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post-ablation

FAQs A-Fib Ablations: Exercise Level Post-Ablation

 FAQs A-Fib Ablations: Exercise Level 

Catheter Ablation

Catheter Ablation

“I’m having a catheter ablation and I love to exercise. Everything I read says ‘You can resume normal activity in a few days.’ Can I return to what’s ‘normal’ exercise for me?”

Caution would say to start off slow, then work your way up. You could get a Polar (or other) heart rate monitor to keep track of your heart rate.

Your heart is considered healed from the scarring of the ablation after three months (possibly sooner). Often you feel so good being in sinus rhythm after an ablation, that you can’t wait to exercise, to do something physical.

But even though you feel great, it’s better to be prudent and rein yourself in for a short while.

Ed Webb, a very active exerciser, shares his experiences and insights. Ed writes:

“It seems the prevailing opinions seem to lean toward resuming normal activities a week to two weeks after the procedure. In fact that’s what my EP had recommended for me (the first time around). I started light walking and cycling, but unrelated to these activities I also was doing some outside work on my boat (during the fall here in Florida where it can be putrid).

On two separate occasions–I happened to be wearing a heart rate monitor–my heart was a comfortable 85 BPM and then WHAM back into A-Fib!

As I am one of those persistent A-Fibbers, I had to be cardioverted both times. This all happened within a span of 3 weeks after the procedure. Needless to say, I was somewhat discouraged thinking the ablation had been a failure.

My EP wasn’t too concerned and just advised me to hang in there. After the second cardioversion, I finally got the hint and took it really easy for the next month, after which I started a walking regimen where I allowed my heart rate to increase from 80 BPM on the first day up to 100BPM at an increase of 1 beat per day.

Once I hit the magic 100, I got back on the bike and picked it up from there and was fine after that (until 2 years later when I had another onset!). The bottom line is I think this all had to do with not allowing enough time for the scar tissue to heal.

My second time around (which was 2 years ago) I pretty much stuck to the same routine. First two weeks, absolutely nothing. Then easy walks allowing my heart rate to increase a little each day. I walked for a month (starting at 80 and finishing at 105).

After 6 weeks or so, I was back on the bike and doing maximum efforts by the end of 3 months. I have been in sinus rhythm ever since (that sound you hear is me knocking on my desk!)

Anyway, I hope this gives you at least one perspective for your recovery. All the best for your procedure.”—Ed Webb

Thanks to Monique Van Zeebroeck for this question and to Ed Webb for sharing his experiences and insight.

Return to FAQ Catheter Ablations

FAQs A-Fib Ablations: Blood Thinner Post-Ablation?

 FAQs A-Fib Ablations: Blood Thinner Post-Ablation? 

Catheter Ablation

Catheter Ablation

“After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin, an NOAC or aspirin?”

You may still have a high CHADS2 stroke risk score or other factors that make it necessary for you to stay on blood thinners.

But if you no longer have A-Fib, you are no longer in danger of having an A-Fib stroke. So, in most cases, you don’t need to be on blood thinners.

A study in 2010 indicates that anticoagulants, like warfarin, can be stopped 3-6 months after a successful Pulmonary Vein Ablation (Isolation).

A recent observational study involving nearly 38,000 patients found that the stroke risk of patients who had a successful catheter ablation was similar to patients with no history of A-Fib. When you are in sinus rhythm, your stroke risk is basically the same as a normal heart-healthy person.

However, there is no medication or treatment that would absolutely guarantee one would never get a stroke, even for people in normal sinus rhythm.

“Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans. ∼Thomas J. Moore, MD

Taking anticoagulants because you might develop A-Fib, however, is like taking out your appendix because at some future date you might develop appendicitis (frowned upon these days). As prolific blogger Dr. John Mandrola says, “And if there is no A-Fib, there is no benefit from anticoagulation.”

Aspirin is No Longer Recommended as First-Line Therapy: Aspirin is no longer recommended as first-line therapy for Atrial Fibrillation patients according to the 2014 AHA/ACC/HRS Treatment Guidelines for Atrial Fibrillation and the 2012 European ESC guidelines for the Management of Atrial Fibrillation.

