Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


Research

Ablation Patients 10 Times Less Likely to Develop Persistent A-Fib Than Those on Drugs

Atrial Fibrillation is a progressive disease. For some that progress can happen quickly. For one in five patients, the path from Paroxysmal A-Fib (occasional) to Persistent A-Fib occurs within one year. (But there are people who’ve had Paroxysmal A-Fib for years.)

Delaying A-Fib Progression: Ablation vs Antiarrhythmic Drugs

The ATTEST study (The Atrial Fibrillation Progressions Trial) compared the treatments of radiofrequency (RF) catheter ablation versus standard antiarrhythmic drugs (AADs) in delaying A-Fib progression.

Patients were followed for three years. Of patients from the standard antiarrhythmic drugs group, 17.5% developed persistent A-Fib. While only 2.4% from the RF catheter ablation group experienced progression.

A-Fib Progression Delayed: The results at three years after study initiation show that patients treated with catheter ablation (aged 67.8±4.8 years) were almost 10 times less likely to develop persistent AF than patients on antiarrhythmic drugs.

“These results…suggest that early use of catheter ablation can significantly delay or prevent the progression of AF more effectively than drug therapy.”Prof. Karl-Heinz Kuck,” ATTEST lead author

The results of the ATTEST clinical trial aren’t at all surprising. It’s intuitive isn’t it? Someone free of A-Fib after a catheter ablation obviously wouldn’t progress to Persistent A-Fib—since they no longer have even occasional (paroxysmal) A-Fib.

The ATTEST study provides us additional clinical proof that catheter ablation may be a better treatment choice for most A-Fib patients compared to a lifetime on antiarrhythmic drugs (AADs).

Consider Working Aggressively to Stop Your A-Fib

Keep in mind there are people who’ve had Paroxysmal A-Fib for years and never progress to Persistent or Long-standing Persistent. But the odds are against you. The longer you have Atrial Fibrillation, the harder it can be to cure it.

Think About Your Treatment Goals: Is managing your A-Fib and increased stroke risk with meds okay with you? Or do you prefer to aim for a cure?

Discuss the options with your doctor. Take action as soon as practical.

For more about the ATTEST clinical trial, see AF Symposium ‘20 After Diagnosis, How Soon Should an A-Fib Patient Get an Ablation?

Resource for this article
ESC 2019: Catheter ablation may be up to 10 times more effective than drug therapy alone at delaying AF progression. Cardiac Rhythm News. September 2, 2019. https://cardiacrhythmnews.com/catheter-ablation-may-be-up-to-10-times-more-effective-than-drug-therapy-alone-at-delaying-af-progression/

A-Fib is Progressive infographic at A-Fib.com

Pre-Ablation Fitness Prevents Recurrence of Atrial Fibrillation

If you are physically fit before your catheter ablation for atrial fibrillation, you have a “much higher chance” of benefiting from the procedure and remaining in normal sinus rhythm (NSR). That’s the findings of a study from the Cleveland Clinic.

Less fit patients have more recurrence, are hospitalized more often, have to continue taking antiarrhythmic drugs longer, and have higher death rates.

Cleveland Clinic Physiology Fitness Study of A-Fib Patients (2012-2018)

In this study from the Cleveland Clinic, the participants were 591 patients scheduled to have their first catheter ablation for A-Fib.

Cardiorespiratory Fitness (CRF) relates to the ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity.

In the 12 months prior to their ablation, all were tested for fitness on a treadmill. Patients’ fitness was ranked as low, adequate, or high according to their Cardiorespiratory Fitness (CRF).

Astonishing Results: The Impact of Fitness

At 32+ months after ablation, findings among the three groups include:

Recurrence rate of:

• 79% of the low fitness group
• 54% of the adequate fitness group
• 5% in the high fitness group

Antiarrhythmic Drugs Use Discontinued in:

• 56% of the high fitness group
• 11% of the low fitness group

Mortality rate of:

• 11% of low fitness group
• 5% of high fitness group
• 4% of adequate fitness group

Comorbidities

Other diseases such as hypertension, diabetes, and obstructive sleep apnea were similar across all three groups.

Study Implications

According to lead investigator Wael A. Jaber:

“Being fit is a great antiarrhythmic… . High physical fitness can keep you in rhythm after A-Fib ablation… . Being physically fit acted almost like a medication…”

Previous Studies about Exercise

Previous studies have shown that exercise, weight loss, and similar lifestyle modifications not only improve A-Fib symptoms, but in some cases even result in freedom from A-Fib.

Lack of fitness has been shown to predict A-Fib and arrhythmia recurrence.

Exercise, weight loss, and similar lifestyle modifications can improve A-Fib symptoms, and in some cases lead to freedom from A-Fib.

Dr. Prashanthan Sanders of Adelaide, Australia has described the great results he is getting in his clinic which includes a weight loss program and counseling. He convinces his overweight patients to buy into the program, lose weight, and keep it off.

The program works so well that just by losing weight patients become A-Fib free.

