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Part III: The Benefits of Ablation Across the AF Spectrum: A-Fib Patients with Advanced Heart Failure–CASTLE-HTx study

2024 AF Symposium

The Benefits of Ablation Across the AF Spectrum: From Early Intervention to Late-Stage Heart Failure: Part III

This important Friday session had five speakers: Dr. Stephen Willems, Dr. Jason Andrade, Dr. Philipp Sommer, Dr. Douglas Packer and Dr. Francis Marchlinski. –
Dr. Philipp Sommer of the University of Bochum, Bad Oeynhausen, Germany, gave the third talk in what was described as the “most important session of the whole meeting.”

AF Ablation in Patients with Advanced Heart Failure: CASTLE-HTx Study

Dr. Philipp Sommer

Dr. Sommer’s presentation could be considered a continuation of or an addition to the CASTLE-AF trial discussed in the 2018 AF Symposium.

As I wrote then, “the findings of the CASTLE AF clinical trial are one of the most important studies for patients in the last decade.” (See Live Longer―Have a Catheter Ablation.)

“If you look at the lectures [in this session], every one of them is Guideline changing This is the most important session of the whole [Symposium] meeting.”—Dr. Nassir Marrouche

All A-Fib patients in CASTLE AF had sick hearts and advanced heart failure (their ejection fractions were less than 35%). They all had ICDs (Implantable Cardioverter Defibrillators).

Patients received either RF catheter ablation or conventional drug therapy. The median follow-up was over 3 years (37.8 months).

Ablation Improves Not Just Quality but Quantity of Life (How Long One Lives)

Key results of the CASTLE AF trial were:

• 47% lower death rate in the catheter ablation group vs conventional therapy;
• 60% of the ablation group improved their ejection fraction by more than 35% thereby curing a major component of heart failure;
• 60% of the ablation group were in normal sinus rhythm after 5 years, compared to only 22% receiving conventional drug therapy;
• 51% reduction in cardiovascular mortality in the ablation group;
• Stroke rate of the ablation group was 50% of the conventional drug treatment group (even though 94% of the patients were taking Coumadin);
• 38% reduction in all-cause mortality and hospital admissions in the ablation group. A-Fib burden (percentage of time in A-Fib) also reduced;
• Heart failure hospital admissions in the ablation group reduced within 6 months of the ablation.

Ablate Heart Failure Patients as Early As Possible

Principal author of CASTLE AF, Dr. Nassir Marrouche, stressed that catheter ablation for A-Fib patients with heart failure should be performed early, the earlier the better, “…Ablate them early on, very soon in the disease stage.”

“Abate A-Fib patients with heart failure early, the earlier the better.”—Dr. Marrouche

Dr. Sommer’s CASTLE-HTx Study

The CASTLE-HTx study was conducted at the University of Bochum, Bad Oeynhausen, Germany, which is one of the leading heart failure centers in Europe. [For example, they do 100+ heart transplants a year].

Dr. Sommer’s CASTLE-HTx study can be considered a continuation of CASTLE AF.

When Is It Too Late for a Catheter Ablation?

Dr. Sommer asked, even though it’s obvious from CASTLE AF that catheter ablation is superior to standard medical therapy, “How sick is too sick, when is it too late for a catheter ablation?”  In one study he cited, end stage heart failure (congestive heart failure) was a risk factor for mortality at 30 days. 43% of end stage heart failure patients were too late to get any benefit from catheter ablation.

Dr. Sommer’s Study

Dr. Sommer and his colleagues did their own study of heart failure patients with a follow-up of 3 years. They compared catheter ablation to medical therapy [1/2 were on the dreaded amiodarone].

In one year, ejection fraction was improved by 8% in the ablation group, A-Fib burden was reduced by 50%, A-Fib progression was stopped and surprisingly regressed even though 70% of their patients were in persistent A-Fib. T

They were able to reduce the amiodarone dosage from 45% to 25%. Ablation improved left ventricular function which decreased A-Fib burden. Catheter Ablation was associated with a lower likelihood of death by a reduction in all-cause mortality. “Catheter ablation produced a regression in the end-stage heart failure population.”

To read other presentations in this series, go to My Summary Reports Written for Atrial Fibrillation Patients.

