Doctors & patients are saying about 'A-Fib.com'...
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Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN
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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
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
A-Fib Drug Therapy: If We’re Sick, Just Take a Pill, Right?
In the US, we’ve been conditioned to think, “if we’re sick, just take a pill”.
When you have Atrial Fibrillation, anti-arrhythmic drug (AAD) therapy is certainly better than living a life in A-Fib. It can be useful for many patients.
And according to Dr. Peter Kowey, Lankenau Heart Institute (Philadelphia, PA), while anti-arrhythmic therapy is not perfect, it can improve quality of life and functionality for a significant percentage of A-Fib patients.
P. Kowey MD
Dr Kowey is an internationally respected expert in heart rhythm disorders. His research has led to the development of dozens of new drugs and devices for treating a wide range of cardiac diseases.
He cautions, though, that A-Fib anti-arrhythmic drugs are just a stopgap measure. The problem is they don’t deal with the underlying cause. And are seldom a lasting cure for A-Fib.
The Trade-Offs of Anti-Arrhythmic Drugs
In our article, Eleven Things I Know About A-Fib Drug Therapy, Dr. Kowey writes:
“An anti-arrhythmic drug is a poison administered in a therapeutic concentration. Like most meds, anti-arrhythmic drugs, (AADs), are a trade-off between the unnatural and possible toxicity with the power to alleviate our A-Fib symptoms.”
Did “an anti-arrhythmic drug is a poison” set off alarm bells for you?
In general, anti-arrhythmic drugs are toxic substances which aren’t meant to be in our bodies―so our bodies tend to reject them.
For more, see our full article with Dr. Kowey’s insights, Eleven Things I Know About A-Fib Drug Therapy. It’s based on his 2014 American Heart Association (AHA) Scientific Session presentation.
Look Beyond the Typical AAD Therapy
Today’s anti-arrhythmic drugs have mediocre success rates (often under 50%).
Beyond AAD Therapy
Many patients often experience unacceptable side effects. Many just stop taking them. And when they do work, they tend to lose their effectiveness over time.
According to Drs. Irina Savelieva and John Camm of St. George’s University of London:
“The plethora of antiarrhythmic drugs currently available for the treatment of A-Fib is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability.”
These drugs don’t cure A-Fib but merely keep it at bay. Most Atrial Fibrillation patients should look beyond the typical antiarrhythmic drug therapy.
See our Treatments page to learn more about Medicines or ‘Drug Therapies’ for A-Fib.
Answering Your Questions About A-Fib Drug Therapies
Since the beginning of A-Fib.com, we have answered thousands of patient’s questions—many times the same questions. Perhaps the same questions you may have right now.
For unbiased information and guidance about medicines and drug therapy treatments, see our page of questions and answers. You’ll find explanations, resources and advice for the most frequently asked questions by patients and their families. Go to FAQ A-Fib Treatments: Medicines and Drug Therapies.
Tony Rejects Drug Therapy: Says to Ask Questions, None are Stupid
Tony Hall, Evansville, IN, was 54 years old when he develped Atrial Fibrillation in January 2014. After confirming his diagnosis at the hospital, he wrote:
“I sit in the passenger seat feeling like a pet heading to a kennel. Suddenly things are different. I no longer have that “healthy as a horse” attitude.”
He started drug therapy. Then came a cardioconversion, but that didn’t keep him in normal sinus rhythm for long. He was in and out of A-Fib, and by August was in persistent A-Fib.
Learning His Treatment Options
Tony didn’t passively accept everything he was hearing from doctors and others.
He and his wife, Jill, read as much as they could and critically waded through the information they found. (I’m continually amazed at how much mis-information there is about A-Fib on the internet and in the media.)
5-months post-ablation, Tony and Jill after 10K race.
After doing his research, educating himself about treatment options and learning what his health insurance would cover, he chose to have a catheter ablation at the Mayo Clinic in December 2014.
During his three month blanking period, he had some sporadic fluttering and early on a couple of brief A-Fib episodes.
Off all medication and A-Fib-free, in March 2015 he completed a 10K race beating his time from the previous year by a fraction.
Becoming his Own Best Patient Advocate
Tony and Jill are great examples for all A-Fibbers of how to become your own best patient advocate. He rejected endless trials of various drug therapies. Instead he opted for a catheter ablation just shy of a year after his initial A-Fib diagnosis.