This program is a holistic approach to health and also is developed to work for diabetes, sleep apnea, hypertension, binge drinking and smoking.

Requiring or Recommending Fitness Program for A-Fib?

The Cleveland Clinic study is probably the first study to look at the effect fitness has on patient outcomes after ablation.

Physical fitness improves your A-Fib symptoms and ablation outcomes.

The results are so convincing we need to look at whether a fitness program before an ablation may alter and improve the chances of a successful A-Fib ablation. i. e., “survival of the fittest.”

For example, many A-Fib centers now routinely require patients with sleep apnea to get treatment before they can get an ablation.

Could this be done for patients with poor fitness as well? (Unfortunately, poor fitness is often a result of being in A-Fib with lower ability to exercise adequately.)

Managing Comorbidities: Many A-Fib centers now target the monitoring and improvement in blood pressure, glycemic control and weight loss in patients with A-Fib. Perhaps, better fitness and exercise capacity should probably be added to this target list, especially before an ablation.

More Study Data Needed: An important follow-up clinical study would be to determine whether modifying fitness prior to ablation improves outcomes.

Bottom Line for A-Fib Patients Considering Catheter Ablation

All A-Fib patients should work to be as fit as they can be. It’s especially important before a catheter ablation.

Exercise and manage any comorbidities. Address your sleep apnea. Lose weight and/or maintain a healthy weight. Eat a healthy diet and limit alcohol consumption. These life choices can reduce or help manage high blood pressure and diabetes.

Resources for this article

• Donnellan E, et all. Higher baseline cardiorespiratory fitness is associated with lower arrhythmia recurrence and death after atrial fibrillation ablation. Heart Rhythm. 2020 Oct;17(10):1687-1693. doi: 10.1016/j.hrthm.2020.05.013. Epub 2020 Aug 3. PMID: 32762978

• Fitness linked to lower arrhythmia recurrence after AF ablation. Cardiac Rhythm News. August 7, 2010. https://tinyurl.com/AFIBFitnessAblationRecurrence

New Research: Rhythm vs Rate Control Drugs for Atrial Fibrillation

Background: Back in the early days of A-Fib research, the 2002 AFFIRM study found no mortality difference between Rate Control and Rhythm Control. Though largely discredited today, many Cardiologists still use the AFFIRM study to justify keeping patients on rate control drugs (and anticoagulants), while leaving them in A-Fib. (If your Cardiologist tells you that, it’s time to get a second opinion.)

Results of Leaving Someone in A-Fib

A-Fib is a progressive disease. Just putting patients on rate control meds (even if they have no apparent symptoms) and leaving them in A-Fib can have disastrous consequences. Atrial Fibrillation can:

Remember: A-Fib is a progressive disease. 

• Enlarge and weaken your heart often leading to other heart problems and heart failure.

• Remodel your heart, producing more and more fibrous tissue which is irreversible.

• Dilate and stretch your left atrium to the point where its function is compromised.

• Progress to Chronic (continuous) A-Fib often within a year; Or longer and more frequent A-Fib episodes.

• Increase your risk of dementia and decrease your mental abilities because 15%-30% of your blood isn’t being pumped properly to your brain and other organs.

AFFIRM (2002) Study: Not Really an Endorsement of Rate Control Drugs

Dr Andrea Natale

Dr Andrea Natale

In the AFFIRM study, most of the rhythm control patients took antiarrhythmic drugs (AADs) to try to stay in sinus. Very few had catheter ablations. But AADs are known to have many toxicities which caused their own set of health problems and negatively influenced the results.

Dr. Andrea Natale of the Texas Cardiac Arrhythmia Institute/St. David’s Medical Center in Austin, TX pointed out that the AFFIRM study was not really an endorsement of Rate Control drugs.

Success of Antiarrhythmic Medications Borderline: According to Dr. Natale, the 2002 AFFIRM study illustrates how ineffective and dangerous current antiarrhythmic drugs can be.

“…data from several trials have demonstrated that the success of antiarrhythmic medications (AADs) in maintaining sinus rhythm is borderline, at best, with increasing failure rates over time… AADs clearly do not cure A-Fib; at best, they are a palliative treatment used to reduce the burden of A-Fib as opposed to eliminating it altogether. …in our experience rhythm control is not only ineffective and poorly tolerated, but only delays an inevitable ablation.”

“…In our experience rhythm control is not only ineffective and poorly tolerated, but only delays an inevitable ablation.”

The AFFIRM study didn’t compare patients in Rate Controlled A-Fib with patients in Normal Sinus Rhythm (the goal of catheter ablation).

Study Conclusion: In fact, the AFFIRM investigators concluded, “the presence of sinus rhythm was one of the most powerful independent predictors of survival, along with the use of warfarin…Patients in sinus rhythm were almost half as likely to die compared with those with A-Fib.”

New Study Confirms Rhythm Better Than Rate Control

EAST-AFNET 4 stands for The Early Treatment of Atrial Fibrillation for Stroke Prevention Triall;  It started in 2011.

