of course, this assumes that the doctor performing the procedure is beyond his/her learning curve. That is, when operating doctors are first performing the procedure, there is a higher risk for procedural complications.)

What About the New Anticoagulants (NOACs)?

Does this research apply to the new anticoagulants like Pradaxa, Xarelto, Eliquis and Savaysa/Lixiana? Technically no. This research only applies to warfarin. But intuitively one would expect the same general principles to apply. All anticoagulants cause bleeding. That’s how they work.

Caveat—Long-Term Effects of Watchman?

What are the long-term effects of leaving a mechanical device like the Watchman inside the heart? We know that, after a few months, heart tissue grows over the Watchman device so that the LAA is permanently closed off from the rest of the heart.

It seems unlikely that complications would develop after a long period of time as has happened with warfarin. But we can’t say that for sure until enough time has passed. The first clinical trial installation of the Watchman device in the US was in 2009 and in Europe in 2004. So far no long-term complications have developed.

CT Brain scan showing Ischemic Stroke

CT Brain scan showing Ischemic Stroke

Preventing Stroke in the Elderly—Even If They Don’t Have A-Fib!

One of the great potentials of the Watchman device is that it may someday be used to prevent stroke in the elderly even if they don’t have A-Fib. Imagine a world where you no longer live in fear of a stroke as you get older, where 90%-95% of stroke risk can be eliminated by a simple 20 minute procedure. The Watchman device (and other Left Atrium Occlusion Devices such as the Lariat and the surgical AtriClip) may change the way elderly medicine is practiced.

How many people turning 70 or 75 would welcome a device that would almost guarantee freedom from the most severe type of ischemic stroke (a cardioembolic stroke)? The Watchman device has the potential to greatly reduce or eliminate the threat of strokes in the elderly!

References for this article

Resveratrol Reduces A-Fib Episodes in Animal Studies

Resveratrol is a natural and safe compound found in certain plants, has antioxidant properties and is known to improve cardiovascular health. It is found in red wine, red grape skins and seeds, peanuts and other foods.

Photo by Stoonn

Photo by Stoonn

A new medicine based on resveratrol, a ‘resveratrol derivative compound 1’ (C1), was effective in reducing the duration of A-Fib episodes in animal studies.

Dr. Peter Light of the University of Alberto, Edmonton, Canada published this study in the British Journal of Pharmacology. (This resveratrol research was funded by the Canadian Institute of Health Research and TEC Edmonton, with additional support from the Center for Drug Research and Development.)

How Does Resveratrol Work?

‘Resveratrol derivative C1’ seems to work by targeting multiple pathways involved in A-Fib, not just one or two as is the case with many current A-Fib drugs. These pathways include several ion channels as well as “pathways that cause adverse restructuring of the atria that may lead to A-Fib.”

Dr. Light thinks that the first in-human trials of ‘resveratrol C1’ may start in two-to-five years.

It’s highly unlikely that the ‘resveratrol derivative C1’ will be significantly better than natural resveratrol.

What This Means to A-Fib Patients

What’s important in this animal study is that a type of resveratrol reduced the duration of A-Fib episodes.

The beneficial effects of Resveratrol on cardiovascular health is well-documented. But, its usefulness for A-Fib patients requires more research. It’s possible Resveratrol could work as a ‘pill-in-the-pocket’ to reduce the duration or stop A-Fib episodes without the need for antiarrhythmic drugs.

Sources of Resveratrol

You don’t have to wait for Dr. Light’s trials to benefit from Resveratrol. (It’s highly unlikely that the ‘resveratrol derivative C1’ will be significantly better than natural resveratrol.) Resveratrol occurs naturally in red wine, red grape skins and seeds, grape juice, peanuts, mulberries, and some Chinese herbs. Resveratrol supplements are also available.

Caution: Resveratrol supplements could interact with medicines like blood thinners, blood pressure drugs, NSAID painkillers, and supplements like St. John’s wort, garlic, and ginkgo.

Talk with your doctor or healthcare provider before adding Resveratrol supplements to your diet.

To learn more about Resveratrol as a supplement, go the Memorial Sloan Kettering Cancer Center/Integrative Medicine database, About Herbs, Botanicals & Other Products, Resveratrol.

NOTE: In the US, substances found in nature like resveratrol cannot usually be patented by pharmaceutical companies and thus be under the control of the FDA. (This isn’t the case in other countries where natural substances are often regulated like drugs and consequently are often difficult to obtain.)

However, pharmaceutical companies can sometimes get around this restriction by making a change in the structure of a natural substance. Now it can be patented because it is no longer ‘natural’. Then it’s up to pharmaceutical reps to convince doctors to prescribe the patented version rather than the natural (and cheaper) substance.

References for this article

Case Studies: Testosterone Cures A-Fib in Aging Men

Much media attention has been paid to the importance of testosterone in men and how testosterone levels tend to decrease with aging. But few studies have looked at how low testosterone affects A-Fib and A-Fib stroke risk.



Low Testosterone Can Cause or Trigger Stroke

Low Testosterone can be responsible for or trigger acute ischemic stroke, stroke severity, and related death in men, according to Dr. George Eby of the George Eby Research Institute. Low testosterone is also associated with coronary disease, myocardial infarction (heart attack) in men, and with all-cause mortality in men.

Case Studies: Testosterone Cures A-Fib in Aging Men

In an article in the journal, Cardiology, Dr. Eby described cases where Testosterone Therapy (TT) made aging men A-Fib free.