In his A-Fib story, he shares this advice to others considering a catheter ablation:
“Make sure, if you desire to have an ablation, that your reasoning is sound and that you have a good argument as to why drug therapy is not the way you want to go.
Having an ablation as front line treatment for A-Fib is not embraced by every EP, and many are reluctant to ablate until drug therapy has failed.
Be persistent and move on [to another doctor] if you are met with resistance.”
For Tony Hall’s personal experience story, see: Very Active 54-Year Old Became His Own Patient Advocate; Chose Ablation as First Line Treatment.
I Couldn’t Believe the Drugs He Was On; How to Ask Questions About Your A-Fib Prescriptions
03/15/2019 5 pm: Corrected a missing link below to the Free Worksheet, Ask These Questions Before Starting a Prescription Drug.
I received a very distressing email from a reader, Kenny, who was worried about his prescribed medications. He wrote that he just had a cardioversion a week ago and is back in A-Fib (unfortunately that’s not uncommon). Alarm bells went off in my head when I read:
“My doctor just prescribed me amiodarone 200mg, 4x a day…I’m a little concerned about the amiodarone and all the side effects!”
“I’m also on Digoxin…Xarelto and aspirin… .”
“I can’t get my doctor’s office or doctor to call me back! Reluctant to start amiodarone until I can talk to someone!”
Drugs Therapies Concerns
Ding, Ding, Ding! I am deeply concerned for him. The doctor prescribing these drugs is in internal medicine, not a cardiac electrophysiologist. While Kenny and I continue to exchange emails, here’s some highlights from my first reply:
• Amiodarone is an extremely toxic drug, and this dosage is 4x the normal dose.
• You must get a second opinion ASAP! (consult a cardiac electrophysiologist)
• Digoxin is also a dangerous drug not normally prescribed for A-Fib patients.
• It’s very unusual to prescribe both Xarelto and aspirin.
Time to Change Doctors? And lastly, I wrote him that if your doctor or his office isn’t calling you back, that’s a sign you should look for a new doctor (don’t be afraid to fire your doctor). You need good communication when you’re in A-Fib and trying to find a cure.
I’m glad Kenny reached out to me so we can get him on the right A-Fib treatment plan for him and his treatment goals.
Ask These Questions Before Starting a Prescription Drug
Download the Free Worksheet
Before starting any prescription drug for your Atrial Fibrillation, you should ask what it’s for and why you should take it.
Download our free worksheet, ‘10 Questions to Ask Before Taking Any Medication’ and use as a guide to ask these questions of your doctor or healthcare provider, and note their responses:
1. Why am I being prescribed this medication?
2. What are the alternatives to taking this medication?
3. What are the side effects of this drug?
4. Are there any precautions or special dietary instructions I should follow?
5. Can it interfere with my other medications?.
6. How long before I know if this drug is working?
7. How will I be monitored on this drug? How often?
8. What happens if this drug doesn’t work?
9. What if my A-Fib symptoms become worse?
10. If I don’t respond to medications, will you consider non-pharmaceutical treatments (such as a catheter ablation)?
Research and Learn About Any Prescription Drug 
You can do your own research about a specific medication and if it’s the right one for you.
An excellent prescription database is the U.S. National Library of Medicine Drug Information Portal. (For an example, see the page on Warfarin [Coumadin].)
Decision Making Time
Your research and the answers to these 10 questions should help you decide about taking a new prescription drug. Remember, it’s your heart, your health. Taking medications is a decision you should make in partnership with your doctor.
Note: File your completed worksheets in your A-Fib binder or file folder to use for future reference and follow-up.)
“Do Not Use This Product” Warnings on Decongestants: Which are Safe for A-Fib Patients
by Steve Ryan
First published Dec. 2017. Last updated: March 14, 2019
It’s cough and cold season, and millions of cold sufferers are reaching for an over-the-counter (OTC) decongestant capsule or nasal spray to clear a stuffy nose.
As an A-Fib patient, did you notice these over-the-counter decongestants often contain a warning such as:
“Do not use this product if you have heart disease, high blood pressure, thyroid disease, diabetes, or difficulty in urination due to enlargement of the prostate gland, unless directed by a doctor.”