The EAST-AFNET 4 trial studied 2,789 patients with early A-Fib (and other cardiovascular conditions). They were randomized to either early rhythm control or rate control (“usual care”).

“Early rhythm control” included treatment with antiarrhythmic drugs or atrial fibrillation catherter ablation. Patients were included if they were diagnosed less than a year before enrollment (median time since diagnosis was 36 days).

Duration of Study: Patients were followed for about five years. The primary outcomes examined were death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome (first primary outcome).

Study Results: The early rhythm-control strategy proved superior to rate control and was associated with a lower risk of adverse cardiovascular outcomes than usual care.

Editor’s Comments:

We should not be surprised that rhythm control proved better for patients than rate control.
Let’s bury the 2002 AFFIRM study once and for all!

Remember: A-Fib is a progressive disease. Leaving people in A-Fib while just trying to control their rate (symptoms) is imprudent and over time can be very harmful to A-Fib patients.

Resources for this article
Wyse DG, et al; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. doi: 10.1056/NEJMoa021328. PMID: 12466506. https://pubmed.ncbi.nlm.nih.gov/12466506/

Kirchhof, P. et al. Early rhythm-control therapy in patients with atrial fibrillation. (EAST-AFNET 4 trial). N Engl J Med., 2020 August 29. https://www.nejm.org/doi/full/10.1056/NEJMoa2019422

Debate “Catheter Ablation should be first line therapy in selected patients with A-Fib” Boston AF Symposium, January 13-14, 2006. https://a-fib.com/boston-af-symposium-2006-summaries/#debate

Insertable Cardiac Monitor (ICM) to Prevent Recurrent Stroke

The CRYSTAL-AF randomized control trial looked at patients who had a cryptogenic stroke (e.g., a stroke with no identifiable cause). These strokes, 20-40% of cases, account for nearly 175,000 ischemic (blocked artery in the brain) strokes every year in the U.S. (American Stroke Association).

This type of stroke i.e., undetected, can be caused by Silent Atrial Fibrillation.

In this study, patients received an Insertable Cardiac Monitor (ICM), such as the Medtronic Reveal LINQ loop recorder, to detect A-Fib. It’s inserted under the skin and works 24/7 for three years. [I have one. It’s very small and not noticeable.]

By detecting silent A-Fib, ICMs lower the risk of a patient having a second stroke.

Nine-Fold Higher A-Fib Detection Rate

The CRYSTAL-AF study found that using ICMs provided a nine-fold higher A-Fib detection rate compared with the standard treatment (e.g.: intermittent ECG and Holter monitoring).

Medtronic Reveal LINQ insertable heart monitor

Insertable Cardiac Monitor (ICM) from Medtronic 

This finding led many patients who had experienced a stroke of unknown cause (cryptogenic), to start taking anticoagulants. [Truth be told, most people who have a stroke and survive it are put on anticoagulants or antiplatelets and don’t have to be motivated to take them.] 

A similar study using the Zio monitor, iRhythm Technologies, Inc., found similar results. While wear time in the study with the Zio patch was up to 4 weeks, an ICM lasts for 2-3 years.

ICMs Improve Quality of Life and People Live Longer

In the CRYSTAL-AF study comparing immediate ICM use versus standard treatment of intermittent ECG and Holter monitoring. Patients showed a benefit in quality-adjusted life-year (QALY) of 0.198 and an improvement of 0.226 in life years.

The Quality-Adjusted Life Year (QALY) is a measure of the value and benefit of health outcomes.

The ICM approach was projected to lead to 60 fewer lifetime ischemic strokes per 1,000 patients. And ICM was shown to be a cost-effective monitoring strategy.

A-Fib Stoke: Higher Risk if Age 65+

If you have an A-Fib stroke and survive, you have about a 50% higher risk of remaining disabled or handicapped (compared to stoke patients without A Fib).

MRIs often show permanent lesions on the brain from the stroke, even if the patient recovers.

All too many people 65+ have a stroke of unknown cause. Only after they have a stroke and survive it, do they find out they had “silent” A-Fib, and that it probably caused their stroke. But obviously, at that point, that’s too late.

CRYSTAL-AF: Find A-Fib Before a Second Stroke

From a public health standpoint, the CRYSTAL-AF study highlights the need to check if a stroke patient has Atrial Fibrillation and treat in time to prevent a second stroke.

