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2020 AF Symposium Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
2020 AF Symposium: AF Management
Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
by Steve S. Ryan
One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.
While several cases were discussed, here I summarize just one case.
Dr Eric Prystowsky
Patient History: 75-Year-Old Female
Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN
Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.
She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.
Any pause over 5 seconds can cause dizziness, fainting and falls and is usually an indication that a pacemaker is necessary.
Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.
Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.
Treatment by Dr. Prystowsky
Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).
The patient had repeatedly been offered a catheter ablation, but she declined each time.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).
Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.
She felt better for 5 days.
Moderate Pericardial Effusion; Medications Adjusted
The patient then developed a moderate (“significant”) pericardial effusion.
Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.
Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”
She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Minimizing Pacing; Medication Adjusted
The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.
To learn about the heart’s QRS, see my article Understanding the EKG Signal.
A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.
He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).
Dr. Prystowsky’s Lament
He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”
One Year Later and Lesson Learned
A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”
Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.
He wrote me that it’s been over a year, and the patient is doing great.
If you find any errors on this page, email us. Y Last updated: Saturday, May 2, 2020
Return to 2020 AF Symposium Reports
How One Reader Detects if He’s in (Silent) A-Fib
Some people have A-Fib with no obvious symptoms. This can be dangerous, lead to a stroke and, over time, to a deteriorating heart. Many of these patients do a self-check during the day to monitor for an irregular pulse. Here’s another idea from a fellow A-Fib patient.
Taking Your Pulse
After reading our article, A-Fib Self-Care Skills: How to Check Your Heartbeat and Heart Rate, our reader, Frank, wrote us about how he goes beyond just a self-check to determine if he’s in A-Fib.
“I read your self-care skills articles and wanted to comment.
I check for when I’m in A-Fib very easily. I purchased a pulse oximeter. And whenever my reading is significantly above my normal resting pulse, then I know I’m in A-Fib. I don’t believe there’s any other reason for my resting heart rate to be elevated unless I’m in atrial fib.
A good oximeter is not very expensive at all, and it may be a very useful tool for others.”
Our thanks to Frank for sharing his advice.
How Pulse Oximeters Measure Pulse Rate
Masimo‘s MightySat fingertip pulse oximeter
Pulse oximeters are easily recognized by their associated clip-type probe which is typically applied to a patient’s finger. They are lightweight and intuitive to use.
When your heart beats, it pumps blood through your body. During each heartbeat, the blood gets squeezed into capillaries, whose volume increases very slightly. Between heartbeats, the volume decreases. This change in volume affects the amount of light (such as the amount of red or infrared light) that will transmit through your finger.
Though this fluctuation is very small, it can be measured by a pulse oximeter.
Not Just for Pulse Rates but Blood Oxygen Levels, Too
Measuring your blood oxygen saturation level (SpO2) is also important for A-Fib patients, because a very low blood oxygen level puts a strain on your heart (and your brain).
Blood oxygen saturation
Using the same type of setup to measure pulse rate, an oximeter indirectly measures the amount of oxygen that is carried by your blood. By measuring the light that passes through the blood in your finger, your blood oxygen saturation level (SpO2) is calculated and expressed as a percentage.
Accuracy: The American Thoracic Society reports that the oxygen level from a pulse oximeter is reasonably accurate. The best reading is achieved when your hand is warm, relaxed, and held below the level of your heart. Most oximeters give a reading 2% over or 2% under what your saturation would be if obtained by an arterial blood gas test. (For example, if your oxygen saturation reads 92% on the pulse oximeter, it may be actually anywhere from 90 to 94%.)
Pulse Oximeters and Sleep Apnea 
Another application for a pulse oximeter. We’ve written about using a fingertip oximeter as an inexpensive way to check if you might have sleep apnea. A blood oxygen saturation level of 90% or lower means you should talk to your doctor, that you may need a sleep study. For more, see Possible Sleep Apnea? Oximeter is DIY Way to Check your Blood’s Oxygen Level.
Know Your Pulse Rate and Blood Oxygen Level
Starting at about $25, an assortment of pulse oximeters are available at Amazon.com and other retailers. One CE and FDA approved unit is the Pulse Oximeter Portable Digital Oxygen Sensor with SPO2 Alarm ($23).
On a personal note: As many of our readers know, I’ve been A-Fib free for 20 years. But nonetheless I often will check my pulse using an oximeter at night before going to sleep. Just as Frank describes, it’s very easy to do.
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Part 3 Update: PVCs/PACs and My Medtronic Reveal LINQ Insertable Monitor
I’ve had my Medtronic Reveal LINQ insertable monitor since the middle of September. (See Has my A-Fib Returned?) It has produced a lot of false positives. The other day, I visited my EP’s office and reviewed my LINQ data results with the nurse/Reveal LINQ specialist.