What does this warning mean for patients with Atrial Fibrillation?
Decongestants, Heart Disease and A-Fib
When you have a stuffed up nose from a cold or allergies, a decongestant can cut down on the fluid in the lining of your nose. That relieves swollen nasal passages and congestion. (In general, an antihistamine doesn’t help with this symptom.)
The Problem: When taking a decongestant, heart rate and blood pressure go up, the heart beats stronger, blood vessels constrict in nasal passages reducing fluid build-up. In general that’s okay for most patients.
But not for patients with high blood pressure, heart disease or, specifically, Atrial Fibrillation. Decongestants cause the blood vessels to shrink and blood pressure to rise. Perfect conditions that can trigger or induce an episode of their A-Fib.
Another concern for A-Fib patients is that some over-the-counter (OTC) medications can interact with the anti-arrhythmic medication they’re taking.
Check your Cold Medicine: The main active ingredient in many decongestants is pseudoephedrine, a stimulant. It is well known for shrinking swollen nasal mucous membranes.
To find out if your cold medicine contains a decongestant, start by reading the label. You can lookup the ingredients of any OTC medication at Drugs.com. Just search by product name or active ingredient.
In addition, you can consult your pharmacist who can check the label of a medicine and let you know if it’s safe for someone with atrial fibrillation and/or high blood pressure.
Drugs.com makes it easy to check the ingredients of any OTC medication, just search by product name or active ingredient.
Drugs.com makes it easy to check the ingredients of any OTC medication, just search by product name or active ingredient.
OTC Decongestants to Avoid: Some OTC decongestants tablets, capsules and nasal sprays to avoid if you have atrial fibrillation include:
• AccuHist DM® (containing Brompheniramine, Dextromethorphan, Guaifenesin, Pseudoephedrine)
• Advil Allergy Sinus® (containing Chlorpheniramine, Ibuprofen, Pseudoephedrine)
• Advil Cold and Sinus® (containing Ibuprofen, Pseudoephedrine)
• Sudafed (pseudoephedrine)
• Afrin and other decongestant nasal sprays and pumps (oxymetazoline)
Phenylephrine: a Safe Substitute? Maybe. A substitute for pseudoephedrine is phenylephrine. In general, phenylephrine is milder than pseudoephedrine but also less effective in treating nasal congestion. As with other decongestants, it causes the constriction of blood vessels and increases blood pressure.
There is anecdotal evidence that products with the substitute phenylephrine might be less of a trigger for A-Fib than products with pseudoephedrine. Products with phenylephrine:
• Sudafed PE Congestion tablets
• Dimetapp Nasal Decongestant capsules
• Mucinex Sinus-Max Pressure and Pain caplets (Sue Greene writes that she has used Guaifenesin (Mucinex) for years which has never put her into A-Fib, 2/15/19. Lompocsue(at)yahoo.com.)
Decongestant-Free Products: These tablets, capsules and nasal sprays are decongestant-free and safe for patients with Atrial Fibrillation (They are marketed for those with High Blood Pressure):
• Coricidin HBP line of products (Chlorpheniramine)
• DayQuil HBP Cold & Flu (dextromethorphan hydrobromide)
• NyQuil HBP Cold & Flu (dextromethorphan hydrobromide)
• non-medicated inhalers such as Vicks VapoInhalers (Levmetamfetamine)
What About Antihistamines?
Antihistamines reduce the effects of histamine in the body which can produce sneezing, runny nose, etc. Though they can lessen your symptoms, some can aggravate a heart condition, or be dangerous when mixed with blood pressure drugs and certain heart medicines.
Antihistamines can be dangerous when mixed with blood pressure drugs and certain heart medicines.
Antihistamines can be dangerous when mixed with blood pressure drugs and certain heart medicines.
Heart-safe Antihistamines: Compared to decongestants, antihistamines are often better tolerated by people with A-Fib. Some heart-safe antihistamines that can help with a stuffy nose from a cold include:
• Claritin tablets (loratadine)
• Zyrtec tablets (cetirizine)
• Allegra tablets (fexofenadine)
• Chlor-Trimeton (chlorpheniramine)
Non-Drug Alternatives for Cold Relief
If you want to avoid medications altogether, you can try a variety of things to clear your head.