“Atrial fibrillation after cryptogenic stroke [of undetermined source] was most often asymptomatic and paroxysmal and thus unlikely to be detected by strategies based on symptom-driven monitoring or intermittent short-term recordings.” -Sanna, et al. NEJM

Editor’s Comments

Editor's Comments about Cecelia's A-Fib story

Danger of Anticoagulants: The CRYSTAL-AF model assumes that all patients would start taking a NOAC ( anticoagulant) once A-Fib is diagnosed.
But should everyone over 65 with silent A-Fib be on anticoagulants? Remember: anticoagulants are high risk drugs and can cause problems such as hemorrhagic strokes. i.e. bleeding in the brain. (See High Hemorrhagic Risk Factors from NOACs and Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.)
Options for A-Fib Stroke Prevention: Beyond Drug Therapy. A-Fib patients have several options to prevent A-Fib strokes rather than having to take anticoagulants (NOACs).
A-Fib patients have several options to prevent A-Fib strokes rather than having to take anticoagulants (NOACs).
The most obvious one is to become A-Fib free through a catheter ablation. You can’t have an A-Fib stroke if you no longer have A-Fib.
Another option is to close off or cut out the Left Atrial Appendage (LAA) where most A-Fib clots originate (strategies include the Watchman device or AtriClip heart surgery).
A third option is natural blood thinners such as Nattokinase, even though they haven’t been tested as much as NOACs.
ICMs Detect Silent A-Fib and Save Lives: Insertable Cardiac Monitors (ICMs) can tell doctors (and patients) if someone has “silent” A-Fib, i.e. without any apparent symptoms. Silent A-Fib accounts for 20%-40% of strokes.
Could lives be saved and brain damage avoided if everyone reaching age 65 could be given an ICM? 
How many people over age 65 have silent A-Fib? How many lives could be saved and brain damage avoided if everyone reaching age 65 could be given an ICM? ICMs aren’t very expensive, especially when one considers the alternative.

From a public health standpoint, we need a concerted effort to educate doctors and patients on the dangers of silent A-Fib strokes and how to reduce the risk.

The Routine EKG May Not be Enough: Compared to getting a routine EKG at your doctor’s office, ICMs are much more effective at detecting silent A-Fib. Perhaps consumer devices like the Apple Watch can provide this same info.

Resources for this article

• Steinhubl SR, et al. Effect of a Home-Based Wearable Continuous ECG Monitoring Patch on Detection of Undiagnosed Atrial Fibrillation: The mSToPS Randomized Clinical Trial. JAMA. 2018;320(2):146–155. doi:10.1001/jama.2018.8102

• SCREEN-AF study results published in JAMA Cardiology, Cardiac Rhythm News. March 3, 2021. https://cardiacrhythmnews.com/screen-af-study-results-published-in-jama-cardiology/

• Sanna T, et al. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF). N Engl J Med. 2014; 370(26):2478-2486

• Sinha, A. et al. Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale https://pubmed.ncbi.nlm.nih.gov/20598970/ DOI: 10.1016/j.ahj.2010.03.032

Catheter Ablation for Atrial Fibrillation Prevents Recurrence Compared to Drugs

Several recent research trials and studies have demonstrated that up to 94% of patients with Atrial Fibrillation treated with catheter ablation are free from arrhythmia recurrence at one year.

And, with nearly one-half the chance of death, stroke, cardiac arrest, and cardiovascular hospitalization when compared to patients on antiarrhythmic drugs (AADs).

In addition, these studies show that catheter ablation could significantly improve patient quality-of-life versus a treatment strategy of drug therapy. (Also, ablation is a more cost-effective option over the long term.)

Recurrences Attributable to Comorbidities (Other Illnesses)

With so many catheter ablations for A-Fib being performed worldwide (some estimate over one million preformed last year), it’s inevitable that anecdotally you’ll hear of people having recurrences.

Comorbidities raise risk of A-Fib recurrence

Comorbidities raise risk of A-Fib recurrence

But recurrences are often attributable to comorbidities such as diabetes, sleep apnea, high blood pressure, obesity, etc.

For example, if you come in with sleep apnea, some centers won’t allow you to have a catheter ablation till you get the sleep apnea problem under control, because of the threat of recurrence.

To lower your risk of recurrence after a successful ablation, aim to avoid other health problems. Address your sleep apnea. Lose weight and/or maintain a healthy weight. Stay fit, eat a healthy diet and limit alcohol consumption. These life choices can reduce the risk of developing high blood pressure and diabetes.

Staying in generally good health (and avoiding comorbidities) will lower your risk of recurrence of your A-Fib.

Why Not to Fear Recurrence: Consider a Worst-Case Scenario

For a moment, let’s discuss a worst-case scenario. At age 60 you are diagnosed with Lone A-Fib (no comorbidities) and have a catheter ablation which makes you A-Fib free.

It lasts 10 years. But think. For all those 10 years, you’ve know what a blessing it is being in normal sinus rhythm (NSR).

If your A-Fib recurs it’s not the end of the world. You and your doctor will deal with it.

Then, at age 70, your A-Fib returns. After a short touch-up ablation (which probably filled in some gaps that appeared in the ablation lines), you’re once again A-Fib free. And, you will probably live in normal sinus for the rest of your life.

(This scenario worked out pretty well, don’t you think.) If your A-Fib recurs it’s not the end of the world. You and your doctor will deal with it.