When is aspirin appropriate? Aspirin is recommended for “secondary” prevention of cardiovascular disease such as to prevent a reoccurrence of a stroke or heart attack.

Silent A-Fib May Appear Post-Ablation

However, though feeling cured of your A-Fib, you may still be experiencing ‘silent A-Fib’ (A-Fib with no symptoms) which can be dangerous.

But doctors today are very good at spotting silent A-Fib and have a wide variety of monitoring devices (such as the Zio patch which you wear like a Band-Aid for two weeks) to alert your doctor that you may still need to be on anticoagulants.

Danger of Taking Anticoagulants

No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers.

Anticoagulants are not like taking vitamins (contrary to the impression of TV ads for NOACs).

No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers. When taking anticoagulants, there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. And anticoagulants often have other bad side effects, make one feel sick, and diminish one’s quality of life.

“Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans, according to Thomas J. Moore, senior scientist at the Institute for Safe Medication Practices. “More than 15% of older patients treated for A-Fib with blood thinners for 1 year have bleeding.”

Bottom Line

Whether you should be on anticoagulants after a successful catheter ablation is a judgment call for you and your doctor.

References for this Article

Last updated: Thursday, February 9, 2017 Return to FAQ Catheters

FAQs A-Fib Ablations: Operating Room Report

 FAQs A-Fib Ablations: O.R. Report 

Catheter Ablation

Catheter Ablation

“I want to read exactly what was done during my Pulmonary Vein Ablation? Where can I get the specifics? What records are kept?”

Ask your doctor or his office for a copy of your O.R. (Operating Room) report. This is a technical, detailed, step-by-step account of what the doctors found in your heart and what was done.

What is an O.R. Report?

An O.R. report is written by the electrophysiologist who performed the catheter ablation. It contains a detailed account of the findings, the procedure used, the preoperative and postoperative diagnoses, etc.

It’s a very technical document. Because of this, it’s usually given to a patient only when they ask for it.

New Report: How & Why to Read Your Operating Room Report

In our new FREE 12-page Report: How & Why to Read Your Operating Room Report, I make it easy (well, let’s say ‘easier’) to learn how to read an O.R. report.

Along with an introduction, I’ve annotated every technical phrase or concept so you will understand each entry. I then translate what each comment means and summarize the report.

Read more at: Special Report How & Why to Read Your Operating Room Report

If you need help understanding your O.R report, email or send me a copy. Together we can probably figure it out.

Return to FAQ Catheter Ablations

FAQs A-Fib Ablations: Post-Procedure Symptoms and Success

 FAQs A-Fib Ablations: Post-Procedure Symptoms 

Catheter Ablation

Catheter Ablation

How long before you know a Pulmonary Vein Ablation procedure is a success? I just had a PVA. I’ve got bruising on my leg, my chest hurts, and I have a fever at night. I still don’t feel quite right. Is this normal?”

After a Pulmonary Vein Ablation procedure, some people feel great and are in perfect sinus rhythm. But for most of us it usually takes two or three months (called a “blanking period”) for the ablation scars to heal and for our heart to learn to beat normally again.

Doctors sometimes help this process by prescribing antiarrhythmic meds for a month or longer. You may also have to continue to take Coumadin for a while.

Right after the PVA(I) you may experience the following:

•  Your groin will generally have two access site points, one on each side. After a Pulmonary Vein Ablation, some minor bruising is common at each site with minor soreness as if you had banged the area. Bruising may occasionally be seen to extend down the leg. This is normal, as is an occasional small quarter sized bump in the area. (If larger swelling or more significant pain occurs at the area, please contact the electrophysiologist who did the procedure.) One of the reasons for this bruising is the heavy dose of blood thinners you were administered during your ablation procedure to prevent a possible stroke.

•  After a Pulmonary Vein Ablation you may have some minor chest pain for the next week or so. The pain will often worsen with a deep breath or when leaning forward. This is pericardial chest pain from the ablation and is generally not of concern. It should resolve within a week, although it might increase for a day or so after the ablation. (This chest pain may be due to the heat from the catheter ablation burns which may temporarily irritate the Pericardium, the sac around the heart.)