Editor's CommentsEditor’s Comments:
Dr. Sommer’s study adds new data to the original CASTLE AF findings that catheter ablation improves heart failure and mortality, even in patients with very sick hearts.
CASTLE-HTx Findings: Catheter ablation not only stopped progression but even regressed it. And being able to reduce the dosage of amiodarone is a significant benefit to patients. (See Amiodarone is a very toxic drug.)
A-Fib burden was reduced by 50%. As in CASTLE AF, ablation reduced the likelihood of death, which is a major physical and psychological improvement for these patients with very sick hearts. These patients were facing imminent death.
Getting Your Life Back! People with congestive heart failure (low ejection fraction) say it sometimes feels like they are suffocating. (For those with advanced heart failure, nearly 90% die within one year.) Can you imagine what patients in the CASTLE studies experienced when their ejection fraction went from less than 35% to a 60% improvement? It’s like someone was giving them their life back again!
Many of the CASTLE patients no longer suffered from heart failure. This is an amazing development in medicine. For people in this study, it’s like a miracle. They can now live more normal lives.
The Bottom Line: Becoming A-Fib free by a catheter ablation doesn’t just make you feel better and gets rid of your A-Fib symptoms. We now have hard data that ablation lets you live a healthier and longer life.
Return to 2024 AF Symposium Reports
If you find any errors on this page, email us. Y Last updated: Thursday, July 18, 2024

Summary: The Benefits of A-Fib Ablation Across the AF Spectrum—From Early Intervention to Late-Stage Heart Failure

2024 AF Symposium

Summary: The Benefits of A-Fib Ablation Across the AF Spectrum—From Early Intervention to Late-Stage Heart Failure

The 2024 AF Symposium’s Friday morning session (February 3, 2024) was moderated by Dr. Nassir Marrouche of Tulane Medical Center. He recalled a phone call from Dr. Moussa Mansour who said, “If you look at the lectures, every one of them is [A-Fib] Guideline changing…I want to remind everyone this is the most important session of the whole meeting.” That was a noteworthy statement.

The Benefits of Ablation Across the AF Spectrum: From Early Intervention to Late-Stage Heart Failure” session featured five speakers:

• Stephan Willems, Asklepios Clinic St. Georg, Hamburg, Germany
• Jason Andrade, VCH Research Institute, University of British Columbia, Canada
• Philipp Sommer, The Heart and Diabetes Center North Rhine-Westphalia, Germany
• Douglas Packer, Intermountain Heart Institute, Murray, UT
• Francis Marchlinski of the Un. of Pennsylvania, Philadelphia, PA

Summary of Key Points

(To read an individual report use the link below.)

1. Dr. Stephan Willems advocated that asymptomatic A-Fib patients (30%-40% of A-Fib patients) should be treated with catheter ablation as soon as possible, rather than just leaving them in A-Fib. Today’s Guidelines do not currently recommend this. A-Fib is a serious, progressive heart disease that usually gets worse over time. (Go to Dr. Stephan Willems’ talk.)

2. Dr. Jason Andrade showed how dangerous A-Fib progression can be. Preventing A-Fib patients from getting worse is a major concern of EPs. His own and other studies showed how ablation reduced progression by 75% and produced a better quality of life. The success rate of drugs was only 32.2%. “Intervening early is the best opportunity for patients.” (Go to Dr. Jason Andrade’s talk.)

3. Dr. Philipp Sommer documented that catheter ablation improves heart failure and mortality, even in patients with very sick hearts. Becoming A-Fib free gets rid of symptoms and makes you feel better. And lets you live a healthier and longer life. (Go to Dr. Philipp Sommer’s talk.)

4. Dr. Douglas Packer, continuing the research into heart failure, identified a large group of heart failure patients with A-Fib and preserved Ejection Fraction (50%-60% of all heart failure patients) who currently aren’t receiving much medical attention. Catheter ablation may become a life-saving therapy for many of these heart failure patients. (Go to Dr. Douglas Packer’s talk.)

5. Dr. Francis Marchlinski documented many studies which show that ablation is superior to medical therapy and is now a first-choice option for many A-Fib patients, though medical therapy still has a place in treating A-Fib. (Go to Dr. Francis Marchlinski’s talk.)

