ABOUT 'BEAT YOUR A-FIB'...


"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"



ABOUT A-FIB.COM...


"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


Pacemakers & ICDs

With 3-4 Second Pauses, Do I Need a Pacemaker?

We’ve answered a new FAQ about understanding A-Fib with long pauses and if a pacemaker is appropriate.

“I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?
My cardiologist recommends a pacemaker to prevent blackouts during a pause as well as other serious heart problems. I am willing, but want to learn more about these pauses first.”

I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.

Pauses are “Normal” in A-Fib

Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.

Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant…Read the rest of my answer… .

 

FAQs Understanding A-Fib: With A-Fib Pauses—Do I Need a Pacemaker?

 FAQs Understanding A-Fib: Pacemaker for Pauses?

FAQs Understanding Your A-Fib A-Fib.com14. “I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?

My cardiologist recommends a pacemaker to prevent blackouts during a pause as well as other serious heart problems. I am willing, but want to learn more about these pauses first.”

I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.

Pauses are “Normal” in A-Fib

Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.

Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant.

Monitoring Your Symptoms

Are you symptomatic? Do you fall or faint from these pauses? (This is different from occasionally feeling lightheaded or dizzy.)

If your cardiologist hasn’t yet suggested it, you may need to wear a holter or similar monitor for a few days (or up to a month or longer).

Monitoring will tell your doctor exactly how long your pauses are and how often you have them.

Avoid Getting a Pacemaker, if You Can

I can understand your cardiologist’s concern, but try to avoid getting a pacemaker, if you can.

If you do have to get a pacemaker, make sure the cardiologist guarantees that it can and will be easily removed once you are restored to normal sinus rhythm (NSR). You don’t want to be saddled with a pacemaker for life when you don’t need it.

Be assertive. You may have to be very assertive about this. Most cardiologists will insist that you keep the pacemaker forever. (But it isn’t so.)

Cure Your A-Fib=No More Pauses

Ask your doctor about antiarrhythmic drugs. They generally don’t “cure” A-Fib but may reduce your pauses.

If your pauses cause you problems, consider a catheter ablation to cure your A-Fib.

Once you no longer have A-Fib, those pauses should stop and your heart should beat again in normal sinus rhythm.

To read a first-hand story about pacemakers see Personal A-Fib Story #50: Pacemaker & A-Fib Ablation—You Can Have an A-Fib Ablation if You Have a Pacemaker

References for this article

Last updated: Wednesday, June 8, 2016

Go back to FAQ Understanding A-Fib

FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?

 FAQs Coping with A-Fib: Pacemaker

FAQs A-Fib afib13. “I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses. What should I do?”

Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.

Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.

As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.

In the words of Dr. John Mandrola:

“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”

But be advised that pacemakers tend to have bad effects over the long term, “…long-term morbidity (is) associated with a pacemaker.”

 Another consideration is that implanting pacemaker ‘leads’ in the veins of the upper chest often prevents or hinders future procedures that require vascular access like a PVI. A pacemaker usually isn’t implanted unless your heart rate is too slow or you have Sinus Node and/or Atrioventricular (AV) Node problems.

References:
¤  Mandrola, John “Choosing wisely: The electrophysiology list of five don’ts.” http://blogs.theheart.org/trials-and-fibrillations-with-dr-john-mandrola/2012/4/9/choosing-wisely.
¤  Atrial Fibrillation Educational Material” University of Pennsylvania. 2002, p. 3.
¤  “Should atrial fibrillation ablation be considered first-line therapy for some patients?” Circulation 2005;112:1214-1231, p. 1228.

Back to FAQs: Coping with Your A-Fib

Pacemakers & ICDs

Pacemakers & Implantable Cardioverter Defibrillator (ICD)

Pacemakers

Illustration of Pacemaker for Atrial Fibrillation, A-fib, afib, a fib

Pacemakers

A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a regular heart rate. In general, pacemakers are not very effective for preventing A-Fib.