Breathe Right nasal strips may help you breathe better at night. Use saline nasal spray (like Ocean or Basic Care) to help flush your sinuses, relieve nasal congestion and curb inflammation of mucous membranes.
A steamy shower or a hot towel wrapped around the face can also relieve congestion. Drinking plenty of fluids, especially hot beverages (like chicken soup), keeps mucus moist and flowing.
Recommendations for A-Fib Patients
Antihistamines and decongestants can give much-needed relief for a runny or congested nose. But A-Fib patients should pay attention to the warnings for heart patients. Here’s some products and procedures to consider:
Decongestant-free: Look for decongestant-free products (e.g. Coricidin HBP, DayQuil HBP Cold & Flu, NyQuil HBP Cold & Flu and Vicks VapoInhalers).
One possible exception are those decongestant products with the active ingredient phenylephrine (e.g. Sudafed PE, Dimetapp and Mucinex Sinus).
Heart-safe antihistamines: You can try one of the heart-safe antihistamines (e.g. Claritin, Zyrtec and Allegra).
Drug-free alternatives: Try drug-free substitutes (e.g. Breath Right nasal strips, saline nasal spray and a steamy shower).
The best advice for you and your A-Fib: Always consult your cardiologist or EP. Ask what’s the best option for your stuffy nose or allergies. And ask about interactions with your other heart medications (especially if you have high blood pressure).
Medical Marijuana: A-Fib Patients Offer Personal Experiences
Due to the increased use of medical marijuana in California and other states, we should soon be getting more data on marijuana’s effects on Atrial Fibrillation.
Several readers with A-Fib have emailed me to share their experiences and observations with marijuana. There seems to be a lot of interest every time I write about this topic.
How about you? I’d love to get more first-hand feedback from A-Fib users. Please email me.
First-Hand Experiences: A-Fib and Medical Marijuana
Jim, an A-Fib patient, has kindly shared his personal use of marijuana and how it helps him. He has tried various meds, cardioversion, and had a failed ablation. He owns his own business in California and is under a lot of stress.
♥ JIM: “Because of all of this, I was having trouble sleeping and was getting very stressed out. But instead of taking something pharmaceutical, I turned to medical marijuana. It changed my life. I come home at night, have some marijuana edibles, and the stress goes away. I sleep wonderfully at night, waking up fresh and ready for another day.
I told my doctor who understands. He says that marijuana edibles shouldn’t have anything to do with A-Fib, and that I can continue to take them.”
On the other hand, John writes that:
♥ JOHN: “99% of his A-Fib attacks occurred while under the influence of marijuana.”
And others add their experiences:
♥ JONATHAN: “I tried a tiny bit of brownie for the first time since being diagnosed with A-Fib (occasional episodes). It was OK until about two hours later. I went into A-Fib and, a bit later, came the closest I ever have to blacking out. I don’t think it’s for me anymore.”
♥ WILLIAM: “The A-Fib ablation has been very successful, except the two times that I went into A-Fib after smoking marijuana. I’m a lifelong recreational marijuana smoker, also smoke to relieve the pain from six surgeries on my right arm. Both times that I’ve gone into A-Fib since my last ablation have been after smoking marijuana. After the latest episode I’ve quite smoking marijuana because of the evidence that it can lead to A-Fib.”
♥ SCOTT: “I am currently 55 years old and have been through 15 cardioversions due to A-Fib. I smoked marijuana pretty much daily and noticed that, when I smoked, my heart rate went up. So, I stopped smoking altogether. Since quitting smoking marijuana 7 years ago, I have not had a single case of going into A-Fib. I’m positive that the two are related.”
Scott added that he also stopped drinking which helped. He used to drink a six pack daily.
PODCAST: Marijuana—Good, Bad or Ugly for Patients with A-Fib?
For my most recent report about A-Fib and Marijuana, listen to my Podcast with Travis Van Slooten, publisher of LivingWithAtrialFibrillation.com. (About 18 min. in length.) Includes transcript.
Marijuana—Good, Bad or Ugly for Patients with A-Fib?
With Steve Ryan and Travis Van Slooten (18 min.)
Why am I Angry at Some Doctors Treating Atrial Fibrillation Patients?