Editor's CommentsEditor’s Comments
The Friday morning session was indeed very important for A-Fib patients. Here’s why:
• Catheter ablation should be done as soon as possible (rather than waiting till one’s A-Fib gets worse), even in patients who are asymptomatic. (Breakthrough research) (Willems)
• A-Fib is a disease whose progression is very dangerous, but catheter ablation reduces progression by 75% and produces a better quality of life. (Breakthrough research) (Andrade)
• Catheter ablation improves heart failure and mortality, even in patients with very sick hearts. These patients live a healthier and longer life. (Breakthrough research) (Sommer)
•  Ablation should be used in patients with preserved Ejection Fraction (HFpEF) who are 50%-60% of all heart failure patients, but who currently are not the focus of much medical attention and therapy. (Packer)
• Ablation is superior to medical therapy. If someone wants to just leave you on antiarrhythmic drugs, get a second opinion. (Marchlinski)
What all this Means for Patients: Remember: You must be your own best patient advocate. Ask questions. Read. Learn (i.e., reading my posts on and AF Symposium reports.)
Don’t wait to act for your best A-Fib outcome. If you qualify for a Catheter ablation, have it done as soon as practical (rather than waiting till your A-Fib gets worse.)
You deserve a better quality of life. Don’t settle for a life on medication.
Return to 2024 AF Symposium Reports
If you find any errors on this page, email us. Y Last updated: Thursday, July 18, 2024

7 Key Points of the new “2023 Guideline for the Diagnosis & Management of Atrial Fibrillation”

This is my second report on the new “2023 Guideline for the Diagnosis & Management of Atrial Fibrillation” published in January 2024. The updated recommendations was a collaborated effort by cardiologists, electrophysiologists, surgeons, pharmacists, patient representatives and other stakeholders. The Guideline was last updated in 2014 and supplemented in 2019.
In my first report, I wrote why the new Guideline is important to all A-Fib patients and covered a few of the important updates. It includes new evidence to guide your cardiologist and electrophysiologist in the treatment of your Atrial Fibrillation.

7 Key Points For Patients to Know

After writing my first report, I continued to study the Guideline (it’s 171 pages after all).

This second report contains several important key points that may influence how you interact with your electrophysiologist and cardiologist. And can affect your choice of which A-Fib treatment(s) is right for you.

To be an informed patient, the main points you should know are:

1. As before, catheter ablation is recognized as first-line therapy for most A-Fib patients.

What that means is that you no longer have to undergo months or a year on antiarrhythmic (drug) therapy before you can have a catheter ablation. Even if you’ve just been diagnosed with A-Fib, you can choose to have a catheter ablation as your first treatment option.

From the Guideline: “Catheter ablation is useful as first-line therapy to improve symptoms and reduce progression to persistent AF.”

“Early rhythm control is associated with a greater likelihood of maintaining sinus rhythm in the long term and minimizing AF burden and reducing the progression of the disease.” And it reduces the likelihood of dementia onset.

2. The Guideline emphasizes the use of catheter ablation (CA) early in the treatment of A-Fib. Studies show an early catheter ablation is beneficial particularly in patients with heart failure.

3. Warfarin is no longer a recommended anticoagulant. Direct oral anticoagulants (DOAC) are preferred over warfarin (with the exception of certain patients with, for example, a mechanical heart valve).

4. Aspirin is no longer recommended as an anticoagulant. “Aspirin…alone as an alternative to anticoagulation is not recommended to reduce stroke risk.”

5. The guideline recognizes that clots take time to form (e.g. “lasting ≥24 hours”). Before, it was thought that even a short A-Fib episode (less than 5 minutes) could cause a clot and stroke.

Under the new guideline, for most patients whose A-Fib episodes last less than 5 minutes should not receive Oral Anticoagulant.

6. Important recognition: The benefits of Left Atrial Appendage Occlusion devices (i.e., Watchman, Amplatzer, etc.) may be a reasonable alternative to an Oral Anticoagulant.

7. The Guideline recognizes that “A-Fib burden” (how severe your A-Fib is and how it affects you) is an important factor in the treatment of your A-Fib.

Read it Yourself

If you haven’t already read it, I recommend you read my first report.

Also, if you want to review the Guideline yourself, the entire document is on the The Journal American College of Cardiology website. It includes a Table of Contents so you can jump to and read a particular section. Footnotes are included and linked to a 32-page Reference section as well as Appendices.

You can also download a copy of the 171 page Guideline as in a .PDF document and review it at your leisure.