•  Your heart may beat faster than before. Usually your heart rate will settle down after the two-to-three month blanking period. But some people report a slightly elevated heart rate even after three months, especially if they have previously been taking rate control or antiarrhythmic meds.

•  Low grade fevers of around 99 degrees are common in the first day or so post-ablation. (If you develop unexplained fevers exceeding 100 degrees anytime within the first 3 weeks post-ablation, you need to contact the electrophysiologist who performed your procedure.)

One or more of these symptoms is considered normal, but discuss any symptoms with your doctor during your post-procedure doctor visits.

Thanks to Marva Harp for this question.

Return to FAQ Catheter Ablations

FAQs A-Fib Ablations: Will My A-Fib Eventually Return?

 FAQs A-Fib Ablations: Will My A-Fib Return? 

Catheter Ablation

Catheter Ablation

“Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

I think your chances of staying A-Fib free are pretty good. A Pulmonary Vein Isolation (Ablation) is like a kind of immunization against A-Fib. If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again.

When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. Intuitively it makes sense that A-Fib wouldn’t reoccur in areas that were successfully ablated and that haven’t reconnected. But it’s too early in the history of PVA(I)s to say this definitively.

NOTE: PVA(I) is a relatively new procedure. I had my catheter ablation in 1998 when I was 57 years old and I’m still A-Fib free today at age 74. However, at that time of my ablation, only one of my Pulmonary Veins was isolated. In theory the other veins could start producing A-Fib signals. But that hasn’t happened. My catheter ablation procedure back in 1998 was primitive compared to what is done today.

Regrowth/Reconnection of Ablated Heart Tissue: There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

Recent research indicates that for a small number of people, a successful Pulmonary Vein Ablation (Isolation) procedure may not be a permanent “cure.” Dr. Francis Marchlinski of the University of Pennsylvania persuaded patients who had experienced successful PV ablations and who were A-Fib symptom free, to be re-examined in the EP lab. He found that some had regrowth/reconnection in their ablated vein openings even though they were A-Fib symptom free. He also examined patients who had regrowth/reconnection and reoccurrence of A-Fib after a successful PV ablation.

He estimated that there is a 5-6% chance of regrowth/reconnection each year (though not necessarily of A-Fib recurrence), out to five years. He doesn’t have data for beyond five years.

Who Is Most Likely to Have Recurrences? The people most likely to get recurrences often have pre-existing conditions or risk factors like obesity, diabetes, high blood pressure, sleep apnea, smoking, binge drinking, etc. Even though their PVs may remain well isolated, these risk factors could stimulate A-Fib in some other part of their heart or perhaps cause regrowth/reconnection in the PVs.

Don’t Fear Recurrence. But let’s say you do have a recurrence, for example, after seven years. It’s nothing to worry about and it can be fixed. You go in for a touch-up ablation which may take a whole 20 minutes to do.

Marilyn Shook

Marilyn Shook

The EP usually only needs to fix a gap or a new spot that has appeared, rather than do a whole ablation and isolation of your PVs and heart. (And remember, you have been A-Fib free for all those years!)

This is exactly what happened to Marilyn. Read Marilyn Shook Updates Her 2008 Personal A-Fib Story. She had a ‘touchup’ ablation September 2014 and wrote us in July 2015 that she’s had no A-Fib since.

Live Life Like You Are Cured! It’s a waste of time to be concerned about something that may never happen (A-Fib recurrence). It’s like worrying about getting struck by lightning.

Thanks to Rob Muscolino for this question and to A-Fib Support Volunteer Jerry for helping write this answer.

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Last updated: Thursday, February 9, 2017

Return to FAQ Catheter Ablations

FAQs A-Fib Drug Therapy: Post Ablation Blood Thinner?

 FAQs A-Fib Drug Therapy: Post PVI Blood Thinners

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

17. “I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner because I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of. Is there anything I can do to get off of blood thinners?”

If you’re no longer in A-Fib, you’re also no longer in danger of having an A-Fib stroke. But you can have a “normal” stroke: i.e., a stroke that doesn’t originate from being in A-Fib. That’s probably what your doctor is worried about.

