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


Q&A: Can Catheter Ablation Be a First-Choice Option?

Q: “I was told that I can’t have a catheter ablation to fix my A-Fib until after at least a year of trying different medications. Is that right? I don’t want to live in A-Fib for a year. I’m very symptomatic. I hate being in A-Fib.”

A: Catheter Ablation Can Be a First-Choice Option. Current Guideline for the Management of Patients with Atrial Fibrillation say you don’t have to wait before getting a catheter ablation. You can have a catheter ablation right away as a first-choice option.

Here is the actual wording of the guidelines:

“The role of catheter ablation as first-line therapy, prior to a trial of a Class I or III antiarrhythmic agent, is an appropriate indication for catheter ablation of AF in patients with symptomatic paroxysmal or persistent AF.”

Guidelines Level of Confidence: Catheter Ablation has a Class IIa Level of Evidence (LOE) indication. This means the “weight of evidence” is in favor of this treatment as useful and effective. (To read more, see Catheter Ablation of AF as First-Line Therapy (p. e307.), in the 2017 HRS/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.)

Drugs First? Your doctor will usually talk about first trying antiarrhythmic meds. This can waste valuable time as most “antiarrhythmic” drug therapies are only effective about 40% of the time cause, can have bad side effect, and often become less effective over time. And, you will most likely still have A-Fib.

Catheter Ablation as a First Choice? If you want to skip the drug therapies, ask your doctor about catheter ablation. If your electrophysiologist won’t talk to you about catheter ablation, seek a second opinion (or change doctors).

As an A-Fib patient, know your rights and be assertive.

Familial A-Fib Alert: Does Just One Drink Per Day Increase A-Fib Risk?

For those with A-Fib, it’s now known that your blood relations are at increased risk of developing A-Fib (Familial Atrial Fibrillation). Consider sharing this research with them.

More Research: Alcohol and Atrial Fibrillation

In a huge European observational study over 14 years, just one alcohol drink a day was linked to a 16% increased risk of developing A-Fib. For 14 years, 108,000 Europeans were followed (participants joined between 1982 and 2010). They were from Sweden, Norway, Finland, Denmark, and Italy.  Median age was 48 years.

None of them had A-Fib at the start of the study. Participants were asked to indicate how often they consumed beer, wine, and  spirits as well as their drinking pattern. They also provided information on their medical histories, lifestyles (including alcohol and tobacco use), employment, and education levels.

Does Alcohol Cause A-Fib?

Alcohol: Does one drink a day matter?

This study didn’t say that alcohol causes A-Fib but only that there is an association.

One caveat of this study is that, despite much research, the mechanism of how or why moderate drinking increases the risk of A-Fib was not identified.

The risk of A-Fib increased with alcohol intake of more than 1/day.

(Other studies have shown that low doses of alcohol are associated with a reduced risk of cardiovascular problems such as heart failure.)  

Binge vs Moderate Drinking

Many patients end up with heart palpations after celebrating three-day holiday weekends. Called Holiday Heart Syndrome, doctors in hospital emergency rooms know all too well that binge drinking produces A-Fib in some people.

But up to now, moderate alcohol consumption was considered not just benign but heart helpful.

Familial A-Fib: Weigh the Risks of Moderate Drinking

My Top 5 articles on inherited A-Fib

While a 16% risk of developing A-Fib is small, it is something you and your family should be concerned about.

Those with A-Fib and those without A-Fib need to ask themselves if the risk of A-Fib is outweighed by the benefits of moderate drinking?

You should also consider your quality of life. Having a drink with your golfing buddies or a party with your girl friends may be more socially important than becoming a teetotaler.

But for those at increased risk of developing A-Fib, it’s something you should discuss with your doctor.

Familial A-Fib: Recent studies suggest that up to 30 percent of all people with atrial fibrillation may have a history of the condition in their family.
To learn more, see my Top 5 Articles about Inherited (Familial) A-Fib.
Resources for this article

• Csengeri, D. et al. Alcohol consumption, cardiac biomarkers, and risk of atrial fibrillation and adverse outcomes. European Heart Journal, Volume 42, Issue 12, 21 March 2021. Pages 1170-1177.  https://doi.org/10.1093/eurheartj/ehaa953

• One small alcoholic drink a day is linked to an increased risk of atrial fibrillation. Science Daily. January 17, 2021. https://tinyurl.com/4d69mm43

• Even moderate alcohol consumption is linked to heart trouble. Bottom Line Personal. Volume 42, Number 9, May 1, 2021. p. 15.

2021 AF Symposium: 5 New Summary Reports Posted

I’ve completed several new reports on presentations made at the 2021 AF Symposium. With each report, I strive to share the current state of the art in A-Fib research and treatments and what’s relevant to patients with Atrial Fibrillation. Symposium presenters are the best clinicians and researchers working in Atrial Fibrillation today. My new reports include:

Two Spotlight Sessions on New Technologies/Drugs: A new antiarrhythmic drug in development, and an inhaler that delivers Flecainide for fast results.