I can’t tell you how angry I am at cardiologists who want to leave their patients in Atrial Fibrillation.
It doesn’t matter even if a patient has no apparent symptoms. Just putting a patient on rate control meds and leaving them in A-Fib can have disastrous consequences.
Silent A-Fib Discovered During a Routine Physical
Discovered during routine exam
I corresponded with a fellow who had just found out he was in “silent” Atrial Fibrillation (no symptoms).
I told him he was very lucky (and should buy his doctor a present in gratitude). His doctor discovered his A-Fib during a routine physical exam. If his silent A-Fib had continued untreated, he might easily have been one of the 35% who suffer a debilitating A-Fib-related clot and stroke.
I would normally commend his cardiologist, but his doctor just put him on the rate control drug, diltiazem, and left him in A-Fib.
That is so wrong for so many reasons!
Rate Control Drugs Don’t Really “Treat” A-Fib
Rate control drugs aren’t really a “treatment” for A-Fib. Though they slow the rate of the ventricles, they leave you in A-Fib.
They may alleviate some A-Fib symptoms, but do not address the primary risks of stroke and death associated with A-Fib.
Effects 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:
• 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.
What Patients Need to Know
For many, many patients, A-Fib is definitely curable. You don’t have to settle for a lifetime of “controlling” your Atrial Fibrillation.
Normal Sinus Rhythm: The goal of today’s AHA/ACC/HRS A-Fib Treatment Guidelines is to get Atrial Fibrillation patients back into normal sinus rhythm (NSR) and stay in sinus rhythm.
Unless too feeble, there’s no good reason to just leave someone in A-Fib (see note below).
Don’t let your doctor leave you in A-Fib. Educate yourself. Learn your treatment options.
Always Aim High! No matter how long you’ve had A-Fib, you should aim for a complete and permanent cure. Shoot for the moon, as they say, and you’ll find the best outcome for you and your type of A-Fib.
5-Year CABANA Trial: Compares Catheter Ablation with Antiarrhythmic Drug Therapy
The catheter ablation procedure for Atrial Fibrillation has been around for 20+ years.
In a randomized controlled trial, the 5-year CABANA study is the largest to compare the A-Fib treatments of catheter ablation (PVI) and antiarrhythmic drug therapy (AAD).
CABANA stands for Catheter Ablation versus Antiarrhythmic Drug Therapy.
CABANA Trial Design
Worldwide, 2,204 patients with new onset or undertreated Atrial Fibrillation were randomized between two treatments: catheter ablation (PVI) or antiarrhythmic drug (AAD) therapy. Patient participants were followed for nearly 5 years.
Patients details: Many patients had concurrent illnesses with Atrial Fibrillation: cardiomyopathy (9%), chronic heart failure (15%), prior cerebrovascular accidents or TIAs (mini-strokes) (10%).
Over half of participants (57%) had persistent or long-standing persistent A-Fib [i.e. harder types of A-Fib to cure].
Drug details: Antiarrhythmic drug (AAD) therapy was mostly rhythm control (87.2%), some received rate control drug therapy.
Anticoagulation drug therapy was used in both groups.
CABANA Trial Results
There was no significant difference between the two arms in the primary endpoint of the trial (the composite of all-cause mortality, disabling stroke, serious bleeding, or cardiac arrest), which occurred in 9.2% of patients in the drug group and 8% of patients in the ablation group (hazard ratio 0.86, CI 0.65-1.15, p =0.303).
Crossover a Major Problem: Many in the AAD therapy arm decided to have a catheter ablation instead (27.5%). And some in the ablation arm decided not to have an ablation (9.2%). [One can not blame patients or their doctors for making these life-impacting choices.]
The problem arises when so many of the AAD therapy arm cross over. In the primary endpoint “intent to treat” group, those who wound up having an ablation were still included in the ADD arm. Whereas when researchers looked at actual “treatment received”, the CABANA results showed catheter ablation was significantly better than drug therapy for the primary endpoint (a composite of all-cause mortality, disabling stroke, serious bleeding or cardiac arrest). [See Additional Research Findings below.] Mortality and death rate were also significantly better for catheter ablation.