“Silent” A-Fib isn’t as much a problem as in the past. Today’s A-Fib catheter ablation doctors follow their patients for long periods of time after a successful catheter ablation and use an extensive array of monitoring devices to tell if a patient is in “silent” A-Fib. (See: A Primer: Ambulatory Heart Rhythm Monitors) It’s unlikely you’d experience a long period of silent A-Fib without your doctor being aware, though doctors and monitoring devices aren’t infallible.

Most doctors say you don’t need to worry about short A-Fib episodes. Conventional wisdom says it takes 24-48 hours of being in A-Fib for a clot to form. Though some doctors think it takes as little as 5 1/2 hours of being in A-Fib for a clot to develop.

Don’t be hesitant about getting a second opinion if you’re worried about having to be on an anticoagulant. No one should be on blood thinners unless there’s a real risk of stroke.

(Be advised that no anticoagulant regimen or procedure will absolutely guarantee you will never have a stroke. Even warfarin [Coumadin] only reduces the risk of stroke by 55% to 65% in A-Fib patients.)

Alternatives to Anticoagulants

Here are some alternatives to taking anticoagulants (discuss with your doctor before making any changes in your treatment plan):

•  Post-Ablation “Pill-In-The-Pocket”: Katharine emailed me several months after her successful catheter ablation. Instead of a daily anticoagulant, she carries rivaroxiban (Xarelto) with her which she would use if she felt an A-Fib episode coming on (though she’s never had to use it). The rivaroxiban would work to prevent a clot from forming. (No clinical trials have been done using this strategy,) This approach means Katharine isn’t on an anticoagulant for long periods of time or for the rest of her life.

Be advised that this web site is not recommending or suggesting that you quit taking prescription blood thinners.

•  “Natural” Blood Thinners: Do your own research, then discuss this option with your doctor. There are several informative articles about Natural Blood Thinners at LIVESTRONG.COM and an extensive article, “Blood Thinners and Nutritional Supplement” by Dr. Lam on his website.

•  Left Atrial Appendage (LAA) Occlusion Devices: The theory behind these devices which close off the opening of the Left Atrial Appendage is that 90%-95% of A-Fib clots come from the LAA.

References for this article

Return to FAQ Drug Therapies

Last updated: Saturday, February 11, 2017

About Recurrence of A-Fib After Successful Catheter Ablation

by Steve S. Ryan, PhD, June 2014

Ed Grossman recently wrote and asked me about recurrence of A-Fib after a successful catheter ablation:

Recurrence of A-Fib After Catheter Ablation“I’ve read studies from the French Bordeaux group that talk about A-Fib recurring after a catheter ablation, that A-Fib tends to come back. Can A-Fib be cured permanently by a catheter ablation? After a successful catheter ablation, what are my chances of A-Fib recurring?”

The French Bordeaux group pioneered the original Pulmonary Vein Isolation procedure.

The studies you refer to were done in 2001-2002 with 100 patients. There’s been a great deal of improvement in the procedure since then, such as the use of irrigated tip catheters and the increased use of circumferential pulmonary vein isolation (PVI). (For example, when I had my procedure done in Bordeaux in 1998, they did what was then called a focal ablation in only one of my pulmonary vein openings. I’ve been A-Fib free “cured” for 16 years. Today though, they routinely isolate all four pulmonary veins.)

Don’t let the threat of recurrence put you off of having a catheter ablation. Recurrence is often influenced by several factors unrelated to the actual catheter ablation procedure, some of which you can control.

Certain Health Conditions Cause Recurrence of A-Fib

There are health conditions which tend to cause A-Fib to recur including hypertension, obesity, sleep apnea, diabetes, smoking and binge drinking. Controlling these conditions will reduce the risk of recurrence.

For example, let’s say patient “Joe” has A-Fib and sleep apnea, then has a successful A-Fib ablation and is A-Fib free. Because of his sleep apnea, Joe’s A-Fib is more likely to recur than someone without sleep apnea. So much so, that Electrophysiologists (EPs) today are insisting that A-Fib patients with sleep apnea be treated and use devices like a CPAP breathing machine before they can get a catheter ablation. In one study sleep apnea was an independent predictor for catheter ablation failure after a single procedure.

Also, those with long-standing persistent A-Fib, or those with vascular heart disease, or cardiomyopathy are more likely to have a recurrence.