• Crawford, Thomas E. et al. 2023 Guidelines for Diagnosis and Management of Atrial Fibrillation: Key Perspectives. American College of Cardiology, Nov. 30, 2023.

• Joglar, Jose A. et al. 2023 ACC/AHA/ACCP/HRS Guidelines for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Circulation Vol. 149, No.1.

2024 AF Symposium: An Overview For Atrial Fibrillation Patients and Families

The 29th annual AF Symposium was held in Boston Feb. 1-3, 2024.

This is the 20th time I have attended the annual AF Symposium. Observing and adequately reporting on it is both a challenge and a privilege. I learn more in three days than in a year of reading A-Fib research reports.

This intense 3-day seminar featured presentations by 85 leaders in A-Fib Research and Clinical Practice from all over the world.

Click on image to read my full report.

These stellar medical scientists, clinicians, and researchers shared recent developments in the A-Fib field in a major scientific forum unmatched by any other conference. This year the Symposium attracted over 1200 participants from all corners of the globe.

Why I Attend Every Year

As always, I attend and write my reports to offer readers the most up-to-date research and developments that may impact their treatment choices. All reports are written in plain language for A-Fib patients and their families. (Look for more of my reports in the coming weeks and months.)

Exciting Breakthroughs: A New World of A-Fib Care

The predominant mood or tone of this year’s Symposium was one of excitement about the extraordinary amount of new and more effective tools now (or soon to be available) to Electrophysiologists (EPs) for treating us patients.

To me the sheer number of new catheters, devices, etc. presented was almost overwhelming. As Dr. Pierre Jais of the French Bordeaux group (LYRIC) said, this a “great era!” There is now an incredible number of new tools EPs can choose from.  -> click to read my full report.

First-Time Catheter Ablation for Atrial Fibrillation Safer Than Ever

For patients with symptomatic A-Fib, catheter ablation is a commonly performed procedure. However, it does have potential complications. As with any procedure, the informed patient needs to know the risk factors.

To determine the most recent complication rates, researchers did a systematic review and pooled analysis of 89 studies from the past 10 years. Their results were published in May 2023.

Research Methods 

EDLINE and EMBASE databases were searched from January 2013 to September 2022 for randomized control trials that included patients undergoing a first ablation procedure using either radiofrequency or cryoballoon.

A total of 89 studies met inclusion criteria. A total of 15,701 patients were included in the current analysis.

By comparison, the complication rate for the common appendectomy is around 18%.

Survey Findings

Vascular complications (i.e., bleeding and clotting) were the most frequent type of complication (1.31%).

The next most common complications were pericardial effusion/tamponade (i.e., fluid buildup around the heart) (0.78%) and stroke/transient ischemic attack (blood clot to the brain) (0.17%).

During the 10-year period of the analysis, procedure-related complication rates were:
• Overall 4.51%
Severe  2.44%

Comparing the earlier 5-year period to the most recent 5-year period, complication rates were:
• Earlier period: 5.31%
• Most recent period: 3.77%.

Over the 2 time periods, mortality rates were stable.

There was no significant difference as to pattern of A-Fib, ablation technique, or ablation strategies beyond the pulmonary vein isolation.

Researchers Conclusions

When you see the term “catheter ablation” it’s shorthand for pulmonary veins ablation (PVA).
Procedure-related complications and mortality rates associated with A-Fib catheter ablation are low.

Complication rates have declined in the past decade (2013-2022).

A significant improvement in the safety of the procedure was observed over the last 5 years (2018-2022).

Neither the type of energy used for ablation nor the creation of additional lesions in addition to the pulmonary veins significantly influenced the procedural complication rate.

Editor's CommentsWhat This Means for A-Fib Patients

One of the drawbacks of these findings from a patient’s perspective it that it doesn’t differentiate between major and minor complications.

All Complications Are Not Equal: For example, vascular complications (such as bruising or bleeding at the catheter insertion points) are usually minor and easily taken care of with no lasting consequences.

More serious complications are:

Tamponade: Blood can bleed into the pericardium sac that surrounds the heart compressing it. Most centers and Electrophysiologists (EPs) are well aware of this and can move swiftly to drain off the extra blood.

