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Who’s at Higher Risk of a Recurrent A-Fib Stroke?
You’ve had an A-Fib stroke—and you survived—hoorah! Now you wonder…am I more prone to a recurrent stroke? The answer may lie with how often your A-Fib episodes occur (i.e., paroxysmal versus persistent/permanent).
A recent observational research study from Japan posed this question:
In patients with a history of ischemic stroke and atrial fibrillation (A-Fib), is there a difference in the risk of future stroke between those with paroxysmal versus permanent atrial fibrillation?
What’s the Risk of a Recurrent A-Fib Stroke?
The SAMURAI-NVAF study included 1,192 A-Fib patients who had suffered an acute or ischemic stroke (where a clot blocks blood flow to the brain) and followed them for around 1.8 years.
Study patients were hospitalized within 7 days of stroke between April 2011 and March 2014 at 18 Japanese stroke centers. The average age was 77.7 ± 9.9 years, 44% were women, and 63.6% had persistent A-Fib.
Findings: Patients with Persistent A-Fib at Higher Risk of Recurrent Stroke
The researchers found a higher risk of ischemic stroke (or systemic embolism) in those with persistent A-Fib. Persistent patients also had higher rates of both ischemic strokes and transient ischemic attacks (TIAs).
Patients with persistent A-Fib were in general less healthy. They were more likely to have comorbidities: congestive heart failure, liver problems, higher alcohol use, and more disability after the first stroke.
Patients with paroxysmal A-Fib were associated with increased odds of “functional independence” 3 months after their A-Fib stroke (i.e., less likely to be disabled after the stroke).
Why More Stroke Risk When Persistent? The researchers noted that patients with persistent A-Fib have larger Left Atrial Appendage (LAA) size and more severe blood flow problems (lower LAA ejection fraction). … Continue reading this report…->
Unsafe Interaction Between Pradaxa and Common Calcium Channel Blockers
An observational study published in 2020 found that people with A-Fib taking two common rate control calcium channel blockers along with the anticoagulant Pradaxa had higher bleeding rates (GI bleeding, minor bleeding, and minor GI bleeding).
The study was an analysis of the potential drug-drug interaction between verapamil or diltiazem and DOACs.
The term DOAC has replaced use of NOAC.
The study was conducted using US population-based data (2010-2015) analyzed between January 1 and July 15, 2019. Data were obtained on 48,442 patients with nonvalvular atrial fibrillation who had received an index prescription of dabigatran, rivaroxaban, or apixaban.
Analysis was restricted to individuals with no history of kidney disease who were receiving standard doses of the DOACs.
Drug-Drug Interactions Found When Co-Administered
Researchers found that taking the drugs Verapamil and Diltiazem (rate control calcium channel blockers) along with the anticoagulant Pradaxa had higher bleeding rates.
Other anticoagulants such as Xarelto and Eliquis didn’t cause more bleeding. (Apixaban [Eliquis] had consistently lower bleeding event rates among all DOACs.)
(For you technical types, Dabigatran functions as a P-glycoprotein inhibitor (P-gp), an important protein that pumps many foreign substances, such as toxins and drugs, out of cells. Verapamil and diltiazem are also P-gp inhibitors.)
Pradaxa Data Compiled and Compared to Four Calcium Channel Blockers
The investigators compiled data from IBM Watson MarketScan Databases.
Comparisons were made between 1,764 Pradaxa (dabigatran etexilate) users taking verapamil or diltiazem versus 3,105 Pradaxa users taking amlodipine (a calcium channel blocker used primarily to lower blood pressure which isn’t a P-gp inhibitor). The overall bleeding rate was 52% higher compared to amlodipine.
In addition, comparisons were made between 1,793 Pradaxa users taking verapamil or diltiazem versus 3,224 Pradaxa users on metoprolol (a beta-blocker which isn’t a P-gp inhibitor). The overall bleeding rate was 43% higher compared to metoprolol.