Less recurrence for those with Lone A-Fib

Around 50% of A-Fib patients have no apparent pre-existing medical condition—called “lone A-Fib” because there’s no other contributing health condition. After a successful catheter ablation, those with lone a-fib are less likely to have a recurrence. But some lone A-Fib patients do have recurrences. (Some studies estimate a 7% chance of recurrence out to five years, though most recurrences occur in the first six to 12 months.)

So why the recurrence for lone a-fib patients? Heart tissue is very tough and tends to heal itself after an ablation. Or, there may be gaps in the ablation lines and the spots may require a touch-up ablation (usually with a much shorter procedure time and easier to perform than the first ablation).

The joy of Years of living in ‘Normal Sinus Rhythm’

Let’s discuss a worst-case scenario. You have a catheter ablation that makes you A-Fib free. Then three years later you develop A-Fib again. But the bottom line is you’ve been “cured” for three years. (The dictionary defines “cure” as “restoration of health; recovery from disease”.)

Most people with symptomatic A-Fib are overjoyed to have a normal heart beat and a normal life for three years, to be freed from both A-Fib symptoms and from the anxiety, fear and depression that often accompany A-Fib.

(See the personal experience stories by patients who had recurrence and a successful second ablation: Jay Teresi, “In A-Fib at Age 25 and Robert Dell’s A-Fib Experience: “Daddy is always tired”.)

Only people with A-Fib appreciate how wonderful it is to be in ‘Normal Sinus Rhythm’ (NSR). For most of us, catheter ablation provides “acceptable” long-term relief from A-Fib. And it’s comforting to know, you can go back for another ablation, if you need it.

Catheter Ablation is the Best Hope for a “Cure”

Today, catheter ablation is the best A-Fib treatment offering hope for a “cure”—for making you A-Fib free. Current medications, for the most part, don’t work or have bad side effects or lose their effectiveness over time. Electrocardioversions usually don’t last. Surgical approaches work, but are generally more invasive, traumatic, and risky, and not recommended as first-line therapy for A-Fib.

Yes, A-Fib can return after a catheter ablation; the benefit may not be permanent. But, as a point of reference, consider heart by-pass operations or heart stents—are they always permanent? (Often they aren’t.)  Do patients need additional surgeries? (Often they do.) With the option to return for an additional or “touch-up” procedure, catheter ablation is still today’s best hope for a life free from the burden of Atrial Fibrillation.

References for this Article

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Return to Index of Articles: Catheter Ablation

Last updated: Monday, August 17, 2015

The 2014 CHA2DS2-VASC Guidelines and the Risks of Life-Long Anticoagulation Therapy

Risks of Life-Long Anticoagulation Therapy

Risks of Life-Long Anticoagulation Therapy

A-Fib-Free After Catheter Ablation, Patient on Anticoagulation Therapy for 10 years Develops Cerebral Microbleeds and Associated Early Dementia.

By Steve S. Ryan, Updated March 2016

Dr. John Day, in an editorial in The Journal of Innovations in Cardiac Rhythm Management, described his patient, Bob, who had been on anticoagulation therapy for 10 years, even though he had had a successful catheter ablation and was A-Fib free.

Of concern, these new guidelines call for many more people to be on anticoagulant therapy, particularly women.

Bob was suffering from early dementia. A cranial MRI revealed many cerebral microbleeds, probably caused by taking anticoagulants for years. Both antiplatelet and anticoagulant therapy significantly increase the risk of cerebral microbleeds which are associated with dementia. These microbleeds are usually permanent and irreversible.

Dr. Day asked, “Could it be that this was an iatrogenic (caused by a doctor’s activity or therapy) case of dementia? Was his 10 years of anticoagulant use for atrial fibrillation the cause of his dementia?”

The New CHA2DS2-VASc Guidelines for Anticoagulation Therapy

Dr. Day discusses the new CHA2DS2-VASc guidelines for anticoagulation therapy. He points out that none of the major studies supporting the CHA2DS2-VASc guidelines have reported the accompanying cerebral microbleed risk. He also calls our attention to the reports from many centers that long-term stroke risk following catheter ablation is very low. Ablation may reduce the total arrhythmia burden or convert recurrences to more organized rhythms, such as an atrial tachycardia, with a lower stroke risk.