My Medtronic Reveal LINQ is inserted just under my skin near my heart:
The LINQ data showed I had Premature Ventricular Contractions (PVCs) and Premature Atrial Contractions (PACs) which made my heart beat irregular but were not A-Fib.
No A-Fib for me: My data showed I always had the P wave component in my EKG signal—which is lost when one has Atrial Fibrillation.
Most PVCs/PACs benign: Most A-Fib doctors aren’t overly concerned about extra beats Premature Ventricular Contractions (PVCs) or Premature Atrial Contractions (PACs), because they are considered benign.
I’m not worried. Everybody gets PVCs and PACs, not just people with A-Fib.
Take a Look at My Premature Atrial Contractions (PACs)
When you look at my LINQ ECG signal (see excerpt below), notice how the PAC comes before one would expect a normal beat. The irregularities above the R wave indicate the signal is coming from atria above the ventricles and is a PAC.
PAC beats comes before one would expect a normal beat
…and a Look at My Premature Ventricle Contractions (PVCs)
When you look at another section of my ECG signal (see excerpt below), the R wave spikes are thicker and wider than the normal R waves indicating they are coming from the ventricles and are Premature Ventricle Contractions (PVCs).
PVCs: R wave spikes are thicker and wider than the normal
Detection Settings for A-Fib Only
To avoid false positives such as PACs and PVCs, the nurse adjusted the settings and sensitivity of the Reveal LINQ monitor to detect A-Fib only. (For Medtronic settings, see below.)
I will return to Dr. Doshi’s office in a month to see if these new setting are working properly. Look for my next update on data from my Medtronic Reveal LINQ insertable monitor.
ECG waveform diagram
Learn to Read Your ECG/EKG
An electrocardiogram, ECG (EKG), is used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart.
The ECG signal strip is a graphic tracing of the electrical activity of your heart.
To learn to read your own ECG/EKG signal, see Understanding the EKG Signal.
My Medtronic Reveal LINQ is inserted just under my skin near my heart: For you tech types, here are the new settings:
• AT/AF Detection—On
• Type—AF only
• AF Detection—Balanced Sensitivity
• Ectopy Rejection—Aggressive (this is probably the most important change in the settings)
• AT/AF Recording Threshold—Episodes >= 60 min
A-Fib Self-Care Skills: How to Check Your Heartbeat and Heart Rate
Some Atrial Fibrillation patients know immediately when their heart is in A-Fib. They experience one or more symptoms including shortness of breath, palpitations, heart flutters, etc. Other A-Fib patients may have subtle symptoms (or silent A-Fib) and can’t be sure.
The following self-care skills will reassure you any time you suspect you’re in A-Fib—how to check for an irregular heartbeat and how to tell if your heart rate is too fast or too slow.
Self-Check if Your Heartbeat is Regular or Irregular
I found an informative post with these self-care skill steps on the Scope Blog by Stanford University School of Medicine. To check whether your heartbeat is regular or irregular:
♥ Begin by placing your right hand on the left side of your chest while seated and leaning forward.
♥ Position your hand so that you feel your heartbeat most strongly with your fingertips.
♥ A normal heart rhythm should feel like a regular drum beat cadence; you can usually anticipate when each beat will come after the last beat.
♥ Because heart rate and the strength of the heartbeat can vary with breathing, sometimes holding your breath for a few seconds is helpful. With an irregular rhythm, it will be hard to predict when the next beat will come.
♥ In addition, some irregular beats will be softer (less strong) than other beats, so the strength as well as the timing may not be consistent.
Self-Check If Your Heart Rate is Too Fast or Too Slow
The Stanford blog continues with a second set of self-care skill steps—how to measure if your heart rate is too fast or too slow so you know when to seek medical care. (An optimal heart rate is 50–100 bpm when you are at rest.) To check your heart rate:
♥ Place your right hand over your heart so that you feel your heart beating under your fingertips.
♥ Use a watch or timer and count the number of beats for 15 seconds.
♥ Be sure to count all heartbeats; including beats that are not as strong or that come quickly following one another.
♥ Take the number of beats you’ve counted and multiply it by four. For example, if you count 30 beats in 15 seconds, then you would calculate 4 x 30 = 120 beats per minute.
♥ Repeat this process three times right away, writing down each heart rate to later share with your doctor.
While an Electrocardiograph (ECG or EKG) or Holter monitor are the only sure ways to document you are in A-Fib, you can use the above self-care skills to recognize A-Fib symptoms of an irregular heart beat or if beating too fast or too slow.
These skills with help you remain calm and confident when you suspect you may be in A-Fib.