Avoid Mixing Pradaxa with Verapamil & Diltiazem
The message of this study is clear. “Clinicians and patients may need to consider alternative DOAC therapy other than dabigatran” when using P-gp inhibitors such as verapamil and diltiazem. (Amiodarone is another P-gp inhibitor.) “It is not safe to combine dabigatran (Pradaxa) with P-glycoprotein (P-gp) inhibitors in people with atrial fibrillation (Afib)” regardless of kidney function.
What This Means to Patients
If you are taking the anticoagulant Pradaxa, along with Verapamil and Diltiazem (rate control calcium channel blockers), talk to your doctor about changing to another DOAC (and take a copy of this article with you).
Happily, there are several DOACs, so there’s seldom an overwhelming need to continue on Pradaxa (dabigatran). Eliquis (apixaban), for example, tested the best and is the safest of the DOACs.
Are Women at Higher Risk of Dementia? A Rotterdam Observational Study
Background: The Rotterdam Study is a population-based study ongoing since 1990 in the city of Rotterdam in The Netherlands. It was a response to the changing demographics leading to an increase of elderly in most populations. Follow-up studies have been effective in finding causes of heart disease and cancer.
Dementia risk is increasing worldwide. An observational population-based study from Rotterdam found that there was a higher risk of dementia in Dutch women versus men (25.9% vs 13.7%). Rates of stroke were similar between women and men. The women had a higher lifetime risk of developing dementia (1 in 3 for women vs 1 in 5 for men).
Is Greater Life Expectancy a Factor?
One can’t help but wonder why these Dutch women had an increased risk of developing dementia as compared to risk of stroke.
The authors of this study speculated that this discrepancy may be due to the fact that women in the Rotterdam study had a higher life-expectancy than men (83.5 years vs 81.7 years for men).
“With longer life-expectancy, individuals (women) in this study simply had more time to develop (dementia) in a timeframe with high age-specific incidence rates.”
The authors also pointed out that the women in this study “were substantially lower educated compared to men, which may have led to a lower dementia resilience in women.”
Gender-Specific Interventions to Reduce Risk of Dementia
Unfortunately, there aren’t any medicines that can cure dementia or slow it down. But there are treatments to help ease some of its symptoms.
The good news: In high income countries, there is a declining number of people developing dementia. This may be due to preventive strategies such as better vascular risk factor management, improved educational attainment, and other public health developments that improve the resilience for dementia.
The authors recommend gender-specific interventions to help reduce the risk of dementia. For example, support for women suffering from loneliness and depression and dietary counseling for men.
Editor’s Comments
Developing Dementia is Related to Aging Not Gender: This observational study does not imply that women are genetically inferior to men with regard to the risk of developing dementia. Developing dementia is related to aging, and women, in general, do live longer than men.
Loneliness and Depression Risk Factors for Dementia: I correspond with a woman with A-Fib who recently lost her husband. He died way too young. She is still devastated by the loss.
It happens all too often. Women out living their husband/life companion of many years.
Though a non-genetic factor, loneliness and depression certainly are risk factors for dementia. As a society we need to recognize what many older women experience and offer support.
How Long Does It Take for an A-Fib Clot to Form? The ASSERT Clinical Trial
Background: Of A-Fib stroke patients, 23% die and 44% suffer significant neurologic damage. This compares to only an 8% mortality rate from other causes of stroke.
How Long Does It Take for a Clot to Form? Some doctors say it only takes around 5 minutes for an A-Fib clot to form and cause a stroke that kills you.
This is generally not accepted thinking among Cardiologists and Electrophysiologists (EPs). The ASSERT clinical trial gives us some insights.
How Do Clots Form and Cause Strokes?
Clots aren’t formed instantaneously. It takes a while for blood to pool and form a clot of significant size. If you have a ten-minute attack of A-Fib, for example, it’s unlikely a clot/stroke will develop.
When someone is in A-Fib, blood is not being effectively pumped out of the left atrium. There are spots where blood can pool such in as the Left Atrial Appendage (LAA). This pooled blood can form a clot.