Implanting a pacemaker seems to be most helpful if you have a slow heart rate or pauses as a result of taking A-Fib medications. But there is a danger for patients with this approach. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath. Some people, particularly athletes, can have a very slow heart rate and be perfectly healthy. The same holds for asymptomatic pauses.

In the words of Dr. John Mandrola:

“Do not implant pacemakers in patients with non-symptomatic bradycardia (slow heart rate).1

Non-symptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker. Another consideration is that implanting pacemaker leads in the veins of the upper chest often prevents or hinders future procedures that require vascular access like a Pulmonary Vein Ablation/Isolation (PVI/A).

A pacemaker usually isn’t implanted unless your heart rate is too slow2 or you have Sinus Node and/or Atrioventricular (AV) Node problems. But be advised that pacemakers tend to have bad effects over the long term, “…a long-term morbidity (is) associated with a pacemaker.”3

For more information on Pacemakers, you may want to visit the pacemaker chat site: pacemakerclub.com.  (Thanks to Mara for alerting us to this site.)

[I admit to not knowing much about pacemakers. Happily one of the A-Fib.com’s contributors installs pacemakers and offers the following observations.

“I like to tell patients who receive pacemakers that, after a couple of months, they can have a VERY active, normal lifestyle. All of the current pacers have a “rate responsive” mode, meaning they are designed specifically for activity. The more active you are, the faster the pacer goes. Three triathlon runners, and two NFL players have pacers. Most people forget they have a pacemaker.

A recent trend is to implant the ventricular lead on the septum vs. the right ventricular apex, which gives better cardiac output and a more ‘normal’ heartbeat. You might want to ask your doctor about this possibility. Even if your doctor does not prefer this technique, he/she will be impressed that you did your homework.

In addition, you always want a dual chamber pacer which will give better cardiac output. It will also attempt to synchronize between the atria and ventricles, unless the patient is in Chronic A-Fib. If the A-Fib is intermittent, the pacer will temporarily switch modes to VVIR (ventricular only pacing) during the A-Fib, and then back to normal DDDR (dual chamber) pacing when the A-Fib terminates. This is all done by the device memory/logic program.

So, during A-Fib, the DDDR pacer will switch to VVIR and pace only the ventricle during the A-Fib.”

Key to the acronyms.4 

Implantable Cardioverter Defibrillator (ICD)

Implantable cardioverter defibrillator (ICD) for Atrial Fibrillation, A-fib, afib, a fib

Implantable Cardioverter Defibrillator (ICD)

An implantable cardiac defibrillator (ICD) is a device that is put within the body and is designed to recognize certain types of abnormal heart rhythms (arrhythmias) and correct them by delivering precisely calibrated and timed electrical shocks, when needed, to restore a normal heartbeat.

Having a defibrillator implanted in your heart is, from the point of view of most A-Fib patients, not a probable option.  A defibrillator shock is painful, like being “kicked in the chest.” Most people would rather have A-Fib than risk being shocked throughout the day and night. Also, it does not address the underlying problem or condition of your heart that causes your A-Fib.

Fewer than 10% of patients get shocked when a shock isn’t needed, according to Edward K. Kasper, MD of The Johns Hopkins Hospital..5 In another study 18% of patients with A-Fib received inappropriate first shocks.6 

More than 30% of people who have ICDs develop emotional problems such as anxiety and depression—in part due to worry and uncertainty over whether the device will deliver an unnecessary shock and the fear of being shocked.7

What’s it like living with an ICD and A-Fib? Roby T. shared:

“The worst part was the ICD firing,” he recalls. “It hit me like a baseball bat and knocked me over.” His wife, Mary, was afraid to leave him alone. And the anxiety levels took their toll, even during sleep. “He became really anxious expecting a firing at any time,” she says. “You could see the fear in his eyes,” she reluctantly remembers. “He had to start taking antidepressants.”8

Our A-Fib.com pacemaker expert writes:

“Defibrillators are far more complicated (than pacemakers). When people report getting a big shock (500-700 volts) from the unit, that was probably for V (ventricular) Fib, not A-Fib, if the unit is programmed properly.
One good thing about the V-Fib is that it is usually (not always) proceeded by Ventricular Tachycardia, a much slower, organized rhythm that often responds to painless anti-tachycardia pacing. We will attempt anti-tachycardia overdrive pacing for several different patterns before we finally give up and go to the full output shock.”