For A-Fib Patients Reluctant About Catheter Ablation

The track record for successful catheter ablation to treat Atrial Fibrillation is impressive. And continues to outperform treatment with antiarrhythmic drugs (AADs).

While recurrence does happen, it’s mostly after years of living A-Fib free in normal sinus rhythm. If that happens, often it only requires a “touch-up” ablation to get back once again in normal sinus rhythm.

It makes no sense to not have a catheter ablation because of some remote possibility you might have a recurrence!

On a Personal Note

My 21-year Catheter Ablation ‘Warranty’ Ran Out! 

My A-Fib returned in Sept. 2018. Recurrence didn’t come as much of a surprise. Back in 1998 my ablation was primitive compared to what EPs are doing today. They actually ablated inside just one of my pulmonary veins (PVs) to eliminate the A-Fib signal source. -> Read how Steve Ryan’s became A-Fib-free again.

Resource for this article

• Biosense Webster, Inc. Announces Catheter Ablation May Be up to 10 Times More Effective Than Standard Drug Therapy Alone at Delaying Progression of Atrial Fibrillation. October 3, 2019. ESC Congress

• ESC 2019: Catheter ablation may be up to 10 times more effective than drug therapy alone at delaying AF progression. Cardiac Rhythm News. 2nd September 2019. https://tinyurl.com/25xykh3k

• Philips, T. et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. https://pubmed.ncbi.nlm.nih.gov/29315411/ doi: 10.1093/europace/eux376

• Johnson &Johnson, October 3, 2019. Biosense Webster, Inc. Announces Catheter Ablation May Be up to 10 Times More Effective Than Standard Drug Therapy Alone at Delaying Progression of Atrial Fibrillation. https://tinyurl.com/4n7xdsh5

Additional Sources:

• Hussein A, et al. Prospective use of Ablation Index targets improves clinical outcomes following ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2017. 28 (9): 1037-1047.

• Taghji P, et al. Evaluation of a Strategy Aiming to Enclose the Pulmonary Veins With Contiguous and Optimized Radiofrequency Lesions in Paroxysmal Atrial Fibrillation: A Pilot Study. JACC Clin Electrophysiol 2018. 4 (1): 99-108.

• Phlips T, et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. Europace 2018. 20. (FI_3): f419-f427.

• Solimene F, et al. (2019) Safety and efficacy of atrial fibrillation ablation guided by Ablation Index module. J Interv Card Electrophysiol 2019. 54 (1): 9-15.

• Di Giovanni G, et al. One-year follow-up after single procedure Cryoballoon ablation: a comparison between the first and second generation balloon. J Cardiovasc Electrophysiol 2014. 25 (8): 834-839.

• Jourda F, et al. Contact-force guided radiofrequency vs. second-generation balloon cryotherapy for pulmonary vein isolation in patients with paroxysmal atrial fibrillation-a prospective evaluation. Europace 17 2015. (2): 225-231.

• Lemes C, et al. One-year clinical outcome after pulmonary vein isolation in persistent atrial fibrillation using the second-generation 28 mm cryoballoon: a retrospective analysis. 2016. Europace 18 (2): 201-205.

• Guhl EN, et al. Efficacy of Cryoballoon Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol 2016. 27 (4): 423-427.

• Irfan G,  et al. One-year follow-up after second-generation cryoballoon ablation for atrial fibrillation in a large cohort of patients: a single-centre experience. 2016 Europace 18 (7): 987-993.

• Boveda S, et al. Single-Procedure Outcomes and Quality-of-Life Improvement 12 Months Post-Cryoballoon Ablation in Persistent Atrial Fibrillation: Results From the Multicenter CRYO4PERSISTENT AF Trial. JACC Clin Electrophysiol 2018.  4 (11): 1440-1447

Research: Catheter Ablation for Atrial Fibrillation Lowers Risk of Dementia

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 that A-Fib was linked to an increased risk of dementia.

Sinus Rhythm Reduces Dementia

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.

Alzheimer’s disease is one type of dementia.

Using data from South Korea’s National Health Insurance Service, they identified 9,119 patients who had ablation and 17,978 who received medical therapies. During the follow-up period (6-12 years) there were 164 cases of dementia 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.

Ablation was linked to a 23% lower incidence of Alzheimer’s disease and a 50% decrease in vascular dementia compared to medical therapies.

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…”

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!

Resource for this article
Catheter ablation linked to lower incidence of dementia in AF patients, Cardiac Rhythm News. October 7, 2020. https://tinyurl.com/LowerDementia

Interview with Michele Straube on Results of Survey of A-Fib Patients and Wearable Devices

by Steve S. Ryan

We are happy share the results of Michele Straube’s survey of A-Fib patients on consumer wearable/portable devices/apps which many of you participated in April 2019. She received a great response―315 replies! You can review the actual survey and tabulated results at: Survey Questions and the Results.

You may want to re-read Michele Straube’s 2010 A-Fib story, Cured after 30 years in A-Fib. She recently had a second catheter ablation June 11, 2020  and is doing fine, “Went for a walk in the mountains yesterday with 500’ elevation gain, and felt good.”