Atrioesophageal Fistula: This is a very rare complication (less than 1 in 1000) but one which can kill you. When a catheter makes an RF burn (lesion) near the esophagus, the heat may damage the esophagus wall which can later be eroded by gastric acids allowing blood to leak into the esophagus. Most centers and EPs now take extensive precautions to prevent this. (The new technology, Pulse Field Ablation, virtually eliminates this complication, see Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation)

Stroke: During a catheter ablation you are on heavy-duty anticoagulants so strokes are rare (0.17%). But as with anyone with A-Fib, strokes can occur.

In this analysis of 89 studies the overall major complication rate was very small.

First-Time Catheter Ablation: The bottom line for us patients is that first-time catheter ablation (PVA) is one of the safest procedures you can have in a hospital. (FYI: By comparison, the complication rate for the common appendectomy is around 18%.)

In practice, for most A-Fib patients, the actual risks are so small that it’s safer getting a PVA than not getting one.

A PVA is safe and afterwards certainly feels a lot better than a life in A-Fib and/or a life on antiarrhythmic drugs and anticoagulants. One reason people get a PVA is so that they don’t have to live the rest of their lives on these drugs.

When choosing to have a catheter ablation, make the effort to find high volume operators and experienced hospitals.

Catheter Ablation is Considered a Low-Risk Procedure: Over 1 million catheter ablations are performed annually in the U.S.

The complication rate has continued to decrease.  In this analysis a significant improvement in safety was observed over the last 5 years.

But Beware of Low-Volume Operators: As patients we need to be aware that complications come mostly from low volume operators (those who perform less than 25 ablations a year), and that 81% of all ablations are performed by low volume operators.

This is important! When choosing to have a catheter ablation, make the effort to find high volume operators and experienced hospitals.

Benali K, Khairy P, Hammache N, et al. Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation. J Am Coll Cardiol. 2023 May, 81 (21) 2089–2099.

New “2023 Guideline for the Diagnosis & Management of Atrial Fibrillation”

Links updated: 12-21-23

Important for all A-Fib patients: The newly issued 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation. The guideline includes new evidence to guide your cardiologist and electrophysiologist in the treatment of your Atrial Fibrillation. It was last updated in 2014 and supplemented in 2019.

Cardiologists, electrophysiologists, surgeons, pharmacists, patient representatives and other stakeholders all collaborated on the updated recommendations.

First issued in 1980, the American College of Cardiology (ACC) and the American Heart Association (AHA) develop and publish these guidelines without commercial support, and members volunteer their time to the writing and review efforts.

ACC/AHA develop and publish these guidelines without commercial support, and members volunteer to write and review them.

ACC/AHA/ACCP/HRS: The 2023 Guideline is endorsed by four medical organizations: American College of Cardiology (ACC), American Heart Association (AHA), American College of Clinical Pharmacy (ACCP), and Heart Rhythm Society (HRS).

A Few of the Important Updates for Patients: I am still reading/studying this document—it’s 171 pages long. Here are a few updates that reflect important shifts in the treatment of A-Fib patients:

• Stages of atrial fibrillation: recognizes A-Fib as a disease continuum that requires a variety of strategies at the different stages;
• A-Fib risk factor: recognizes lifestyle and risk factor modification as a pillar of A-Fib management to prevent onset and progression;
• Catheter ablation of A-Fib: can be first-line therapy; Recognizes the superiority of catheter ablation over drug therapy for rhythm control;
• Left atrial appendage occlusion devices: recognized for safety and efficacy.

Steve Ryan at the 2023 AF Symposium

If you read regularly, you know these topics have filled my posts for years. I write about these topics after reading the newest research, evidence and findings, querying the experts and learn the latest innovations at the annual AF Symposiums from presentations by leading electrophysiologists, cardiologists, scientists and researchers (read my 2023 AF Symposium posts).

I’ll write more about these changes.

You Can Read it Yourself. It’s available on the websites of the American College of Cardiology ( and the American Heart Association (

Newly released: 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines; Issued by American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines; See or


A-Fib Patients: Know Your Risk During Non-Cardiac Surgeries

For patients with Atrial Fibrillation, any surgery is riskier than for patients without A-Fib. That’s the finding of a 2022 study.

In a study from the Cleveland Clinic, patients with A-Fib undergoing non-cardiac surgery were associated with higher risks of mortality, heart failure, and stroke.

“Non-cardiac Surgery” means any surgery that doesn’t involve the heart.

Study Parameters: Non-cardiac surgery was classified as vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. (Basically any major surgery not involving the heart.)