Part 2: Has My A-Fib Returned? 21 Day Results from My Medtronic Reveal LINQ loop recorder
In Part 1, Steve describes how during a recent medical exam, one of his doctors (not a cardiologist) detected an irregular heart beat. Steve didn’t feel any symptoms but went to see his EP who checked him over and found no A-Fib.
But, just to be sure, his EP implanted a tiny wireless heart monitor so he can review Steve’s heart activity over time. Go here to read our first post.
21 Days of Data with my Medtronic Reveal LINQ ICM
Section of Steve’s ECG
After having worn the Medtronic Reveal LINQ loop recorder for 3 weeks, I went in to check my results with my EP, Dr. Shephal Doshi, at Pacific Heart in Santa Monica, CA. (Reports are sent wirelessly each night by the bedside transmitter.)
The monitor report was saying I was having multiple A-Fib attacks, though I didn’t feel anything. When Dr. Doshi did an EKG of me, I was in perfect sinus. He suspected the monitor or I might be producing false positives.
Steve & his CAM
I Get a 7-Day Carnation Ambulatory Monitor, Too
To check the accuracy of the LINQ monitor, he gave me a Carnation Ambulatory Monitor (CAM) to wear for a week. It’s similar to a Zio Patch, but is stuck vertically along my sternum.
For the next 7 days I should avoid immersing the device in water. I was told I could take a shower, but I am being cautious and just taking sponge baths.
I’m supposed to keep a log of when I eat meals, exercise, drink any alcohol, and include any A-Fib symptoms. If I do feel symptoms, I’m to press the button on the monitor. So far, I haven’t had any occasion to press the button. I’ll return the monitor to Dr. Doshi’s office in a week.
Monitoring the Monitor
Carnation Ambulatory Monitor
Reveal LINQ loop recorder
Since the LINQ monitor is still actively collecting data, my EP can compare the LINQ results with the results collected by the Carnation Ambulatory Monitor. Hopefully, Dr. Doshi will find no occurrences of A-Fib (just false positives).
I’ll write more when I have something to report.
Have you worn a Carnation Ambulatory Monitor? Email with your experience.
Apple Watch 4: Do ECG Readings Give A-Fib Patients a False Sense of Security?
We received a couple of emails about the new Apple Watch 4. As many A-Fib patients may be aware, recently Apple unveiled the next generation of Apple Watch which includes a second generation optical heart sensor.
Among several interesting features, it can generate an ECG tracing similar to that of a single-lead electrocardiograph.
In her Sept. 14, 2018 editorial on Medscape.com, ECG Readings From the Apple Watch? This Doctor Is Leery, Dr. Hansa Bhargava gives her perspective of this feature for those diagnosed with atrial fibrillation. She writes that she finds the Apple Watch’s ability to do a one-lead ECG interesting but has some reservations.
“…Here’s what I worry about: the false sense of security that a person could have.
Apple Watch 4 screens
Being able to do a one-lead ECG is definitely interesting, but does it always help? Here’s a scenario. A 40-year-old runner starts feeling dizzy, lightheaded, and has chest pain. He worries but remembers that there is an ECG function on his watch. He proceeds to do the ECG which then reads “normal.” Because of this he decides to continue to run.
What he doesn’t know is that this is only a one-lead ECG, and even though it seems normal, it is an isolated data point; more information is needed to diagnose what is going on. What if he is having angina? In fact, 30% of cardiovascular events happen to people under the age of 65. One lead on an ECG could certainly miss this; in fact, even a 12-lead ECG, if the only isolated data point, could miss this.
Dr. Andrew Moore, an emergency department physician at the Oregon Health and Science University is also skeptical of the Apple Watch 4 ECG feature:
“The ECG thing is a little bit overhyped in terms of what it will really provide. …The tech that Apple is working with is very rudimentary compared to what we’d do for someone in a hospital or health care setting.”
While the watch can detect changes in the patterns of a person’s heart rate such as too fast, too slow, or beating irregularly—signifying A-Fib, the watch doesn’t diagnose a medical issue.
Apple Watch and Other DIY Heart Rate Monitors
Guide to HRMs and Handheld ECG monitors
Keep in mind these doctors’ concerns apply to all consumer heart rate monitors (HRM), those with optical heart sensors and those with electrode-containing monitors.
Wrist vs. Chest Bands: Wrist-band optical heart-rate monitors (like Apple Watch 4) may be more convenient or comfortable and have advanced over the years. But researchers found that electrode-containing chest-strap monitors were always more accurate than their wrist counterparts and more reliable and consistent. To learn about this research, read When Tracking Your Heart: Is a Wrist-Worn Heart Rate Monitor Just as Good as a Chest Strap Monitor?
Blue-tooth chest-band with smartphone app
As an A-Fib patient, when monitoring your heart beat rate is important to you (while exercising or doing heavy work), you’ll want to stick with an electrode-containing monitor (chest band-style, shirts or sports bras with built-in electrode pads, etc.).