Michele Straube

Interpreting the Survey Data

I asked Ms. Straube to share her insights and conclusions about her survey data and how it might or should affect A-Fib treatment strategies.

“What do you think is important in your survey’s responses?”

It’s important how many people responded, and the fact that these AFib patients are very interested in having data about their condition.

It’s clear that AFib patients are interested in being an active part of the team managing their condition. Doctors should welcome this (but see below).

For device and apps developers: there’s a huge market for wearables with apps that help inform AFib patients and gain peace of mind when making treatment decisions. Current devices don’t necessarily give us all the information we’re seeking.

There should be greater collaboration between the device developers and patients in future research and design.

Review the actual survey and tabulated results at: Survey Questions and the Results.
 “What information were you looking for?”

I wanted to know if AFib patients use wearable devices? And if so, why and how they use the data. What device or apps would they like someone to design for them.

 “Were you surprised by any of the results?”

I was surprised how many different devices there are that give some kind of relevant data (over 45 different brands), yet virtually none of the A-Fib respondents were 100% satisfied with their device’s capabilities.

About 10% of the respondents said that their doctors were not interested in seeing the data from wearable devices!!!

Many of the respondents wished for device capabilities that already exist; i.e., the devices are not being marketed to the right audience.

 “What results do you think should be published?”

I wanted to know how AFib patients currently use the data available and what they wish would be developed.

“How do you think your results should influence A-Fib treatment strategies?”

Educate: AFib patients should be educated about the various types of consumer devices and encouraged to use them to help manage their AFib.

Medical providers: doctors should welcome this independently collected additional data (especially for patients who experience AFib episodes when they’re not in the doctor’s office).

Treatment costs: A patient’s use of wearables and apps can reduce the overall expense of AFib treatment.

Michele shared how she used a wearable device:

Using myself as an example, I take an ECG reading on my device, email it to the doctor’s office, and we discuss what to do about a “bad” reading via email or phone. 

The one time my device was not working correctly, I had to go into the office for an official EKG reading, which took up much more of everyone’s time and cost oodles of money … and the end result (modification of my meds) was the exact same had I emailed a reading from my device.

We appreciate Michele’s survey work and sharing the results and her conclusions with A-Fib.com readers.

Review the actual survey and tabulated results at: Survey Questions and the Results.

Michele expressed her gratitude to all who participated in this survey, and to A-Fib.com and other sites that solicited A-Fib patients to take the survey. Michele Straube can be reached at mstraube@mindspring.com

Results of Survey of A-Fib Patients and Wearable Devices

Michele Straube

In the spring of 2019, Michele Straube (who was cured of her A-Fib in 2010), conducted a survey of A-Fib patients about consumer wearable technology and apps designed to collect and share a patient’s cardiac data in real-time. The survey was completed by 315 A-Fib patients.

Read our interview with Michele in August 2020 who shares her insights and conclusions about the survey data.