Additional CABANA Findings: Ablation vs AAD Therapy
▪ Catheter Ablation significantly reduced the recurrence of A-Fib versus AAD therapy.
▪ Catheter Ablation improved ‘quality of life’ (QofL) more than AAD therapy, though both groups showed substantial improvement.
▪ Catheter Ablation patients had incremental, clinically meaningful and significant improvements in A-Fib-related symptoms. This benefit was sustained over 5 years of follow-up.
▪ Catheter Ablation was found to be a safe and effective therapy for A-Fib and had low adverse event rates.
Take-Aways for A-Fib Patients
Ablation Works Better than Antiarrhythmic Drugs: Rather than a life on antiarrhythmic drug therapy, the CABANA trial and other studies show that a catheter ablation is the better choice over antiarrhythmic drug therapy.
In an editorial in the Journal of Innovations in Cardiac Rhythm Management, Dr. Moussa Mansour, Massachusetts General Hospital, wrote about the CABANA trial:
“It confirmed our belief that catheter ablation is a superior treatment to the use of pharmacological agents, and corroborates the findings of many other radomized clinical trials.”
Lower Recurrence: What’s also important for patients is the lower risk of recurrence of A-Fib versus AAD therapy.
Reduced Ablation Safety Concerns: Ablation significantly improved overall mortality and major heart problems.
Immeasurable Improvement in Quality of Life! Perhaps even more important for patients on a daily basis, catheter ablation significantly improved quality of life.
Don’t Settle for a Lifetime on Drugs
Over the years, catheter ablation for A-Fib has become an increasingly low risk procedure with reduced safety concerns. 
(Ablation isn’t surgery. There’s no cutting involved. Complication risk is similar to tubal ligation or vasectomy.)
An ablation can reduce or entirely rid you of your A-Fib symptoms, make you feel better, and let you live a healthier and longer life (for people who are older, too). A catheter ablation significantly improves your quality of life (even if you need a second “re-do ablation” down the road).
For many, many patients, A-Fib is definitely curable. Getting back into normal sinus rhythm and staying in sinus rhythm is a life-changing experience, as anyone who’s free from the burden of A-Fib can tell you.
See also: Does a Successful Catheter Ablation Have Side Benefits? How About a Failed Ablation?
Blood Thinner Myths Debunked by Healthcare Monitor Guide to AFIB
Every Atrial Fibrillation patient has to deal with the increased risk of clots and stroke and that often includes taking a blood thinner or anticoagulant.
At my doctor’s office I came across one of those “free take home copy” publications about Atrial Fibrillation. Healthcare Monitor Guide to Living with AFib 2018 had an interesting sidebar with a few myths and truths about blood thinners. I’d like to share a few misconceptions they list:
Guide to Living with AFib 2018
• “I’m afraid of shaving because I hear it’ll take forever to stop bleeding.”
• “Blood thinners will make me feel tired.”
• “It seems I bruise much more easily now-and that can’t be good.”
Do any of these ring a bell with you? Are you concerned with the same issues? Healthcare Monitor debunks these as myths and explains way.
Blood Thinner Myths Debunked
“I’m afraid of shaving because I heart it’ll take forever to stop bleeding…If bleeding while shaving is a problem, consider using an electric shaver. And remember: Even if you seem to bleed more easily now, suffering a stroke could cost you your life.
Blood thinners will make me feel tired. There’s no evidence that blood thinners cause or worsen fatigue. In fact, fatigue has not been identified as a problem in numerous studies done in thousands of patients. Of course, several things can effect your energy levels, including other medications you’re taking and lack of sleep. If you’re feeling more exhausted than usual, bring it up with your doctor.
It seems I bruise much more easily now-and that can’t be good. It’s true that bruising may be somewhat increased while you’re on a blood thinner. Although this can be a nuisance, it is important to remember that you are taking this medication to lower the risk of stroke. So the trade-off—accepting a slight increase in bruising—is worth the protection from dangerous clots.”
An Alternative to Blood Thinners
Catheter placing Watchman in LAA
But blood thinners are not like taking vitamins. They have their own set of risks and side effects. However, preventing a stroke is for most people a welcome trade-off for any bad effects of anticoagulants.
If you can’t or don’t want to take blood thinners, an option is to have a device installed to close off the Left Atrial Appendage. The LAA is a small pocket of heart tissue located above the left atrium where 90%-95% of A-fib strokes originate.