For help selecting a HRM, see our article: Guide to DIY Heart Rate Monitors (HRMs) & Handheld ECG Monitors (Part I). Also take a look at Steve’s list on Amazon.com: Top Picks: DIY Heart Rate Monitors for A-Fib Patients.
Keep in mind: None of these DIY heart rate monitors are diagnostic tools. But they can be helpful once you know you have A-Fib, A-Flutter or suffer from PVCs, PACs, etc. Just don’t make medical decisions based on their readings. See your doctor if you have any concerns or symptoms.
Remember: None of these DIY heart rate monitors are diagnostic tools
Has My A-Fib Returned? I Get an Insertable Wireless Monitor to Find Out
Update 5 pm (see below): During a recent medical exam, one of my doctors (not a cardiologist) detected an irregular heart beat. I didn’t feel any symptoms before, during or after the appointment, so I wasn’t alarmed. But I did make an appointment with my EP.
Medtronic Reveal LINQ ICM
When I met with my EP, he took an ECG but didn’t find A-Fib (thank goodness). But, just to be sure, he recommended implanting a tiny wireless heart monitor so he can review my heart activity over time.
I Get a Reveal LINQ Insertable Cardiac Monitor
So yesterday, as an outpatient, I had a tiny cardiac monitor implanted just under the skin near my heart. The minimally invasive procedure took the doctor about 2 minutes to do. (Most of my time at the hospital was spent doing paperwork).
My doctor used the Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM)—one of the world’s smallest cardiac monitors—the device is approximately one-third the size of a AAA battery.
MyCareLink transmitter
The Reveal LINQ System includes a bedside unit that collects heart rhythm data from the ICM and wirelessly sends it to my doctor every evening.
The device allows my cardiologist to continuously monitor my heart for up to 3 years.
Setup to transmit: I got it all set up and it’s working. But I don’t expect to get any feedback from my EP any time soon. I’ll publish an update when I have something to report.
My incision for the ICM
Update 5 pm: I forgot to mention that I had no pain with this procedure. They used some numbing agent on the incision area, but I’ve had no pain afterwards (it’s now about 36 hours since the insertion). No sutures. They applied a clear bandage that holds the tissue together while healing.
There’s no visible sign of the device. If I press the area I can barely feel the outline of the ICM. It’s possible this will diminish with time as the surrounding tissue encases it.
I’ll write more: I’ll talk with my EP in a couple of weeks when he has reviewed some of the data received via the MyCareLink wireless transmitter. (I assume he has some data processing feature that will alert him before that if the readings are outside normal specs.)
VIDEO: The Insertion Procedure
An animated video (music, no narration) by Medtronic, shows how the Reveal LINQ ICM monitor is inserted through a tiny incision just under the skin near the heart. Special tools are used to make a small incision and another to hold the ICM and “plunge” it under the skin. About 2:45 min.
To enlarge video: click and start the video. At the lower right, click on the frame icon. To exit, click again.
Updated Article: Guide to DIY Heart Rate Monitors (HRMs) & Handheld ECG Monitors
We’ve updated our Guide to DIY Heart Rate Monitors (HRMs) & Handheld ECG Monitors (Part I) with new models of chest bands/wristwatches sets, Bluetooth versions and wearable technologies.
A consumer heart rate monitor (HRM) is useful when Atrial Fibrillation patients want to monitor their heart rate and pulse when exercising or when performing physically demanding activities.
To our section on handheld real-time ECG monitors, we added the Contec PM-10. Our recent review read in part:
Three ways to hold the Contec PM-10 when taking an ECG scan
“The Contec PM10 (about $79 on Amazon.com) is a very easy-to-use small 4 oz. unit that can track a single channel ECG waveform. You can observe the scan live, then download the recordings (up to 30) to your computer or smartphone for review and print to share with your doctor.” Read the full review.
Also updated: WEARABLE TECHNOLOGY WITH WIRELESS SENSORS
From Sensoria Fitness
“Wearable technology” offers a new option for those who find a chest strap uncomfortable or chafing. Instead of the chestband, these workout clothes have sensors built-in. Just snap on your heart rate sensor from your chestband. Starting at $75.
♥ Sensoria Fitness Men’s T-Shirt with standard sensor snaps (no heart rate sensor)
♥ Sensoria Fitness Sports Bra with standard sensor snaps (no heart rate sensor)
To read the updated article, go to: Guide to DIY Heart Rate Monitors (HRMs) & Handheld ECG Monitors (Part I)
Not to be Confused with Optical Fitness Wristbands
Optical LEDs on inside of fitness wristband
The HRM sensors/monitors in our guide work by being in contact with the skin. Don’t confuse DIY/consumer heart rate monitors with fitness bands like Fitbit or running/sport watches.