Last updated: Monday, August 24, 2015

 Return to Treatments for Atrial Fibrillation

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References    (↵ returns to text)
  1. Mandrola, John “Choosing wisely: The electrophysiology list of five don’ts http://www.medscape.com/viewarticle/802018
  2. “Atrial Fibrillation Educational Material” University of Pennsylvania. 2002, p. 3.
  3. Prystowsky, “Should atrial fibrillation ablation be considered first-line therapy for some patients?” Circulation 2005;112:1214-1231, p. 1228.
  4. Key to the acronyms used in the Pacemaker quote:
    “DDD” signifies a dual chamber pacer, capable of sensing and pacing in both the atrium and the ventricle
    “VVI” is ventricle only
    “AAI” is atrium only
    “R” signifies Rate Response, a programmable on/off feature which increases the pacing during activity
  5. Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9.
  6. Cesario, D. et al. The Role of Atrial Fibrillation in CRT-D Patients: The ATTITUDE Study Group. The Journal of Innovations in Cardiac Rhythm Management. 6 (2015), 1873-1880.
  7. Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9
  8. Roby’s Arrhythmia Story. Published on MyFastHeartBeat.com Last accessed November 5, 2012.

A Primer: Ambulatory Heart Rhythm Monitors

A Primer: Ambulatory/Long-term Heart Rhythm Monitors

By Steve S. Ryan, PhD

ECG pads positioned

Source: www.afa.org.uk patient education brochure

If your arrhythmia is intermittent, your doctor may have you wear a mobile type of heart rhythm monitor to capture the electrical activity of your heart. As a general rule, in order to make a diagnosis of an arrhythmia, some form of electrocardiographic recording (i.e., EKG,) must be made at the time the arrhythmia is occurring.

If an arrhythmia becomes persistent and is present day-in and day-out, as often is the case for A-Fib, the diagnosis is quite easy with a routine EKG done in the physician’s office.

The challenge is when an arrhythmia occurs intermittently (on and off) or is self-limiting. In this case, an EKG performed in between A-Fib episodes can be completely normal. To circumvent this problem, one would go to the next level of evaluation with a long-term monitor.

Long-term monitors

Long-term monitors basically are EKG recorders that patients can take with them (ambulatory). They fall into two major categories: continuous recording (Holter) and intermittent recording (Event).

The Holter Monitor

Mortara H12+ Continuous 12-lead Holter recorder

Mortora H12+ Continuous 12-lead Holter recorder

A Holter Monitor (named after Dr. Norman Holter, go figure) records continuously the EKG of a patient, usually for 24 – 48 hours. More modern Holter units record onto digital flash memory devices. The data are uploaded into a computer where software analyzes the input, counting ECG complexes, calculating summary statistics such as average heart rate, minimum and maximum heart rate, and finding candidate areas in the recording worthy of further study.

The advantage of a Holter is that every single heartbeat during that day is recorded and can be analyzed. The disadvantage is that if an arrhythmia did not happen on that particular day, the Holter data would not be useful.

The Event Monitor

Cardionet wireless event monitor

Cardionet wireless event monitor

An Event Monitor, on the other hand, is a long-term monitor that can be used for up to 30 days or longer. The advantage is that the longer the recording period, the better chance of “catching” an intermittent arrhythmia. The disadvantage is that an Event Monitor must be activated by the patient and downloaded telephonically, a task that requires a certain amount of manual dexterity and may be difficult for some patients.

Some event monitors are patient activated when having an episode and save the last several minutes of data; others detect the irregular heart rate and automatically record the data.