When the left atrium again beats normally, it can push this clot downstream into the left ventricle and into the bloodstream. From there, the clot can travel into the brain causing an ischemic (blocking) stroke.
Patients in permanent A-Fib are at higher risk of clots and stroke. But not in just a few minutes.
(Another risk of A-Fib is a hemorrhagic stroke when a blood vessel bursts, causing bleeding in the brain.)
ASSERT stands for “Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial”.
The ASSERT Study
The ASSERT clinical trial is a fascinating study with data collected by pacemakers and defibrillators (ICDs). Researchers looked at pacemaker patients and their risks of developing Silent A-Fib and stroke. Their primary question was: Do Pacemakers Prevent A-Fib?
A secondary benefit of the study is the A-Fib patient data collected. In particular, when and how long it takes for A-Fib patients to develop a serious risk of stroke.
The study gives us insight into when and how long it takes for A-Fib patients to develop a serious risk of stroke.
Study Description: The ASSERT study enrolled 2,580 patients, 65 years of age or older, with hypertension and no history of A-Fib, in whom a pacemaker or defibrillator (ICD) had recently been installed.
The pacemaker and ICD devices were programmed to detect silent A-Fib (i.e., Subclinical Atrial Tachycardia [SCAF]) when the heart rate reached 190 beats or more per minute lasting more than 6 minutes. The devices were checked at a clinical visit 3 months later. These patients were then followed up for around 2.5 years.
How Long in Silent A-Fib to Significantly Increase Clot/Stroke Risk
In the ASSERT study they found that it took more than 17.72 hours to significantly increase the annual stroke risk. The results of all patients are divided into four quartiles:
| Duration Quartile: Time in Silent A-Fib | Annual Stroke Risk |
| ≥ 0.86 Hours | 1.23 % |
| 0.87-3.63 Hours | 0 % |
| 3.64-17.72 Hours | 1.18 % |
| ˃ 17.72 Hours | 4.89 % |
Researchers found the annual stroke risks are similar to the stroke risk for healthy people (which is considered to be 1%).
The ASSERT study basically said that it takes around 24 hours of silent A-Fib to develop a serious clot/risk of stroke (on average 3.1%).
Contrary Interpretation: In a later analysis of the same ASSERT study by Van Gelder (2017), patients with lengths of Subclinical Atrial Tachycardia (SCAF) from 6hrs to 24hrs were not significantly different from patients without SCAF.
Similar Trial Results: The TRENDS study, a prospective, observational study, also used implanted devices and found similar results as the ASSERT study.
Do Pacemakers Work to Prevent A-Fib?
The primary question of the ASSERT study was: Do Pacemakers Prevent A-Fib?
Finding: Pacemakers (continuous overdrive pacing) “does not prevent clinical atrial fibrillation.”
Editor’s Comments
Shorter Episodes of A-Fib Not Generally Dangerous: Despite studies such and ASSERT and TRENDS, we still need many more studies on how long it takes for a clot/stroke to form. Probably the most useful data to date does come from the ASSERT study where it took around 24 hours of silent A-Fib before clot/stroke risk was significantly increased.
People with shorter episodes of A-Fib or silent A-Fib, such as may occur after a successful catheter ablation, may not need to be on anticoagulants at all. Remember that anticoagulants are high risk drugs that shouldn’t be taken unless there is a real risk of stroke.
The general consensus is that A-Fib clots/strokes take around 24 hours to develop. In a popular article in Bottom Line Health, Dr. Antonio Gotto, cardiovascular disease specialist at Weill Cornell Medical College in New York City, says it takes one day for a clot to form.
ADVENT Trial of Pulsed Field Ablation (PFA) for Paroxysmal A-Fib! PFA a True Game Changer
Fundamentally different from traditional methods for cardiac ablation, I expect the FARAPULSE Pulsed Field Ablation (PFA) will change the way catheter ablations are done and will become an innovative and most effective treatment option for Atrial Fibrillation.