Results of Survey of A-Fib Patients and Wearable Devices

Q1 The Survey Introduction; completed surveys: 315
Q2:  Which type of AFib do you suffer from?
  • Paroxysmal (>55% — more than half)
  • Persistent (~13%)
  • Permanent (~8%)
  • No longer in AFib (~15%)
  • Other (~7%, variations on the above themes)
Q3:  How long have you been diagnosed with AFib?
  • Less than 1 year (10%)
  • 1-2 years (~22%)
  • 3-5 years (~25%)
  • More than 5 years (~39%, plus ~4% other)
Q4:  Do you regularly use any of these wearable/portable devices/apps to provide you with AFib-related information?
  • Handheld (portable) ECG/EKG monitor (~47% — almost half)
  • Wristband HR monitor (~32%)
  • Wristband ECG/EKG monitor (~15%)
  • Lead- and wire-free event monitor (~3%)
  • No, don’t use any devices (~13%)
  • Other (15%) – BP monitor, implanted loop monitor, pacemaker, etc.
Q5:  Brands
  • Alivecor/Kardia: 150 (almost half)
  • Apple Watch (some version): 62 (20%)
  • Fitbit/Garmin (some version) 56 (~19%)
  • Ziopatch: 6 (~2%)
  • Others: ~40 other separate brands
Q6:  What made you decide to regularly use the wearable/portable device/app?
  • Prescribed by my doctor (~10%)
  • Personal decision (~73%)
    • Be informed / peace of mind / decide about meds (101, one-third)
    • ID “silent” AF episodes / document AFib to doctor when not in office (60, 20%)
    • Reduce ER visits / decide whether to contact doctor (24, ~8%)
    • Prevent overdoing it during exercise (18, ~6%)
Q7:  If you do use a device/app, which AFib-related information do you find valuable?
  • HR – instantaneous reading (~75%)
  • Heart rhythm (~71%)
  • HR – trends over time (~48%)
  • ECG/EKG (~44%)
  • HR variability (~35%)
  • Sleep data (from CPAP and other device) (~30%)
  • BP (20%)
  • Oxygen saturation (10%)
Q8:  Does having AFib-related information from your device/app change your behavior?  How?
  • No, does not change behavior (100, almost one-third)
  • Yes, does change behavior (a little over two-third)
    • Actions to end/prevent AFib (85, ~28%)
    • “Emotional comfort blanket” / reduced anxiety (45, ~15%)
    • Modify meds (24, ~8%)
    • How fast to get to ER, contact doctor (14, ~5%)
  • Makes me panic / become obsessed with HR (7, ~2.5%)
Q9:  Do you share any of the data with your doctor?  How?  What does doctor do with it?
  • Yes: 177 (more than half)
  • No: 87 (~30%)
  • What share?
    • Rhythm strip (108, one-third)
    • HR trends / HR spikes (21 (~7%)
    • times / length in AFib (20, ~7%)
    • Summaries / trends (14, ~5%)
    • Own charts analyzing info (8, ~3%)
  • How?
    • In person (93, almost one-third)
    • Email (61, 20%)
    • Automatic access (18, ~6%)
  • What does doctor do with it?
    • Diagnosed with AFib from device data (5)
    • Doctor not interested (30, ~10%)
    • Decide what treatment (19, ~7%)
    • Pleased for additional info (15, ~5%)
Q10:  Think about the AFib-related information you wish you could get from a device/app.
  • What would you like someone to design for you?
    • Some things asked for already exist—may need to do better education/ marketing
    • ID any arrhythmia / name type of arrhythmia (51, ~16%)
    • Auto/continuous AF monitoring / 24/7 event recorder (37, ~12%)
    • Alert when in AFib (32, ~11%)
    • Greater accuracy / fewer “possible”, “unclassified”, “indeterminate” readings (28, ~10%)
    • All-in-one watch (ECG/EKG, HR, HRV, BP, oximeter, sleep) (20, ~7%)
    • Less bulky, cheaper, easier to read (18, ~6%)
    • Greater patient access to device data / automatic interpretation / show trends (18, ~6%)
  • How would this feature/information improve your quality of life and/or change your behavior?
    • Inform treatment decisions (55, ~18%)
    • “Knowledge is power,” peace of mind (35, ~12%)
    • Cause and effect / look for triggers, patterns (18, ~6%)
Q11:  Is there anything else you’d like to share with the Heart Rhythm 2019 audience?
  • Complaints about specific devices
  • Have insurance cover cost of devices
  • Educate doctors about the existence and value of these devices
  • Power to the patient
    • “Anyone with arrhythmias should be assigned one of these devices”
    • “We need full access to what is happening in our bodies so we can make informed decisions and be partners in our care with doctors”

End of survey and results

Go to our interview with Michele Straube about her survey conclusions.

If you find any errors on this page, email us. Y Last updated: Thursday, August 6, 2020

2020 AF Symposium Abstract: High Hemorrhagic Risk Factors from NOACs

2020 AF Symposium Abstract

High Hemorrhagic Risk Factors from NOACs

by Steve S. Ryan

VIDEO A-Fib Clot Formation & Stroke Risks

NOAC Hemorrhagic Stroke Risk

When I read in this abstract from Massachusetts General Hospital in Boston, these NOAC findings almost jumped off the page at me! We know that NOACs are high risk meds (though they are certainly better than having an A-Fib stroke). But, add to that, also a high risk of Hemorrhagic risk factors, too?

This is a most important and relevant study for A-Fib patients.

Brain MRI to Detect NOAC Hemorrhagic Stroke Risk

Researchers from Massachusetts General Hospital in Boston used MRI to identify markers of increased intracerebral hemorrhage risk (ICH).

This was a single center study conducted from January 2011 to May 2019. In the study were 282 patients of which 76% had Atrial Fibrillation; Of the 282 patients, 49 were taking NOACs and 233 were taking warfarin. All demographic variables, vascular risk factors, etc. were similar between the two groups.

Study Findings

Analyzing the MRI data of the 282 participants revealed:

• cerebral microbleeds (67%)
• moderate-to-severe white matter hyperintensities (76%)
• cortical superficial siderosis (excess iron in body tissue) (18%)

In particular, of the 49 patients taking NOACs:

• 97% had at least one of these markers
• 60% had two
• 4% had all three

Conclusion

Established MRI markers of increased ICH (intracerebral hemorrhage) were common in the NOAC study group.

High hemorrhagic risk markers were present in an overwhelming 97% of NOAC patients.

Editor’s Comments:

Does taking a NOAC long-term mean you’ll eventually develop a hemorrhagic stroke?
No, the researchers didn’t go that far. This was a limited study as the number of patients who were on NOACs was 49 compared to those on warfarin which was 233.
Red Flag Warning: But this study should raise a red flag for anyone taking NOACs long term. Almost all patients on NOACs (97% in this study) had “evidence of neuroimaging markers of high ICH risk.”
The authors recommended that prescribers (and patients) look at nonpharmacological stroke prevention methods. Eliminating the need for lifelong NOAC anticoagulation “may decrease the incidence of fatal/disabling hemorrhages in A-Fib patients.”