Case #1:  A 59-year-old man with a low Testosterone level of 361 ng/dl had daily A-Fib episodes for the last year. Other than PACs, he had no other heart problems.
Within 45 days of daily Testosterone Therapy (TT), his serum Testosterone rose to 1,489 ng/dl, and he had no instances of A-Fib and very few PACs. (After the second week of TT, his INR increased from 2.5 to 5.4 which required his Warfarin dosage to be lowered.)
 Case #2: A 59-year-old man had strongly symptomatic nocturnal paroxysmal A-Fib and depression. His serum Testosterone was only 150 mg/dl which is much lower than normal. Previously he had had congestive heart failure and persistent A-Fib which had been treated with ablation and cardioversion.
 He received both DHEA (25 mg/day) and natural testosterone (50 mg/day) as a gel applied to his shoulders. After Testosterone Therapy, his depression and ectopics ended with only two observed instances of A-Fib after two weeks.

Dr. Eby’s Conclusions

• “Testosterone Therapy (TT) is necessary, safe, and superior to antiarrhythmic drugs, and may prevent A-Fib and stroke in aging men.” According to Dr. Eby, “TT is a necessary, superior and safe natural rhythm treatment for A-Fib.” “TT may play an important role in treating A-Fib and preventing stroke in aging men.”

• “Testosterone is low in men with Lone A-Fib.” Testosterone has been shown to be low in men with lone A-Fib compared to non-A-Fib controls.

• “Beta-blockers lower testosterone [levels] in men.” Dr Eby also pointed out that beta-blockers lower testosterone in men.

• “Low Testosterone is a risk factor for stroke and death in men.” Testosterone is an independent risk factor for acute ischemic stroke, stroke severity, and related death in men. Low Testosterone is also associated with coronary disease and with myocardial infarction (heart attack) in men, and with all-cause mortality in men.

What This Means to Male A-Fib Patients

These may be the first reported cases of Testosterone Therapy for A-Fib and to prevent stroke in men. Obviously more research then a few case studies needs to be done on this subject.

If you are an aging man with A-Fib, you should have your Testosterone level checked. And for those with low Testosterone, raising your level, besides making you feel better and more youthful, may also prevent A-Fib and stroke.

References for this article

A-Fib Non-PV Triggers Predict Need for Multiple Ablations

Could the necessity for multiple ablation procedures be predicted? According to a new research study, the answer is YES!

In a study of patients who had catheter ablation of the Pulmonary Veins (PVs) for paroxysmal (occasional) A-Fib, 8% had to have more than two ablations to be A-Fib free.

The only independent predictor of the need for multiple procedures was the presence of non-PV triggers. According to this research, EPs should check for non-PV triggers such as at the ligament of Marshall.

This 2015 published study was done before the widespread use of Contact Force sensing catheters which seem to have reduced recurrence and the need for multiple ablation procedures.

What This Means to Patients

The lesson to be learned from this study: When having an ablation, make sure your Electrophysiologist (EP) is experienced at tracking down (mapping) and ablating (isolating) non-PV triggers.

For example, I recently read an O.R. (Operating Room) report of a patient who, after isolating the PVs, was still in A-Fib. Instead of looking for non-PV triggers, the EP just electrocardioverted the patient back into sinus rhythm. This does sometimes work. But not in this case. The ablation failed.

This is particularly important for EPs doing CryoBalloon ablations.

Arctic Cryoballoon Catheter

Arctic Cryoballoon Catheter

Find EPs Experienced at Ablating Non-PV Triggers

When getting a CryoBalloon ablation, you need to find an EP who is willing to do more than just isolate your PVs—someone who will put out the extra effort to find and ablate non-PV triggers such as at the ligament of Marshall.

To do this, your EP may have to replace the CryoBalloon catheter with an RF catheter to ablate these non-PV triggers. This may require mapping and ablation skills not all EPs have.

What to Ask Prospective EPs

To find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?

(You want to hear they’ll search for and ablate non-PV triggers.)

For more about Ablating Non-PV Triggers, see my article: CryoBalloon Ablation Study: 30% of Patients Required RF to Achieve Isolation

See the glossary for Ligament of Marshall.

References for this article

FAQs A-Fib Drug Therapy: Hormone Replacement Therapy and A-Fib

 FAQs A-Fib Drug Therapy: HRT

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

22. Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?”

Intuitively one would expect that, if properly administered, HRT would have good effects like decreasing menopause symptoms, improving bone density, improving cardiovascular health, etc. HRT might reduce the risk of A-Fib by improving a woman’s overall health. But research on this topic isn’t all that clear. I found two contradictory studies.

Danish Study 2012: I found one Danish observational research study that HRT was associated with a decreased risk on new-onset A-Fib in women who had had a heart attack. They looked at 32,925 women and followed them for a year after discharge from the hospital after a heart attack. New onset A-Fib was diagnosed in 1,381 women (4.2%). But A-Fib rates decreased significantly if the women were on HRT (37.4 incidence rate vs. 53.7 for no HRT use).

Womens Health Initiative Study: Another observational study found a “modest” link of HRT to Atrial Fibrillation. These results were somewhat unusual in that women [with a hysterectomy] taking estrogen alone had a higher rate of A-Fib. But women with an intact uterus taking estrogen plus medroxyprogesterone didn’t have a significantly higher rate of A-Fib.

The lead author, Dr. Marco V. Perez, described how anecdotally women say that at certain times-during a period, pregnancy, or menopause-their arrhythmias can flare up. Hormones may play a role in A-Fib in women. Dr. Perez said he would now add A-Fib to the list of risks associated with taking HRT.

Takeaway: These two studies obviously contradict each other. But the results in the Dr. Perez WHI research were so “modest” and even contradictory that, when making decisions about HRT, we should probably favor the Danish study. However, much more research needs to be done in this area. If properly administered HRT improves your overall health, that might decrease your risk of developing A-Fib.

(I am way out of my comfort zone discussing womens’ health and HRT and would welcome comments from women or from anyone with insights about this topic.)

References for this article

Last updated: Monday, September 28, 2015

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