Participants included 8,635,758 Medicare patients admitted from 2015 to 2019 for various surgeries not involving the heart (non-cardiac surgery). Out of this number of patients, 16.4% of patients had A-Fib at the time of their surgery.

For patients with Atrial Fibrillation, any surgery is riskier than for patients without A-Fib.

Focus of the Study: Did post-surgery adverse events differ for A-Fib patients compared to the other participants?

Findings: The study found that pre-existing A-Fib is independently associated with postoperative adverse outcomes after surgery. These include increased risk of stroke, heart failure and other heart-related complications.

Editor's CommentsEditor’s Comments

Established Protocols: There are well established and known protocols to prevent, diminish or neutralize A-Fib when undergoing noncardiac surgery. The researchers, Waterford and Ad, state that preoperative oral amiodarone is the single most powerful intervention to dramatically reduce rates of POAF.
They recommend 400 mg oral amiodarone per day for 3 days prior to surgery, followed by 200 mg per day for 10 days through and following the operation regardless of whether or not POAF developed. It’s recommended that a patient be on a beta-blocker or a statin whenever possible.
Ideally, Become A-Fib Free Before the Surgery: If you have A-Fib and have to undergo non-cardiac surgery, try to become A-Fib free before the surgery. (This is even more important if undergoing cardiac surgery such as bypass).
Medication Adjustment: Even if you can’t have a catheter ablation, your EP can often adjust your meds so that you are A-Fib free at the time of the noncardiac surgery.
Proper Pre-Op Treatment: If it isn’t possible to be A-Fib free before the your surgery, make sure your surgeon knows about and uses protocols to prevent and diminish the effects of A-Fib on non-cardiac surgery. See Having Surgery? Post-Operative A-Fib & Protocols to Prevent it.
Be Insistent! Be Assertive! Be aware that many surgeons (and their staff) don’t know about or use these protocols.
If you’re told by the surgeon’s office staff to “Don’t worry about that.” or “The surgeon is very experienced,” don’t settle for platitudes.
You may have to be very assertive with your surgeon to make sure they understand your concerns and treat you properly before the surgery.

It’s Okay to Fire Your Surgeon: If your surgeon won’t work with you, there are many surgeons who will. It’s okay to fire your surgeon, and find another one who will address these concerns.

• Prasadam S. et al. Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery. JACC Journals, Vol. 79 No. 25.

• Waterford and Ad. 7 Pillars of Postoperative Atrial Prevention. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery. Editorial. November 25, 2021. doi: 10.1177/15569845211043485.

Research: Use of Illicit Drugs and Risk of Developing A-Fib

We are living in a time when law makers are considering more lenient laws on the use of illegal drugs. One unexpected effect of this shift may lead to more people developing Atrial Fibrillation.

Observational Research

This observational study used databases of the California Office of Statewide Health Planning and Development. The study included all adults in California from 2005 to 2015 who were A-Fib free at the time and received care in an emergency room department, same-day surgery unit, or hospital.

In this large, long-term study over 23 million patients were included. Of this study population 98,000+ used methamphetamine, 48,000+ used cocaine, 10,000+ used opiates, and 13,200+ used cannabis.

The researchers analyzed associations between the use of each substance and a new diagnosis of atrial fibrillation.

Risk Findings

Researchers found use of illicit drugs (methamphetamines, cocaine, opiates, and cannabis) was associated with a higher risk of developing atrial fibrillation compared with other known risk factors.

Of the total study population, over 998,000 patients (4.2%) developed Atrial Fibrillation during the 11-year study.

By Drug: Methamphetamine use nearly doubled the risk of developing A-Fib (86% increased risk). The corresponding increased risk for opiates, cocaine, and cannabis were 74%, 61%, and 35%, respectively.

By Multiple Drug Use: The researchers also investigated the impact of the number of drugs and frequency of use. Participants using two or more illicit drugs were 63% more likely to develop A-Fib than single drug users. The risks were basically the same for habitual versus occasional users.

Researchers Conclusion

Users of illicit drugs were at substantially greater risks of atrial fibrillation compared to non-users.

“This was the first large, long-term study examining the relationship between methamphetamines, cocaine, opiates, cannabis and atrial fibrillation,” said study author Professor Gregory Marcus of the University of California, San Francisco, U.S.

All four drugs were associated with higher risks of developing atrial fibrillation than many conventional risk factors including high cholesterol and diabetes. This indicates that avoiding these substances could help prevent the condition.

