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Baltimore, MD
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.
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.
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 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.
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
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.
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 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
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.
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.
Magnesium Works in ERs to Reduce Risk of A-Fib or Return to Normal Sinus Rhythm
In the United Kingdom, it is common practice in critical care (E.R.) to administer serum magnesium to prevent A-Fib or to return patients to normal sinus rhythm.
This isn’t commonly done in the U.S.
UK ER Study: Magnesium Used in the ER to Prevent A-Fib
Research published in 2022 describes a study done of an adult critical care unit/emergency department (casualty) at the University College London Hospital between January 2016 and December 2017.
This single center observational study examined the preferences of critical nurses using Mg in patients who had undergone non-cardiac surgery.
Of 9,114 opportunities to administer intravenous Magnesium (Mg), there were significant variation practices depending on the individual nurses.
But still, intravenous Mg was associated with a 3% decrease in the relative risk of getting A-Fib after non-cardiac surgery.
Austrian ER Study: IV Magnesium Returns Normal Sinus Rhythm
A study from Vienna, Austria, looked at 2,546 episodes of non-permanent A-Fib in the emergency room (ER). Admission of Intravenous Magnesium (145.8 mg) and Potassium (24 mEq) were compared to no administration of either supplement.
Researchers found that Intravenous Magnesium and Potassium was associated with increased odds of returning patients to normal sinus rhythm (19.2% vs 10.4%) (but didn’t affect A-Flutter.)
Editor’s Comments
Though the above studies differ, they both show that administering Intravenous Magnesium in the ER is an effective tool in avoiding A-Fib or in returning A-Fib patients to normal sinus rhythm.
Some ERs in the U.S. do use Magnesium to return patients to normal sinus rhythm. (But many doctors still consider Magnesium [and most supplements] as little more than snake oil.)
This research is encouraging and indicates that Magnesium can be a useful tool with critical care patients. More research is needed.
What This Means for A-Fib Patients: If you wind up in the emergency room or urgent care for your Atrial Fibrillation, ask if they intend to administer an IV of Magnesium. (If not, why?)
For more about Magnesium, see my article, Cardiovascular Benefits of Magnesium: Insights for Atrial Fibrillation Patients.
Parlay an Ablation to Keep Dementia Away
I have written 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.
Good news! A recent research study tells us there’s a way to break that link.
Observational Study: Ablation Reduces Dementia
In a fascinating observational study from Turin, Italy, catheter ablation for A-Fib was associated with a nearly 50% reduction in dementia during a 4.5-year follow-up.
The researchers looked at four observational studies from 2020-2021 that included 40,146 patients of whom 11,312 had catheter ablation for A-Fib.
Compared to patients who developed dementia, they found having a catheter ablation for A-Fib reduced the risk of developing dementia by 50%!
Researchers concluded: ”Correct management of the arrhythmia holds the potential to delay or avoid cognitive decline occurrence.”
Important Research Findings for Patients with A-Fib!
We know that going from A-Fib to normal sinus rhythm increases and improves blood flow to the brain. So it’s intuitive to suppose that improving brain function would reduce the risk of dementia.
A-Fib patients who have a catheter ablation may now add another benefit to becoming A-Fib free, they may also significantly reduce the risk of developing dementia!
Seek Your Cure and a Two-For-One
If you have A-Fib, don’t settle for a life on meds. Don’t just “manage” your A-Fib. Seek your Cure.
A two-for-one! If your path to a cure includes a catheter ablation, you may also be reducing your risk of developing dementia. That’s a double whammy!
COVID-19 Increases Odds of Developing A-Fib
It’s unfortunate but we have to add developing A-Fib to the list of effects of having COVID-19.
A retrospective study from the Mass General Brigham hospital system in Boston studied the risk of hospitalized COVID patients to develop onset of atrial fibrillation. The study used data from between March 1, 2020 and February 28, 2021 and matched 11,004 COVID-19 negative patients to 2,283 COVID-19 positive patients.
They found that COVID-19 positive patients had 19% higher odds of developing Atrial Fibrillation compared to COVID-19 negative patients. And 57% higher odds of developing A-Fib compared to pre-pandemic patients.
Sad to say, during this world-wide pandemic, a greater risk of developing Atrial Fibrillation is yet another fallout of COVID-19 disease.
Treatment for Familial A-Fib: We know that Atrial Fibrillation runs in families. Recent data suggests that up to 30% of atrial fibrillation patients may have a family history of the condition. This includes offspring too.
If you have A-Fib and a blood relative develops COVID-19, there is treatment to reduce their chance of developing A-Fib. An antiarrhythmic medication can be prescribed on a temporary basis to prevent or better control early on-set A-Fib. Talk with them and their doctor about this treatment.
A-Fib Patients: When you have A-Fib, the risk for complications is elevated. Get vaccinated against COVID-19 and keep up with your booster shots. To avoid making your A-Fib worse, do everything you can to avoid catching COVID-19.
Pulsed Field Ablation Proves Safe Without Cerebral Complications
We have written many articles on Pulsed Field Ablation (PFA), a new and very effective treatment option for the ablation of A-Fib. (For a background on PFA, see my post: Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation.)
PFA continues in clinical trials, is awaiting FDA approval in the U.S. (expected in 2024), and is already in daily use in some countries.
Previous studies have shown that PFA performs catheter ablation effectively with no adverse effects, such as coronary artery stenosis, persistent phrenic nerve palsy, or esophageal damage. PFA doesn’t damage surrounding non-cardiac tissue.