This group of fitness wristbands use an optical sensor to shine a light on your skin illuminating your capillaries to measure your pulse. Optical sensor wristbands are not accurate enough for A-Fib patients.
For more, see my article: When Tracking Your Heart: Is a Wrist-Worn Heart Rate Monitor Just as Good as a Chest Strap Monitor?
Possible Sleep Apnea? Oximeter is DIY Way to Check your Blood’s Oxygen Level
As many as 43% of A-Fib patients also suffer with obstructive sleep apnea (OSA). An easy preliminary step towards finding out if you have a sleep disorder is with the use of an inexpensive oximeter. To check your blood’s oxygen level, just insert your finger.
Fingertip Pulse Oximeter Blood Oxygen Saturation Monitor
Designed for pilots and sport enthusiasts who want to obtain their SpO2 (Blood Oxygen Saturation Levels) and PR (Pulse Rate) on the go. A-Fib patients can use one, too.
The pulse oximeter LED display faces you so it’s easy to read. (The Zacurate, Facelake and Santamedical are brands of Fingertip Pulse Oximeters. Reasonably priced, starting at $13 on Amazon.com. )
Taking a reading is easy. Just clip it on to your finger and turn it on at the press of a button. The large LED display makes viewing the results a snap. (The one from Zacurate comes with 2 AAA batteries so that you can use it immediately.)
Y
our Blood’s Oxygen Level
A reading of 90% or lower means you should talk to your doctor, you may need a sleep study.
HINT for after you have taken your initial oxygen level: Take a BIG deep breath and HOLD it. You should see the reading increase as more oxygen enters your blood stream.
To learn more about sleep apnea and A-Fib, see Sleep Apnea: When Snoring Can Be Lethal and the Podcast: The Double Whammy? Sleep Apnea and Atrial Fibrillation.
Which Comes First: Sleep Apnea or Atrial Fibrillation?
Obstructive Sleep Apnea (OSA) affects about 100 million people worldwide with 85% of cases going undiagnosed.
Of Atrial Fibrillation patients, about 43% additionally suffer with Obstructive Sleep Apnea.
Could undiagnosed sleep apnea be linked to development of Atrial Fibrillation?
OSA Link to A-Fib
OSA is characterized by repetitive episodes of shallow or paused breathing during sleep that lead to a drop in blood oxygen level and disrupted sleep.
85% of Sleep Apnea cases go undiagnosed.
New research has found that patients with Sleep Apnea may be at greater risk of developing Atrial Fibrillation. Abnormal oxygen saturation level during sleep may be responsible.
Patients with OSA are more likely to have high blood pressure, or hypertension, which is a major risk factor for heart disease and other cardiovascular conditions.
Risk of New Onset A-Fib: The Clinical Cohort Study
Lead author Dr. Tetyana Kendzerska, Ph.D., of the University of Ottawa in Canada, and colleagues reviewed the records of 8,256 adults (average age 47) with suspected OSA. Individuals with any diagnosis of arrhythmias were excluded. Participants were followed for an average of 10 years. During that time, 173 developed A-Fib resulting in hospitalization.
Study Results
The reviewers found that the amount of sleep time spent with lower than normal oxygen saturation (below 90 percent) was a significant predictor of developing Atrial Fibrillation.
By contrast, the number of breathing pauses during each hour of sleep did not appear to affect A-Fib risk.
Study participants who developed A-Fib during the follow-up period were more likely to be older, current or former smokers, and have a high level of comorbidities (e.g. high blood pressure, or hypertension).
“The association between oxygen desaturation and A-Fib remains significant, suggesting that OSA can directly cause A-Fib.”
What This Means to Patients
In light of this study, a diagnosis of Atrial Fibrillation raises the question, ”Could my A-Fib have been brought on by undiagnosed Sleep Apnea?”
Sandy from Boston
Sandy from Boston and her doctor say ‘yes”. Updating her personal A-Fib story, she wrote:
“After my [successful] CryoBalloon ablation at BWH in 2014, I underwent a sleep study that revealed during REM sleep I stopped breathing an average of 32 times every hour. My physician suspected that my traumatic brain injury in 1995 caused my undiagnosed sleep apnea, which in turn caused Paroxysmal A-Fib. I have been using a CPAP ever since.”
Take Action: Sleep Apnea Can be Lethal: If you have untreated Sleep Apnea, you are at greater risk of having a more severe form of A-Fib or of not benefiting from an A-Fib treatment.
So many A-Fib patients also suffer from sleep apnea that many Electrophysiologists (EPs) routinely send their patients for a sleep apnea study.
Sleep apnea isn’t a minor health problem, and it’s a condition you can do something about. To learn more, see Sleep Apnea: When Snoring Can Be Lethal.