For more on NOACs and stroke, see my article Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.

Resource
Das, A.S et al. Etiology and Imaging Risk Markers of Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. AFS2020-17. AF Symposium 2020 brochure, p. 42.

If you find any errors on this page, email us. Y Last updated: Friday, January 22, 2021

Return to 2020 AF Symposium Reports

2020 AF Symposium: Terminate Persistent A-Fib by Ablating Higher Frequency Modulation Areas

2020 AF Symposium

Terminate Persistent A-Fib by Ablating Higher Frequency Modulation Areas

by Steve S. Ryan

Background: Previous studies by Dr. Jose Jalife, University of Michigan, Ann Arbor, MI.:
• A-Fib Produces Fibrosis—Experimental and Real-World Data: Dr. Jose Jalife’s ground-breaking research studies with sheep demonstrated conclusively that A-Fib produces fibrosis;
Experiments in Atrial Remodeling in Sheep and the Transition From Paroxysmal to Persistent A-Fib: Dr. Jalife’s later research showed how A-Fib progresses in time from paroxysmal to persistent A-Fib.

Jose Jalife MD

At this year’s AF symposium, Dr. Jalife presented findings by research colleagues showing how leading-driver regions of A-Fib have higher frequency modulation (iFM) areas which, when ablated, usually terminate persistent A-Fib.

His presentation was entitled “Using Instantaneous Amplitude and Frequency Modulation to Detect the Footprint of Stable Driver Regions as Targets for Ablation of Persistent AF.” Dr. Jose Jalife, University of Michigan, Ann Arbor, MI.

Clinical Study

Researchers have used sheep and pigs in previous studies. This time to detect rotors in sheep, researchers developed algorithms based on amplitude modulation (iAM) and frequency modulation (iFM).

They then switched to pigs who underwent high-rate atrial pacing to develop persistent A-Fib.

Frequency modulation (iFM) /instantaneous amplitude modulation (iAM) approach to patients with persistent atrial fibrillation

Using the PentaRay Catheter (Biosense Webster) to produce high-density electroanatomical atrial mapping, they found that regions of higher than surrounding average iFM were considered leading-drivers.

These iFM areas also had the highest dominant frequency. “They are the footprints of rotors.”

Not all rotors are drivers. Only those with the highest frequency and greater stability are A-Fib drivers. “IFM helps identify the regions with the highest frequency drivers.”

Researchers constructed two leading-driver + rotational-footprint maps (rotors) 2.6 hours apart from each other to test for stability and to guide ablation. Leading-driver regions remained in approximately the same spots in each map.

The trial showed high iFM areas are responsible for maintaining persistent A-Fib

Study Results

When these areas were ablated, persistent A-Fib terminated in 12 of the 13 cases (92.3%). Rotational-footprints (rotors) were found at every leading-driver region, but not all rotors had higher iFM. “In pigs, ablation of leading-driver regions usually terminates persistent A-Fib and prevents its sustainability.”

Conclusion

Dr. Jalife concluded that high iFM areas are responsible for maintaining persistent A-Fib. And using iFM results in higher sensitivity and specificity without the need for high resolution and costly panoramic mapping.

Editor’s Comments:

(I had never heard of the term “frequency modulation” (iFM) applied to A-Fib before.)
High Areas of iFM a New Discovery in A-Fib: The researchers have re-defined the field of mapping and catheter ablation.
This research shows that higher regions of iFM help identify the regions with the highest frequency drivers (rotors) and are more easily mapped in persistent A-Fib.

Dr. Jalife and his colleagues have given EPs and researchers a new tool to better ablate persistent A-Fib, the most difficult arrhythmia to fix.

Resource and Footnote
Dr. Jalife added: “The work I described in my presentation was not mine, but the result of a team effort led by a young Spanish physician and scientist named David Filgueiras Rama. David trained with me a few years ago but now has his own independent laboratory at the National Cardiovascular Research Center (CNIC) in Madrid, Spain. The idea of using iFM modulation to localize drivers was an inspiration of Jorge Quintanilla who is the first author in the paper you have cited. Together, Jorge and David generated the hypothesis, designed the experiments and wrote the paper. My roll was primarily advisory, and I helped with the final draft of the manuscript. Thus, I was only acting as a messenger at the AF Symposium.

Quintanilla, JG et al. Instantaneous Amplitude and Frequency Modulations Detect the Footprint of Rotational Activity and Reveal Stable Driver Regions as Targets for Persistent Atrial Fibrillation Ablation.  Circ Res. 2019 August6 30; 125(6):609-627. Epub 2019 Aug 1. https://www.ncbi.nlm.nih.gov/pubmed/31366278  doi: 10.1161/CIRCRESAHA.119.314930.

If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020

Return to 2020 AF Symposium Reports

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