Number of Electrodes

The number and position of electrodes varies by model, but most Holter monitors employ between three and eight, whereas the Event Monitors typically use two. Both the Holter and Event monitors record electrical signals from the heart via a series of electrodes attached to the chest. The Loop (event) monitor is not attached to the patient but is instead pressed to the chest by the patient when experiencing an A-Fib episode.

Implantable ambulatory event monitors

Medtronic Reveal® DX insertable cardiac monitor (ICM) continuously monitors

Medtronic Reveal® DX insertable cardiac monitor (ICM) continuously monitors

Implantable event monitors are also available for those instances where individuals experience such infrequent symptoms that extended monitoring is needed.

These devices are inserted just under the skin in the chest area during an outpatient surgical procedure. The device may remain implanted for over one year.

Implantable loop recorders have the ability to record events either automatically (auto activated) or by manual activation (self-activated).

Real Time Remote Cardiac Recording

CardioNet MCOTos Event wireless event monitor

CardioNet MCOTos Event wireless event monitor

An example of the newer monitoring technologies is the Ambulatory Cardiac Telemetry (ACT), a wireless cardiac telemetry system.  This event monitor is designed for remote arrhythmia monitoring in any location.

A small transmitter worn on the patient sends the ECG data to a portable handheld device where it is analyzed.  If an arrhythmia is identified, the data is automatically transmitted to a Monitoring Center for immediate review. Integrated into a state-of-the-art mobile phone, the ACT provides next generation cardiac arrhythmia monitoring. What’s interesting is the transmitter is a dongle type device worn around the neck with leads placed on the chest. You carry or have available what, in essence, is a mobile phone (it’s actually more than a phone). It is small and not cumbersome.

No patient input is required. Data collected from the monitors is transmitted to the monitoring center via a cellular network, the internet, or over the phone (based on model). Data from the monitors is not intended to be used directly by the patient but rather by the monitoring center and your cardiologist.

Next-Generation: the ‘Smart Band-Aid’ Zio Patch

Steve wearing a Zio Patch

Steve wearing a Zio Patch

The ‘Smart Band-Aid’ provides the next-generation ambulatory cardiac monitoring service with beat-to-beat, real time analysis, automatic arrhythmia detection and wireless ECG transmission.

The sensors in the Band-Aid can be modified to monitor a number of different tasks as they can also provide a comprehensive suite of post-symptom, looping, and auto trigger event monitors as part of its turn-key cardiac event monitoring service.

Additional Reading

For a scholarly review of medical heart rate monitors, see: New Methodologies in Arrhythmia Monitoring by Anderson & Donnelly.

References for this article

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Return to Index of Articles: Diagnostic Testing

Last updated: Thursday, September 3, 2015

>

Treatments for Atrial Fibrillation

Treatments for Atrial Fibrillation at A-Fib.com

Treatments for Atrial Fibrillation include both short-term and long-term approaches aimed at controlling or eliminating the abnormal heart rhythm associated with A-Fib.

Diagnostic Testing

Doctors have several technologies and diagnostic tests to aid them in evaluating your A-Fib. Go to Diagnostic Testing ->

Additional readings:
• Sleep Apnea: Home Testing Now Available
• A Primer: Ambulatory Heart Rhythm Monitors
Guide to DIY Heart Rate Monitors & Handheld ECG Monitors (Part I) 
• 
Guide to Heart Rate Monitors: How They Work For A-Fib Patients (Part II)
• Understanding the EKG Signal
• The CHADS2 Stroke-Risk Grading System

Mineral Deficiencies

A deficiency in minerals like magnesium or potassium can force the heart into fatal arrhythmias. When you have A-Fib, a sensible starting point is to check for chemical imbalances or deficiencies. Go to Mineral Deficiencies ->

Additional readings:
• 
Frequently Asked Questions: Mineral Deficiencies & Supplements
• ‘Natural’ Supplements for a Healthy Heart
• 
Alternative Remedies and Tips
• Acupuncture Helps A-Fib—Specific Acupuncture Sites Identified
• Low Serum Magnesium Linked with A-Fib