Updated Video: Zio Patch Single-Use Ambulatory Cardiac Monitor
The Zio® Patch by iRhythm is an interesting advancement in single-use ambulatory heart monitors. It looks like a big band-aid! After use, you return it to your doctor for downloading of the data.
The ZIO XT Patch
My first-hand experience: I wore one awhile back, after a prostate exam when my heart appeared to briefly be in A-Fib. As a followup, my cardiologist had me wear a Zio® Patch for two weeks. Result: no A-Fib! It turned out to be a one-time occurrence brought on by the medical test.
Updated Video: Zio® XT Patch
We’ve posted an updated video of the the Zio® XT Patch (iRhythm):
Patient with a Zio Patchvo
Description: The Zio® Patch cardiac monitor (iRhythm) looks similar to a 2-by-5-inch adhesive bandage and sticks to a patient’s chest.
In the video, Electrophysiologists, Dr Parri Dominic and Dr Ryan Jones of LSU Health Sciences Center, talk about this single-use ambulatory, continuously cardiac monitor that records for up to 14 days. No need to removal during exercise, sleeping or bathing. (2:04 min.) Posted by University Health News Network. Go to video->
Video: What is the Upright Tilt Table Test?
Do you experience dizziness or fainting spells? The upright tilt table test is a simple and effective way for collect important data for a diagnosis. In this short video, Natalie Zalmanova, NYCVA physician assistant, explains the steps of the tilt table test. With footage of in-progress test. (1:15 min.) Posted by New York Cardiovascular Associates on Oct 19, 2012.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.
If you find any errors on this page, email us. Y Last updated: Tuesday, February 20, 2018
Return to Instructional A-Fib Videos and Animations
Video: The Zio® Patch (iRhythm) Single-Use Ambulatory Cardiac Monitor
The Zio® Patch cardiac monitor (iRhythm) looks similar to a 2-by-5-inch adhesive bandage and sticks to a patient’s chest. Electrophysiologists, Dr Parri Dominic and Dr Ryan Jones of LSU Health Sciences Center, talk about this single-use ambulatory, continuously cardiac monitor that records for up to 14 days. No need to removal during exercise, sleeping or bathing. (2:04 min.)
Posted by University Health News Network, Sept 25, 2017.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.
If you find any errors on this page, email us. Y Last updated: Tuesday, February 20, 2018
More FREE ‘Learn the Heart’ ECG Online Review Courses
Recently I posted about a FREE online course ‘ECG Basics‘ at Healio/LearnTheHeart.com designed to expand your understanding of Electrocardiograms (ECG or EKG) (see our description page).
More ‘Learn the Heart’ ECG Review Courses
This week I expanded the list of Healio ECG short courses that may be of interest to Atrial Fibrillation patients. Each includes examples of 12-lead ECGs and, where appropriate, specific criteria. Check out the following:
Illustration: Healio ‘Atrial Fibrillation ECG Review‘
• Atrial Fibrillation ECG Review‘
• Atrial Flutter ECG Review
• Premature Atrial Contractions (PACs) ECG Review
• Left Atrial Enlargement (LAE) ECG Review
• Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review
ECG Quizzes, Too
You can also challenge yourself with the Beginner ECG Quiz featuring detailed answers and links to pertinent explanation pages. Or test your overall knowledge of Atrial Fibrillation with a multiple choice Atrial Fibrillation Quiz.
Steve’s Brief Overview: The EKG Signal
If you want just a brief overview of the ECG waveform signal and how to “read” an ECG tracing, go to my report, Understanding the EKG Signal.
Learn to Read Your ECG: Free Online Self-Paced Courses at Healio.com
Start with the ‘ECG Basics’ course
For the reader wanting a more extensive understanding of the Electrocardiogram and A-Fib, we offer you a link to Healio Learn the Heart—a FREE online cardiology resource for those seeking to increase their knowledge of ECG tracings interpretation and cardiovascular diseases.
‘Learn the Heart’: A Review or ECG Basics
I suggest you start with the ‘Atrial Fibrillation ECG Review‘ then move on to the ‘ECG Basics‘ to analyze each part of the ECG tracing. Included are detailed explanations and ECG images of the heart in Atrial Fibrillation.
The ‘ECG Basics‘ is concise and focused on only what you need to know, yet very thorough — from waves to segments to complexes. On the LearnTheHeart.com website:
⇒ Go to the Atrial Fibrillation ECG Review->
⇒ Go to the ECG Basics training module->
Reviews and Quizzes, Too
Healio ‘Atrial Fibrillation ECG Review‘ ECG graphic
You can even challenge yourself with the Beginner ECG Quiz featuring detailed answers and links to pertinent explanation pages. Or test your overall knowledge of Atrial Fibrillation with a multiple choice Atrial Fibrillation Quiz.