Editor's Comments

Editor’s Comments

The results of this observational study are very clear. If you take illicit drugs, your risk of developing A-Fib increases significantly.
This was a substantial study—over 23 million patients and long-term—over 10 years. The findings have important implications.
Professor Marcus offers this warning. “As some regions take steps towards legalizing recreational cannabis and adopting more lenient laws on the use of other illicit drugs, our research suggests caution and the importance of disseminating information on the potential harms.”

When considering less stringent control of these four drugs, legislators need to consider the personal and fiscal impact of more people developing Atrial Fibrillation.

• Marcus, Gregory. Illicit drugs linked with serious heart rhythm disorder. European Heart Journal, European Society of Cardiology, Oct. 18, 2022.

• Lin, A L, et al. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation, European Heart Journal, Volume 43, Issue 47, 14 December 2022, Pages 4933–4942,

Study Measures Cognitive Impairment/Dementia in Individuals over 65

My personal experience with dementia: My mother-in-law lived a great life till age 100. She was a grade school teacher with a Master’s degree, a championship bridge player and did the crossword puzzles in ink! But in her last 5 years her short-term memory deteriorated until all was lost. (Thankfully, due to her long-term memory, she still knew all of us.)

I wrote recently about studies documenting that A-Fib leads to or causes dementia. How A-Fib doubles the risk of dementia. And that there’s a direct cause and effect relationship, independently relating A-Fib to cognitive decline and dementia.

In 2021, about 6.2 million U.S. adults aged 65 or older lived with dementia.

Study Measures Cognitive Impairment in Individuals or 65

In a 2016 national study, 3,496 individuals over age 65 completed a comprehensive neuropsychological test battery and informal interview to determine if they had Dementia and/or Mild Cognitive Impairment (MCI).

Mild cognitive impairment (MCI) is a condition in which people have more memory or thinking problems than other people their age.

This nationally representative cross-sectional study found that approximately one-third of 3496 individuals 65 years and older had dementia or MCI. (10% were classified as having dementia; 22% were classified as having mild cognitive impairment.)

The results were similar to other US-based studies.

Prevalence of Dementia

No differences were found between females and males (though 60% of the participants in the study were female). But prevalance did vary by age, education, and race and ethnicity.

Age Increases Risk of Dementia: Every 5-year increase in age was associated with a higher risk of dementia.

What Decreases Risk? Each year of education was associated with a decrease in risk of dementia and MCI.

Dementia vs. MCI by Race: Dementia was more common among Black individuals, while mild cognitive impairment was more prevalent among Hispanics.

These findings are from the first representative study of cognitive impairment in more than 20 years.

There is Good News

In the U.S., the prevalence of dementia is declining among people over age 65, dropping 3.7 percentage points from 2000 to 2016, according to a new RAND Corporation study.

The age-adjusted prevalence of dementia declined from 12.2 percent of people over age 65 in 2000 to 8.5 percent of people over age 65 in 2016—a nearly one-third drop from the 2000 level.

Editor's CommentsEditor’s Comments

These are sobering, frightening statistics especially for us as we get older. One-third of those over 65 were found to some form of dementia.
That’s something none of us wants to experience.
How can those with A-Fib reduce their chance of developing Early Onset Dementia? Don’t stay in A-Fib! Do everything you can to become A-Fib free.
Don’t just “manage” your A-Fib. Don’t learn to live with it. Don’t settle for a life on drugs. Seek your cure!

For more reading about Dementia, see: A-Fib and Dementia: My Top 5 Articles

• George, Judy. Dementia Strikes One in Ten Americans Over 65. MedPage Today, October 24, 2022.

• Manly JJ, et al. Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US: The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project. JAMA Neurol. 2022;79(12):1242–1249. doi:10.1001/jamaneurol.2022.3543

• Hudomiet, P., et al. Trends in inequalities in the prevalence of dementia in the United States. PNAS, November 7, 2022. 119 (46) e2212205119.


Bleeding From Anticoagulants—All Anticoagulants are Dangerous

No one likes to take anticoagulants. They are inherently dangerous.

Drug therapy with oral anticoagulants in patients with atrial fibrillation is based on finding the ideal balance of effectiveness versus safety of these drugs.