Two Clinical Trials: Results comparing the effectiveness of CryoBalloon ablation vs. Drug Therapy; and Findings from the ATTEST trial.

Research: The role of anticoagulants in A-Fib patients who develop cognitive impairment, cerebral microbleeds and dementia entitled “Cerebral Amyloid Angiopathy (CAA).

The new reports (with links):

Spotlight Session: New Technologies and Drugs―Flecainide Inhaler by InCarda Therapeutics
Spotlight Session: Drug in Development from Acesion Pharma
Anticoagulants and Cerebral Amyloid Angiopathy (CAA): Prevalence, Detection and Management
ATTEST Trial: Catheter Ablation to Modify Progression of AF
Another Study Finds Ablation Better First-Line Treatment Than Medication

Look for more of my reports from the 2021 AF Symposium in the next weeks and months. And, as always, my reports are written in plain language for A-Fib patients and their families.

Go to my list of all 2021 AF Symposium Reports

’21 AF Symposium Report: Pulsed Field Ablation for Atrial Fibrillation with Lattice-Tip Catheter

I’ve posted a new report about an ablation for a patient with persistent A-Fib who had been cardioverted and was now in Atrial Flutter. Drs. Reddy and Neuzil demonstrated a new, innovate strategy of using Pulsed Field Ablation (PFA) combined with RF ablation developed by AFFERA, Inc.

The AFFERA lattice catheter

The AFFERA lattice catheter

Symposium attendees watched the ablation live via streaming video from the Czech Republic.

The AFFERA system uses a single lattice-tip catheter but two different energy generators, one for PFA and another for RF ablations.

One of the great advantages of Pulsed Field Ablation (PFA) is that the PF energy doesn’t damage adjacent tissue or structures such as the Phrenic nerve or the esophagus. So the doctor can switch back and forth between energy sources depending on the lesion location and surrounding tissue/organs.

When the AF Symposium audience joined the live video feed, the doctors and their team had started the procedure. The Pulmonary Veins (PVs) were already isolated and they had created a Flutter map. To continue reading…go to “Pulsed Field Ablation for Atrial Fibrillation Using a Lattice-Tip Focal Catheter”.

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 (relatively few had ablations). 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. The study was stopped early, because the rythm control group did so much better than the usual-care group (3.9 negative events vs 5.0). As one would expect, sinus rhythm was more common in the rhythm control group (82% vs 61% at two years)

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

Book Review: “Your Complete Guide to AFib” by Percy Morales, MD

Review by Steve S. Ryan, PhD

I received an advance copy of “Your Complete Guide to AFib―The Essential Manual for Every Patient With Atrial Fibrillation” by Dr. Percy Morales and asked for a review. The opinions given are my own.

Caveat: $149.95 to be Cured of AFib

Abbreviations for Atrial Fibrillation include: AFib, A-Fib and AF.

Dr. Morales’ book encourages readers to sign up for his “takecontroloverafib.com” program at $149.95 a pop. It’s very surprising to see a medical doctor engage in a direct marketing-type sales hustle. His “Guide to Healthy Living” reads like a Tony Robbins motivational presentation but applied to AFib.

[I personally was very discouraged and depressed reading Dr. Morales’ work.]

Style of Dr. Morales’ Book

“Your Complete Guide to AFib” is written by a working Electrophysiologist (EP). It’s a thin book, 119 pages, without a lot of content. But what’s there is clear and based on Dr. Morales’ own experience.

In terms of style, Dr. Morales’ book is a dull read with too many proofreading errors for such a small volume.

Instead of standard footnotes, he cites actual web sites which doesn’t work well. (Website addresses and pages change every day. As a solo source, they are not a reliable one.)

Is There No Cure for AFib?

A major shortcoming of Dr. Morales’ book is he doesn’t acknowledge that AFib can be cured, that you don’t have to live in AFib. This is discouraging and a turn-off for many readers. He isn’t big on hope.

Causes of AFib

Under “Causes of AFib” Dr. Morales doesn’t discuss or acknowledge Lone AFib where people who are perfectly healthy get AFib and don’t have any comorbidities (around 50% of AFib cases, including me) (p. 16). But on page 99 he does acknowledge that, “some younger patients will be diagnosed with AFib where there is no clear cause for it.”

Most people who develop AFib are not sick with other diseases. And even if one is sick with, for example, high blood pressure, we can’t say for sure that high blood pressure “caused” a particular person’s AFib.

Is AFib Your Fault?

Dr. Morales implies that it’s a patient’s fault that they developed AFib, because they let themselves get sick with “comorbidities” which brought on their AFib (p. 16). … Continue reading this book review..->

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

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