U.S. Trial of Pulsed Field Ablation (PFA)
The U.S. trial of the FARAPULSE Pulsed Field Ablation (PFA) system is underway. The first patients in the ADVENT Trial were treated at New York’s Mount Sinai Hospital by Vivek Reddy, M.D., Director of Cardiac Arrhythmia Services.
” I believe PFA will define a new era in the ablation of AF and possibly other arrhythmias.” – Dr. Pierre Jais, French Bordeaux LIRYC
The ADVENT Trial is a prospective randomized pivotal trial of the FARAPULSE Pulsed Field Ablation System compared with standard of care ablation in patients with paroxysmal atrial fibrillation.
“…We look forward to how our study can move adoption of this procedure forward,” said Dr. Vivek Y. Reddy.
ADVENT Trial is Recruiting: You May Quality
There are 37 study locations participating in the ADVENT Trial (see the list). Recruiting is underway and you may qualify.
Key inclusion criteria: Patients are required to meet all the following inclusion criteria to participate in this study (there are also exclusion criteria):
• Age 18-75
• Paroxysmal atrial fibrillation
• Anti-arrhythmic drug failed for efficacy or intolerance
Learn more about the ADVENT Trial on the FARAPULSE website. Prospective patients of The ADVENT Trial should contact their physician.
How PFA Works
As an emerging technology, there are many concepts and treatment strategies that will be brand new to you (they were for me).
Pulsed Field Ablation (PFA) is fundamentally different from traditional methods for cardiac ablation. PFA is very tissue selective.
PFA is Tissue Selective; Green labels are Preserved tissue; Red label is Ablated tissue
Through a process called irreversible electroporation, cardiac tissue targeted for ablation is rendered electrically inactive while collateral tissues are spared.
Unlike traditional thermal methods, PFA works on the selected cell types while leaving others alone.
Based on European clinical trials, these electric fields have proven very effective in durably “silencing” abnormal heart signals, while reducing the risk of damage to other nearby tissues.
For more on how PFA works, see my report: 2020 AF Symposium Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.
First Approved in Europe
In March 2021, Pulsed Field Ablation (PFA) from FARAPULSE, Inc. received CE Mark approval and can now market in the Europeans Union and other CE Mark countries. FARAPULSE plans to launch by first partnering with a select number of physicians, then move to a broader rollout.
Boston Scientific has expanded investment in FARAPULSE, Inc. and secured an exclusive option to acquire it.
Editorial: Elderly With A-Fib and Dementia Still Given Blood Thinners
In a disturbing article about our elderly living in nursing homes, a third of older patients with A-Fib and severe dementia were still given anticoagulants during the last 6 months of their lives. This is according to analysis of patients Medicare data.
According to study authors, Dr. Gregory Ouellet of Yale University and his colleagues, “We were surprised that patients with markers of very high short-term mortality—for example, difficulty swallowing and weight loss—were more likely to be receiving anticoagulants…This is counterintuitive since the potential benefits of these medications are the lowest in this group.”
“These findings underscore the fact that, while practice guidelines contain a well-defined threshold for starting anticoagulation for AF, there is no clear standard for stopping it,” Dr. Ouellet and colleagues wrote in their article.
Dr. Ouellet unexpectedly found that greater bleeding risk (their ATRIA score) was also associated with greater odds of anticoagulant use. The greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants.
Improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.
Nursing home length of stay was more strongly associated with anticoagulant use instead of the patients’ stroke risk (CHA2DS2-VASc score).
In their study, Ouellet and co-authors used Medicare data to evaluate 15,217 nursing home residents with atrial fibrillation and advanced dementia who had at least moderate stroke risk (CHA2DS2-VASc score of 2 or more) and who died from 2014 through 2017.
That Makes No Sense! Is This the Way We Treat Our Elderly?
I was astounded to read this analysis found the greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants. This improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.