But what about cerebral damage?
Thermal (RF) Ablation: Silent Cerebral Lesions
When using thermal ablation (Radio Frequency), procedure-associated stroke, while rare, can be among the most severe disabling complications of RF ablation.
Recent studies using magnetic resonance imaging (MRI) have shown the occurrence of silent cerebral lesions and/or events with possible cerebral complications using RF ablation.
Are there cerebral complications with Pulsed Field Ablation as the energy source?
Pulsed Field Ablation: No Neurological Problems
In a small (though probably definitive) study from Germany, 30 patients with symptomatic paroxysmal A-Fib received a Pulmonary Vein Isolation using Pulsed Field Ablation energy. Stroke scores, using the National Institutes of Health Stroke Scale, were assessed before the ablation and afterwards at 2 days and 30 days.
One day after receiving their Pulsed Field Ablation, patients underwent a cerebral MRI. Of patients, 97% showed no silent cerebral lesions or events. One patient did have a single, newly visible, asymptomatic, transient brain lesion. But forty days after the procedure, a follow-up MRI scan showed complete regression of the lesion.
None of the patients receiving the Pulsed Field Ablation had any neurological deficits.
Editor’s Comments:
Yet another study demonstrating the neurological safety of Pulsed Field Ablation (PFA). This study from Germany, used MRI to detect possible brain damage and found that PFA produced no neurological problems.
In practical terms, PFA is safer than current ablation energy sources.
Pulsed Field Ablation is a true game changer! I repeat my previous prediction that Pulsed Field Ablation will supersede all other types of catheter ablation for A-Fib.
Post-Operative A-Fib Happens Too Often and is Dangerous
A friend of ours had to undergo heart bypass surgery. Though I forewarned him, he did go into A-Fib after surgery. It’s called Post-operative A-Fib (POAF).
Why did this happen? The surgeon didn’t pretreat him before the surgery so that he wouldn’t get A-Fib.
Fortunately, after the surgery, the surgeon did put him on a protocol (amiodarone for a short time) that did bring him back into normal sinus rhythm. Luckily, he has remained free of A-Fib. Not all surgery patients are so lucky.
Post-operative atrial fibrillation (POAF) is a well-recognized consequence of surgery.
Nonetheless, doctors tend to view Post-Operative A-Fib as a benign event, triggered by the stress of the surgery.
Observational Study: How Often Does POAF Occur?
In an observational retrospective study of nearly 3 million patients, researchers collected data on health claims from 2016 to 2018 for discharges from acute care hospitals across 11 states in the USA.
Patients were followed up for an average (median) of 1.7 years. The researchers adjusted their analyses to account for factors that could affect the results such as age, sex, race, insurance status, medical history and body mass index.
Study Findings: Among 76,536 patients who underwent heart surgery, 14,365 (18.8%) developed A-Fib.
Among 2,929,854 patients without a history of heart disease who had surgery for non-heart-related conditions, 23,763 (0.8%) developed A-Fib.
The risk of hospitalization for heart failure for both groups of patients increased regardless of whether or not the surgery was for a heart condition. (Increased by a third and doubled, respectively.)
Risks of Post-Operative A-Fib
Occurrence rates of POAF are difficult to generalize as they vary by the type of surgery. It’s been estimated that Post-Operative A-Fib (POAF) occurs in as high as 64% of patients undergoing heart surgery (and from a low of 0.4% to a high of 26% of patients undergoing non-cardiac surgery.
Evidence is emerging that Post-Operative A-Fib is linked to longer term problems such as stroke and death from any cause and increased risk of hospitalization for heart failure. And may require more aggressive treatments for other risk factors such as high blood pressure, diabetes and narrowing of the arteries.
Editor’s Comments
These findings add to a growing body of literature suggesting that POAF is not just a transient response to surgery.
Post-Operative A-Fib and Heart Failure: The most disturbing point of this study is that post-operative A-Fib is linked to an increased risk of hospitalization for heart failure.
Insist on Use of Protocols: Anyone having surgery should make sure their surgeon knows about and uses protocols to prevent A-Fib after their surgery. They should insist on pre-op treatment.
It’s a shame that most surgeons don’t know about or use these protocols, it’s so simple to do.
To learn about pre-op treatments, go to my post, Having Surgery? Post-Operative A-Fib & Protocols to Prevent it.
References:
New Anticoagulant with less Bleeding Risk―Asundexian Factor XI (Bayer)
Today’s anticoagulants (DOACs-Direct Oral Anticoagulants) have a residual risk of major bleeding of 1.5-3.6%/year. That means that after stopping a DOAC anticoagulant, the effects can continue to affect you for 1½ to 3½ years afterward.
The result is you continue to be at a higher risk of major bleeding even though you are no longer taking the anticoagulant.
Alarming, bleeding events remain a high risk for you.
These bleeding events are associated with increased mortality, high costs, and compromised adherence to treatment. Especially for patients 65 and older, anticoagulants increase the risk of hemorrhagic-type strokes. (For more about anticoagulants, see my post: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.)
Pacific-AF clinical trials
Drug to Reduce Bleeding Event in Clinical Trial
Currently the PACIFIC-AF clinical trials is studying Asundexian, a new anticoagulant. Asundexian is an oral factor XI (FXIa inhibitor). Early clinical results indicate that FXIa inhibition works to prevent stroke with reduced bleeding risk. Clinical trials and phases are continuing.
If FXIa inhibition proves to be safer and as effective as existing DOACs, it would be a major advance in stroke-prevention therapy.