Other ‘Learn the Heart’ ECG Review Courses
Other ECG courses from Healio review all common ECG findings including normal and abnormal. Each review includes example 12-lead ECGs and, where appropriate, specific criteria. Of particular interest to Atrial Fibrillation patients may be:
• Atrial Flutter ECG Review
• Premature Atrial Contractions (PACs) ECG Review
• Left Atrial Enlargement (LAE) ECG Review
• Atrioventricular Nodal Reentrant Tachycardia (AVNRT) ECG Review
Steve’s Brief Overview: The EKG Signal
If you want just a brief overview of the ECG waveform signal and how to “read” an ECG tracing, go to my report, Understanding the EKG Signal.
Learn to Read Your ECG: My Brief Overview or a Healio.com Training Course
When I developed Atrial Fibrillation, one of my first courses of study was to learn how to read my own Electrocardiogram (ECG or EKG). If this interests you, too, consider my brief overview of the ECG waveform signal and how to “read” an ECG tracing. Go to my report, Understanding the EKG Signal.
FREE ECG Training Course
For the reader wanting a more extensive understanding of the Electrocardiogram and A-Fib, we offer you a link to LearnTheHeart.com – a FREE online cardiology resource for those seeking to increase their knowledge of ECG tracings.
Start with ECG Basics: I suggest you start with the ‘ECG Basics‘ to analyze each part of the ECG tracing; included are detailed explanations and ECG images of the heart in A-Fib. The tutorial is concise and focused on only what you need to know, yet very thorough — from waves to segments to complexes. Go to LearnTheHeart.com ECG Basics.
VIDEO: Graphic Display of Actual Heart in Atrial Fibrillation
Click to go to video
See an ECG waveform of an actual heart in Atrial Fibrillation–how it could look to your doctor. Your ECG may look different, but it will be fast and erratic. (You’ll see the changing heartbeat rate in the lower left.)
Go to video: ECG of Heart in Atrial Fibrillation on Monitor.
New Video: EKG of Actual Heart in Atrial Fibrillation
We’ve added a new video to our Library of Videos & Animations. A graphic display of actual heart in Atrial Fibrillation. How it could look to your doctor on an EKG/ECG monitor; (Your EKG may look different, but will be fast and erratic). Includes display of the changing heartbeat rate in the lower left.
For comparison, we’ve included a graphic comparing the tracing of a heart in normal sinus rhythm vs. a heart in A-Fib.
Share with you family and friends when you talk about your A-Fib. (:59 sec) Go to video->
EKG tracing
How to Interpret an ECG Signal
A-Fib is fairly easy to diagnose using EKG. The ECG signal strip is a graphic tracing of the electrical activity of the heart.
An electrocardiogram, ECG (EKG), is a test used to measure the rate and regularity of heartbeats. To learn more, see our article, Understanding the EKG Signal.
Video: EKG of Heart in Atrial Fibrillation on Monitor
Graphic display of actual heart in Atrial Fibrillation. How it could look to your doctor on an EKG/ECG monitor; (Your EKG may look different, but will be fast and erratic). Notice the changing heartbeat rate in the lower left. Compare to normal ECG below.
Share with you family and friends when you talk about your A-Fib. (:59 sec) Posted by jason king, Published on Aug 24, 2017.
Graphic: ECG of Heart in Normal Heart Rhythm and in Atrial Fibrillation
In the case of Atrial Fibrillation, the consistent P waves are replaced by fibrillatory waves, which vary in amplitude, shape, and timing (compare the two illustrations below).
How to Interpret an ECG Signal
EKG signal components
An electrocardiogram, ECG (EKG), is a test used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart.
The ECG signal strip is a graphic tracing of the electrical activity of the heart. To learn more, see our article, Understanding the EKG Signal.
If you find any errors on this page, email us. Y Last updated: Friday, September 8, 2017
VIDEO: Your Heart’s Ejection Fraction (EF): What You Need to Know
Three short videos about Ejection Fraction with Dr. Robert Fishel
In the following three short videos, cardiac electrophysiologist, Dr. Robert Fishel, discusses the ejection fraction (EF) a measurement of the pumping efficiency of the heart and why cardiac patients should know their EF percentage. (Videos hosted on the Sharecare.com website.)
Video 1: What is the ejection fraction? (:54 sec.)
Dr. Robert Fishel explains that cardiac ejection fraction (EF) refers to the percentage of blood pumped from the heart’s main chamber during each heartbeat, and relays its importance to A-Fib patients.
Video 2: Who should know their ejection fraction (EF)? (:34 sec.)
Measurement of your Ejection Fraction (EF) is an important test for cardiac patients to know. Dr. Robert Fishel explains why A-Fib patients need to know their EF number.