Nursing home patients with greater risk of bleeding should not be prescribed anticoagulants, but they were.
What this finding says is that many the nursing homes weren’t all that concerned about actual stroke risk when prescribing anticoagulants.
The most important treatment for elderly patients with severe dementia and limited life expectance is, as much as possible, to help their quality of life, to let them die in peace and as much comfort as possible. … Continue reading this book review..->
Catheter Ablation for A-Fib Lowers Dementia Risk
In an important study from South Korea, researchers found that patients undergoing a successful catheter ablation for A-Fib had a reduced risk of dementia.
Previous research had shown a link between patients with Atrial Fibrillation and an increased risk of dementia.
Normal Sinus Rhythm Reduces Dementia Risk
Successful ablation for A-Fib linked with reduced risk of dementia.
Using data from South Korea’s National Health Insurance Service, researchers identified 9,119 patients with Atrial Fibrillation who had a catheter ablation and 17,978 who received medical therapies.
During the follow-up period (6-12 years) dementia was found in 164 cases in the ablation group and 308 cases in the medical therapy group. Ablation was linked to a 23% lower incidence of Alzheimer’s disease and a 50% decrease in vascular dementia compared to medical therapies.
Intuitively one would think that going from A-Fib to normal sinus rhythm would increase and improve blood flow to the brain, thereby improving brain function.
And indeed, in this retrospective study, catheter ablation reduced the incidence of dementia by nearly a third (27%) compared to those who tried to control their A-Fib with medication alone.
Ablation Reduced Dementia by 44%!
According to one of the lead researchers, Dr. Gregory Lip of the University of Liverpool (UK), “…successful ablation was significantly associated with a 44% reduced risk of dementia compared to medical therapy…” (But not if the ablation failed.)
Editor’s Comments
Improved blood flow reduces Alzheimer’s. What’s perhaps most important about this study is the reduced risk or incidence of Alzheimer’s disease after a successful catheter ablation for A-Fib.
When people develop Alzheimer’s, it’s considered the end, that there’s very little that can be done to help these patients. But restoring blood flow to their brains seems to prevent or reduce Alzheimer’s.
Can we prevent or reduce Alzheimer’s by improving blood flow to the brain? Could these researchers have discovered a way to cure or improve Alzheimer’s? This could be ground-breaking research!
Hospitalized Pot Users with Arrhythmias at Higher Risk of Death
Marijuana or cannabis is the most commonly used psychoactive substance worldwide. However, there is limited knowledge about the safety of the drug in people with cardiac arrhythmias (i.e., Atrial Fibrillation and abnormally slow or fast heart rate).
Pot Users with Arrhythmias More Likely to Die in Hospital
An observational study of 2.4 million cannabis users hospitalized from 2016-2018 was conducted using the National Inpatient Sample database, which covers 97% of the US population.
Marijuana and A-Fib
Examined was the burden of arrhythmias in drug users admitted to hospital. The study also compared length of hospital stay and deaths in hospital between those with and without an arrhythmia.
The study found that cannabis users with an arrhythmia were 4.5 times more likely to die while in hospital than those without an arrhythmia, according to Dr. Sittinum Thangjui of Basset Healthcare Network, Cooperstown, NY.
Patients with an arrhythmia accounted for 7.6% (187,825) of the 2,457,544 adult cannabis users. Atrial fibrillation was the most common arrhythmia, followed by abnormally slow heart rate and abnormally fast heart rate.
“People should …be careful when using cannabis if they have a concomitant heart problem. -Dr. Sittinum Thangjui
The arrhythmia group were older: the average age was 50.5 years compared to 38.3 years for those without an arrhythmia. Those with arrhythmias also had more co-existing health conditions.
“People should be aware of this devastating outcome and be careful when using cannabis if they have a concomitant heart problem” says Dr. Sittinum Thangjui. He didn’t indicate or speculate how or why cannabis use caused or was associated more hospital deaths in patients with arrhythmias.