Top 10 Questions Families Ask About A-Fib - Download Free Report

Top 10 Questions Families Ask About A-Fib – Download Free Report

Drug Therapies

Medications (drug therapies) for A-Fib patients are designed to regain and maintain normal heart rhythm, control the heart rate (pulse), and prevent stroke. Go to Drug Therapies ->

Additional readings:
 
Frequently Asked Questions: Drug Therapies and Medicines
 
Anticoagulant Therapy after Successful A-Fib Catheter Ablation: Is it Right for Me? 
• Warfarin vs. Pradaxa and the Other New Anticoagulants
 
Amiodarone: Most Effective and Most Toxic
Research Findings: Anticoagulants for Stroke Prevention
 
Watchman: the Alternative to Blood Thinners

Cardioversion

The goal of cardioversion is to restore your heart to normal rhythm. There are two types of cardioversion: chemical and electrical. Cardioversion through the use of drugs is called chemical cardioversion. Electrical cardioversion uses a timed electrical shock to restore normal rhythm. Go to Cardiversion ->

Catheter Ablation

RF Catheter Ablation and CryoAblation are minimally invasive catheter procedures that block electrical signals which trigger erratic heart rhythms. Go to Catheter Ablation ->

Additional readings: 
• 
New Ablation Technique by Dr. Andrea Natale 
• Frequently Asked Questions: Catheter Ablation, Pulmonary Vein Isolation, CyroBalloon Ablation  

• 
Considering a Catheter Ablation? Know Complication Rates When Choosing Your Doctor 
• 
Ablation Success Rate Much Better With Weight Control 
• 
A-Fib Research: Live Longer―Have a Catheter Ablation 
• Recurrence of A-Fib After Successful Catheter Ablation 
• A Cryo Ablation Primer
• Radiation Exposure During an Ablation Procedure: How to Protect Yourself from Damage
• Risks Associated with Pulmonary Vein Procedure
• 
The Evolving Terminology of Catheter Ablation
• 
Bordeaux Five-Step Ablation Protocol for Chronic A-Fib
Bordeaux Procedures & Costs
 

Cox Maze & Mini-Maze Surgeries & Hybrid Surgery/Ablation

The traditional open-heart Cox-Maze is usually performed concurrent with other heart disease treatments. More common are the various Mini-Maze surgeries which are stand-alone surgeries performed through small port-size incisions in the chest. Go to Maze, Mini-Maze & Hybrid ->

Additional readings:
Advantages of the Convergent Procedure by Dr. James Edgerton
• FAST Trial: Surgical Versus Catheter Ablation―Flawed Study, But Important Results for Patients
• Advances in Surgical Therapy for A-Fib by Dr. David Kess
• Role of the LAA & Removal Issues

Ablation of the AV Node and Implanting a Pacemaker

From a patient’s point of view, this is a procedure of last resort. By ablating or eliminating this AV Node, your Atrial Fibrillation signals can’t get to the ventricles which does stop your heart from racing. But you must have a permanent pacemaker implanted in your heart for the rest of your life. Go to Ablation of the AV Node->

Pacemakers & ICDs

Pacemakers may be implanted for pacing support, or in conjunction with Ablation of the AV Node (see above). Implanting a pacemaker seems to be most helpful if you have a slow heart rate or pauses as a result of taking A-Fib medications. But be advised that pacemakers tend to have bad effects over the long term. Go to Pacemakers & ICDs ->

Decisions About Treatment Options

When considering treatments for atrial fibrillation, you may ask,“Which is the best A-Fib treatment option for me?” This is a decision only you and your doctor can make. Here are some guidelines to help you. I’ve listed A-Fib conditions as patients might describe them. Select one (or more) that best describes your A-Fib and read your possible options. Go to Decision About Treatment Options ->

Remember

A-Fib is a progressive disease – Don’t wait – Seek a CURE as soon as practical.
I Beat my A-Fib—So can YOU!

Last updated: Sunday, January 3, 2016

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