Video 3: How is an ejection fraction measured? (:56 sec.)
Ejection fraction (EF) can be measured by various techniques including an echocardiogram, ventriculogram and other methods.
Dr. Fishel is Director of Cardiac Electrophysiology, JFK Medical Center Atlantis, FL. Dr. Fishel graduated from New York University School of Medicine in 1987 and has been in practice for 30 years. He is board certified in Electrophysiology and Clinical Cardiac Electrophysiology.
If you find any errors on this page, email us. Y Last updated: Monday, January 15, 2018
The Threat to Patients with “Silent A-Fib” How to Reach Them?
‘Silent A-Fib’ is a serious public health problem. Anywhere from 30%-50% of those with A-Fib aren’t aware they suffer from A-Fib and that their heart health is deteriorating.
In his A-Fib story, Kevin Sullivan, age 46, wrote about his diagnosis of Silent A-Fib.
“I was healthy, played basketball three times per week, and lifted weights. I started to notice on some days playing basketball, I was having some strange sensations in my chest. And sometimes, difficultly catching my breath. But the next day I would feel fine. I assumed this was just what it felt like to get old.”
He writes, that at the time, he happened to see a cardiologist about medication for high cholesterol:
“I went to see a cardiologist. They looked at my heart with ultrasound and asked if I could feel “that.” I asked them what they were talking about, and they told me that I was having atrial fibrillation. That was the first time I had ever heard of the phrase.”
‘Silent A-Fib’ vs. ‘Symptomatic A-Fib’
Silent (asymptomatic) A-Fib can have similar long-term effects as A-Fib with symptoms. Silent A-Fib may progress and get worse just like symptomatic A-Fib. Increased fibrosis may develop, the atrium may become stretched and dilated, the frequency and duration of the unnoticed A-Fib attacks may increase over time (electrical remodeling).
Silent A-Fib may progress and get worse just like symptomatic A-Fib.
Is “Silent A-Fib” Really Silent? Some people question whether “silent” A-Fib is really silent (from a clinical aspect). Even with Silent A-Fib, one loses 15%-30% of normal blood flow to the brain and other organs which certainly has an effect. (For Kevin Sullivan, he experienced occasional pain in his chest and shortness of breath while playing basketball.)
Those with Silent A-Fib may get used to their symptoms, or they write off the tiredness, dizziness or mental slowness like Kevin Sullivan did. Nonetheless, almost everyone in Silent A-Fib is affected and changed by their A-Fib to some extent.
‘Silent A-Fib’ More Dangerous: Increased Risk of A-Fib Stroke
When left untreated, A Fib patients have a 5X higher chance of stroke, and a greater risk of heart failure. Often, an A-Fib patient is hospitalized or dies from an A-Fib-related stroke without anyone ever knowing the patient had A-Fib.
And if the patient with A-Fib survives, they have about a 50% higher risk of remaining disabled or handicapped (compared to stoke patients without A Fib).
Tactics to Find Undiagnosed ‘Silent A-Fib’
Today, during a routine physical exam, general practitioners (GPs) will listen to your heart with a stethoscope and would notice if your heart beat was irregular. After a certain age, your exam may also include an ECG (EKG), and the tracing would show if you are in Atrial Fibrillation, even if your not aware of it. Cardiologists routinely perform an ECG and catch Silent A-Fib (like Kevin Sullivan’s cardiologist did).
But, to be detected, A-Fib must be present at the time of the ECG, and we know that A-Fib is often intermittent. If intermittent A-Fib is suspected, your EP has an array of A-Fib wearable event monitoring devices (like the band-aid-size ‘Zio patch’ monitor).
What if A-Fib isn’t even on the patient’s radar? What’s the remedy? More frequent and regular screenings! But how? First, by healthcare personnel teaching ‘at-risk age groups’ how to use pulse-taking palpation (which can be readily taught). See also the VIDEO: “Know Your Pulse” Awareness Campaign.)
Second, through community-sponsored health screening events when patients who are interacting with their healthcare provider for another reason, such as an annual flu vaccination.
Think of the lives and permanent disabilities that would be saved by inexpensive screening and easily administered monitoring for Silent A-Fib.
The Future of Screening for Silent A-Fib: Heart-monitoring apps and devices are growing in popularity. Two FDA-approved devices are the iPhone app called Cardio Rhythm, and the AliveCor Kardia device that connects to a app-equipped smartphone.
In this emerging era of ‘wearable’ technology, the wearer, themselves, may be the first to detect an irregular heart beat.
What Patients Need to Know
If you have A-Fib, discuss it with your family and friends. Answer their questions. Because A-Fib runs in families, urge your immediate family members to discuss A-Fib with their doctors.
Encourage your friends over 60 years old to do the same. Support community-sponsored health screening events.
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