This research was presented at the EHRA 2021, an online scientific congress of the European Society of Cardiology (ESC).
Editor’s Comments:
Atrial Fibrillation patents who use cannabis be aware. Especially if you are older (50+) and have concomitant health problems such as diabetes, heart failure, chronic kidney disease or obesity.
However, common sense would indicate that these older arrhythmia patients would be more likely to die in the hospital, whether or not they used cannabis. (Only a brief abstract is currently available and not the complete study.)
Hospitalized COVID-19 Patients and Cardiac Scar Tissue
Much has been learned about COVID-19 in the last year. Of special interest to A-Fib patients are the possible effects on the heart.
Some studies of hospitalized COVID-19 patients report it’s common to find scars on the muscular tissue of the heart (myocardial lesions). Even those with a milder case of the virus are experiencing adverse effects on their heart health.
Currently, we don’t know if those cardiac scars could lead to future rhythm disorders. In the short-term, there seems to be no consequences.
A-Fib causes fibrosis that remodels your heart
What’s All the Fuss about Cardiac Scar Tissue (Fibrosis)?
Scar tissue is basically dead tissue with reduced or no blood flow. Over time it makes the heart stiff, less flexible and weak. This fibrotic tissue overworks the heart and reduces pumping efficiency.
Danger of Fibrosis: Any type of scarring and fibrosis in the heart may eventually affect heart function that could lead to heart failure and sudden cardiac death.
COVID-19 and A-Fib? We know that being in A-Fib can lead to scarred tissue (fibrosis) especially over time. Could COVID-19 produce the same type of scarring and contribute to your A-Fib?
You can reduce this risk by getting the COVID-19 vaccine to protect your heart.
VIDEO: Feb 2021: “How COVID-19 Affects the Heart“
Interview with Dr. Teresa Daniele, chief of cardiology at UCSF Fresno who shares with us how COVID-19 can affect people’s cardiac systems; and how the virus can cause direct inflammation of the heart, weakness and formation of muscle scar tissue. Published by MedWatch Today. Feb 22, 2021. (3:13 min.)
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click on arrow icon to start playback.
Air Quality, Pollution and Atrial Fibrillation: Is There a Link?
Millions of people live in areas where air pollution can cause serious health problems. Local air quality can affect our daily lives. Like the weather, it can change from day to day.
Researchers wanted to know if there’s a role of traffic & non-traffic air emissions in triggering cardiovascular (CV) hospitalizations.
They tested levels of air pollution (i.e. particulate matter, PM) in multiple urban areas of New York State, then the next day correlated this data with hospitalizations for arrhythmia.
Research Findings: This research revealed that higher pollution levels lead to:
• more than doubled hospitalization for A-Fib;
• nearly quadrupled hospitalizations for stroke.
This is a wake-up call for anyone with Atrial Fibrillation who lives in an urban setting.
Air quality is a measure of the solid particles and liquid droplets found in outdoor air. These pollutants (particulate matter) are emitted from power plants, industries and automobiles.
How Can I Reduce My Exposure to Air Pollution? You can use air quality alerts to protect yourself and others when particulate matter (PM) reaches harmful levels.
The Air Quality Index (AQI) tells you how clean or polluted your outdoor air is, along with associated health effects that may be of concern. Learn how you can get AQI notifications sent to you.
Check the Air Quality Data Where You Live: There’s a nifty little app to check your area’s air quality rating for today. Just enter your city name (it displays the best matches to select from) or enter your zip code.
The AQI “dial” will appear with your location’s information. See graphic example (right). To check your area’s air quality, go to AirNow (https://www.airnow.gov/)
Bottom Line if You Have A-Fib: Be aware of the air quality where you live. Protect yourself. Stay informed. (Many news channels report the AQI each day.)
If you have an inkling that your air quality might be low that day, go online and check the Air Quality Index for your locale. If it’s low, stay indoors. Curtail or postpone outdoor activities. If you must go out, use your car’s air conditioner.
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