In real-world clinical practice, bleedings were the most typical and common adverse events from treatment with oral anticoagulants (NOACs). Data from observational studies are an additional source of information for the adverse events (AEs) that come from taking anticoagulants.

Bleedings were the most typical and common adverse events from treatment with oral anticoagulants (NOACs).
One observational study, “ANTEY”, is a study from Russia that followed 186 A-Fib patients taking anticoagulants. The study reported 55 adverse events (AEs). There were 25 serious events, including 4 deaths.

The incidence of bleeding of those treated with NOACs was approximately 8% to 9%. (The bleeding risk with warfarin, was much higher.)

How Anticoagulants Decrease Your Risk of Blood Clots and Stroke

To decrease your risk of blood clots and stroke, anticoagulants hinder the clotting ability of your blood. The result is anticoagulants can cause or increase bleeding. That’s how they work.

In addition, they increase your risk of microbleeds in the brain, hemorrhagic stroke, early dementia, and gastrointestinal bleeding.

“Oral anticoagulants are high-risk medications” (Drs. Witt & Hansen).

Alert to Anyone Taking Anticoagulants

This study from Russia is another Red Flag alert for anyone taking anticoagulants.

It’s like playing Russian Roulette with your health. One out of ten times you’re at risk of a bullet to the brain (i.e., 8%-9% risk of Adverse Events when taking anticoagulants).

None the Less, Anticoagulants Do Reduce Your Chance of Stroke

But in spite of the possible negative effects of anticoagulants, if you have A-Fib and are at real risk of stroke, anticoagulants do work.

You’re no longer 4–5 times more likely to have an A-Fib (ischemic) stroke. Taking an anticoagulant to prevent an A-Fib stroke also may give you peace of mind.

If You Have A-Fib, Can You Safely Stop Taking Anticoagulants?

Never just stop taking your anticoagulant or reducing the dosage. That’s a decision for you and your doctor.

Yes! The best way to deal with the increased risk of stroke and side effects of anticoagulants is to no longer need them.

Here are three options:

#1 Alternative: Get rid of your A-Fib

As EP and prolific blogger Dr. John Mandrola wrote: “…if there is no A-Fib, there is no benefit from anticoagulation.”

Action: Request a catheter ablation procedure. Today, you can have an ablation immediately (called ‘first-line therapy’). You don’t have to waste a year on failed drug therapies. See Catheter Ablation Reduces Stroke Risk Even for Higher Risk Patients

#2 Alternative: Close off your Left Atrial Appendage (LAA)

The Left Atrial Appendage is where 90%-95% of A-Fib clots originate. Close off your LAA and you may no longer need to take an anticoagulant.

Action: Request a Watchman occlusion device. The Watchman device is inserted to close off your LAA and keep clots from entering your blood stream. See Watchman Better Than Lifetime on Warfarin

#3 Alternative: Consider non-prescription blood thinners

Ask your doctor about your CHA2DS2-VASc score (a stroke risk assessor). If your score is a 1 or 2 (out of 10), you are at low risk of having a stroke. You may not need to take an anticoagulant at all.

Action: Ask your doctor if you could take a non-prescription approach to a blood thinner. Perhaps you can benefit from an increase in natural blood thinners such as turmeric, ginger, vitamin E or, especially, the supplement Nattokinase. See FAQ: “Are natural blood thinners as good as prescription blood thinners?”  (Only change your medication under your doctor’s supervision.)

What this Means for A-Fib Patients

Bleeding from taking anticoagulants is a serious side effect. Drug therapy with oral anticoagulants  is based on finding the ideal balance of effectiveness versus safety of these drugs.

Perhaps the best balance may be to avoid needing anticoagulants in the first place:

Your options: Seek your A-Fib cure, i.e., get rid of your Atrial Fibrillation. Reduce your risk of stroke by closing off your Left Atrial Appendage. Or seek a non-drug natural blood thinner option to taking an anticoagulant.

• Martsevich, S. Y. et al. Analysis of Adverse Events in the Treatment of Patients with Non-Valvular Atrial Fibrillation with Oral Anticoagulants: Data from the “ANTEY” Observational Study. Pharmaceuticals. 2022, 13, 1209, MDPI.

• Witt, Daniel W. and Hansen, Alisyn L. New Oral Anticoagulants Can Require Careful Dosing Too. by Scott Baltic. Editorial, Medscape/Reuters Health Information, December 29, 2016.


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