This effect of A-Fib ablation isn’t recognized in the latest guidelines.

So, the question is, ‘Why the risks of life-long anticoagulation therapy if the patient has had a successful ablation procedure?’

Also, these new guidelines call for many more people to be on anticoagulant therapy, particularly women. Dr. Day does not go so far as to say the new guidelines are in error (as I do), but he does ask,” What about the 35 year old woman with borderline hypertension and only one A-Fib recurrence each year? Should she now take anticoagulants for the rest of her life even if she has had a successful ablation?”

(See more research contradicting the 2014 Guides: A study using the Taiwan Research Database of 186,570 A-Fib patients, they discounted female gender and only looked at females with a CHA2DS2-VASc score of 2 (one additional risk factor besides being female).1,2,3

Warning: The Risks of Life-long Anticoagulation Therapy

Dr. Day concludes, “Somehow I think we have lost sight of the total picture with the new A-Fib management guidelines. In my mind, I am not convinced that the long-term stroke risk of a CHA2DS2-VASc score of 1 or 2 (depending on which risk factors are present) justifies all of the risks of life-long anticoagulation therapy, particularly if the patient has had a successful ablation procedure.”4 Dr. John Mandrola echoes Dr. Day, “And if there is no A-Fib, there is no benefit from anticoagulation.”5 Anticoagulants are not like taking vitamins, “Oral anticoagulants are high-risk medications.”6

Editorial comments:
“But CHA2D2-VASc are just guidelines, aren’t they? Doctors don’t have to follow them, do they?”
Unfortunately once guidelines like these become official, they in effect become the law of the land. If a doctor doesn’t follow them and a patient has a stroke, the doctor is almost guaranteed a losing malpractice law suit. The first thing a trial lawyer will point out to an arbitrator or jury is that the doctor didn’t follow current guidelines.
This puts doctors in a very difficult position. Even though Dr. Day knows all too well and agonizes over the fact that his anticoagulant therapy probably caused his patient Bob’s dementia, he can’t change the guidelines.

See also my articles: Women in A-Fib Not at Greater Risk of Stroke! and Israeli Study-Being Female Not a Risk Factor for Stroke.)

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Return to Index of Articles: Research and Innovations

Last updated: Saturday, December 31, 2016

References for this article
References    (↵ returns to text)

  1. Chao TF, et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation? J Am Coll Cardiol. 2015 Feb 24;65(7):635-42. doi: 10.1016/j.jacc.2014.11.046. PubMed PMID: 25677422. http://www.ncbi.nlm.nih.gov/pubmed/25677422
  2. Amson, Yoav et al.  Are There Gender-Related Differences In Management, And Outcome Of Patients With Atrial Fibrillation? A Prospective National Study. Arrhythmias and Clinical EP. Acc.15. JACC. March 17, 2015, Volume 65, Issue 10S.  doi: 10.1016/S0735-1097(15)60469-7 http://content.onlinejacc.org/article.aspx?articleid=2198096&resultClick=3
  3. Friberg et al. Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1. J AM Coll Cardiol. 2015; 65(3):a-232. URL: http://www.sciencedirect.com/science/article/pii/S0735109714070119. doi:10.1016/j.jacc.2014.10.052
  4. Day, John. Letter from the Editor in Chief. The Journal of Innovations in Cardiac Rhythm Management, 5 (2014), A6-A7. Last accessed May 15, 2014, URL: http://www.innovationsincrm.com/cardiac-rhythm-management/2014/may/586-letter-from-the-editor-in-chief
  5. Mandrola, John. Atrial Flutter–15 facts you may want to know. In AF Ablation, Atrial fibrillation. August 5, 2013. http://www.drjohnm.org/2013/08/atrial-flutter-15-facts-you-may-want-to-know
  6. Wilt, Daniel M. and Hansen, Alisyn L. editorial in New Oral Anticoagulants Can Require Careful Dosing Too. Medscape/Reuters Health Information by Scott Baltic, December 29, 2016. http://www.medscape.com/viewarticle/873821?src=wnl_edit_tpal

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