To learn more see my articles: Watchman: the Alternative to Blood Thinners or LAA Occlusion for A-Fib Patients: The Lariat II Versus the Watchman Device.
Or watch the 3:28 min. video: The Watchman Device: Closure of the Left Atrial Appendage.
A-Fib Patients (and Others): Should You Be Prescribed Fewer Drugs?
Did you know you can outgrow your medication? Perhaps your lifestyle has changed with more physical activity, better nutrition or weight loss and subsequently you may no longer need medications for diabetes, cholesterol or high blood pressure.
But you keep taking them, because no one told you to stop.
Simple errors can occur, too. Dr. Michael A. Steinman, a geriatrician at the University of California, San Francisco, recalled asking a patient to bring in every pill he took for a so-called ‘brown bag review’. He learned that the man had accumulated four or five bottles of the same drug without realizing it, and was ingesting several times the recommended dose.
“We spend an awful lot of money and effort trying to figure out when to start medications and shockingly little on when to stop.”
Dr. Caleb Alexander, Johns Hopkins Center for Drug Safety and Effectiveness
De-Prescribing: A Brown Bag Review
Always keep an accurate and updated list of medications you are taking. (See our free download form below.)
Periodically ask your physicians or pharmacist for a ‘brown bag review’. Discuss whether to continue or change any of your regimens. Ask about:
▪ any medicines you no longer need?
▪ any medications you can do without?
▪ if a lower dose would work for any of your medicines?
▪ if any of your medications might interact with another?
▪ any non-pharmacologic alternatives?
If your doctor agrees to ‘de-subscribe’ a medication, realize it isn’t as simple as saying “stop” taking it. It’s a process requiring caution and skill by your doctor. (Afterwards, remember to update your list of medications.)
Free Download: Keep an Inventory List of Your Medications
Keep your doctor and other healthcare providers up-to-date on all the medications you are taking by using this Medications List from Alere. Download (and remember to save the PDF to your hard drive).
Besides prescriptions, the form has sections to list over-the-counter drugs, vitamins, herbs and mineral supplements, too (as they can interact).
Print several copies of the blank form and keep handy in your A-Fib file or binder. When completed, give a copy of your inventory to each of your healthcare providers.
Also see my article: Are Your Herbal Supplements Interacting With Your Medicines?
‘A Patient Cured is a Customer Lost’ & Other Facts About Big Pharma
Did you know drug companies spend twice as much on marketing and advertising as on researching and developing new drugs? (I was shocked.)
Of special interest to me is the ‘Direct to Consumer’ drug advertising which has significantly increased drug sales in the U.S.
‘Direct to Consumer’ drug advertising is so misleading that it is banned in all countries except two: the U.S. and New Zealand. (No wonder that 70% of drug companies’ profit comes from the U.S.)
Misleading Drug Ads
To be specific, I hate those misleading TV commercials that target A-Fib patients. What these ads for anticoagulants don’t tell you is:
• You are on their meds for life! (they want lifelong customers!)
• These meds do nothing to treat your A-Fib (only your risk of stroke)
• A-Fib can be cured (you don’t have to be on meds for the rest of your life)
These ads for anticoagulant medications imply that if you just take their pill once a day, you’ve taken care of your A-Fib. Wrong! Don’t fall for the hype.
Bad Pharma—How Drug Companies Mislead Doctors & Harm Patients
The author of Bad Pharma does an excellent job of shining a light on the truths that the drug industry wants to stay hidden.
Those truths include how they mislead doctors and the medical industry through sales techniques, and manipulate consumers into becoming life-long drug customers. (For doctors, that industry influence begins in medical school and continues throughout their practice.)
We also learn truths about the internal workings of the medical academia, the U.S. FDA, and medical journals publishing.
The arguments in the book are supported by research and data made available to the reader. The author, Ben Goldacre, is a doctor and science journalist, and advocates for sticking to the scientific method, full disclosure and advocating for the interest of the patients. Read a critical review of Bad Pharma in the British Journal of Clinical Pharmacology.
My Best Advice: ‘Educate Yourself’
One of our tenets at A-Fib.com, is ‘Educate Yourself’! if you want to be a more savvy consumer of health care services (I highly recommend Bad Pharma. I also recommend Ben Goldacre’s other book, Bad Science).
Bonus Idea: If you pair this book with “Know Your Chances: Understanding Health Statistics” by Steven Woloshin, you’ll have a complete course on how the drug industry skillfully markets their products. Read my review.
Read the book for FREE: The ebook version is online at U.S. National Library of Medicine PubMedHealth, and you can download the .PDF version (remember to save to your hard drive).
See my post: How Big Pharma Issues Misleading News and Why it Matters.
Features the report by the online watchdog group HealthNewsReview.org.
Don’t Settle for a Lifetime on Medications—
Seek your A-Fib Cure
Drugs Don’t Cure Atrial Fibrillation But Merely Keep it at Bay
Advice from Patients Now Free from the Burden of Atrial Fibrillation
Daniel Doane, Sonora, California, USA, shares his mistake:
Daniel D.
“Don’t think that the medication is a long term solution. Don’t put up with nasty side effects.
That was the mistake I made. I thought I could tough out the medication as long as I stayed out of A-Fib.
Terry D.
Terry DeWitt, Massachusetts, USA, advises act sooner than later:
“I knew I could continue on medication for several years, but I was concerned about the remodeling of my heart. …I would need an ablation…and sooner seemed better when my heart was still strong.”
Max Jussila, Shanghai, China, says meds are for the short term:
Max J.
“Do not listen to your doctors if they suggests medication as a long-term solution!
The doctors who see medication as a solution commit serious negligence and are ignorant of the terrible nature and consequences of Atrial Fibrillation.”
Don’t Just Manage Your A-Fib with Meds. Seek your Cure.
According to Drs. Irina Savelieva and John Camm of St. George’s University of London, London, UK:
“The plethora of antiarrhythmic drugs currently available for the treatment of A-Fib is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability.”
In general, don’t expect miracles from current medications. Antiarrhythmic drugs are only effective for about 40% of patients; many can’t tolerate the bad side effects. When they do work, the drugs become less effective or stop working over time.
In his, personal A-Fib story, Dr. Sam T. MD, from Tennessee, USA, shares:
“At this time when all medicines and cardiac procedures have their risks and limitations, finding a way to get to NSR [Normal Sinus Rhythm] and staying in NSR is most important.”
The goal should be to end your A-Fib episodes not manage them. Learn more at: Drug Therapies. Always Aim for a Cure!
Drugs Have a Role, but Other Treatment Options Target a Cure.
From The Top 10 List of A-Fib Patients’ Best Advice’ , a consensus of valuable advice from fellow Atrial Fibrillation patients; Chapter 12, Beat Your A-Fib: The Essential Guide to Finding Your Cure by Steve S. Ryan, PhD.
Go to Top 10 List of A-Fib Patients’ Best Advice
♥ Please, share the advice ♥
FAQ Update: For stroke prevention—warfarin (Coumadin), an NOAC or aspirin?
We’ve updated our answer to the Frequently-Asked-Question (FAQ):
“For A-Fib patients, which is the better to A-Fib-related stroke—warfarin (Coumadin), an NOAC or aspirin?”
For decades, people more at risk for A-Fib-related stroke have been on warfarin (Coumadin). In the last few years, many of these patients have switched to the newer NOACs. A-Fib patients with low or no risk factors for stroke are often put on aspirin, or nothing at all.
Differences with the Same Goal
Aspirin is an antiplatelet drug that decreases the stickiness of circulating platelets (small blood cells that start the normal clotting process), so that they adhere to each other less and are less likely to form blood clots. (Cost: dirt cheap.)
Warfarin (brand name Coumadin) is an anticoagulant that works by slowing the production of blood clotting proteins made in the liver. Warfarin is highly effective, reducing the annual risk of stroke by approximately two thirds, but does require periodic lab tests to maintain the proper therapeutic level. (Cost: dirt cheap + lab tests.)
NOACs stands for Novel Oral AntiCoagulants. NOACs are alternatives for vitamin K antagonists (e.g., Warfarin). NOACs don’t require periodic blood testing as with warfarin. The clinical trials indicate NOACs work as well as warfarin. (Cost: Extremely expensive.)
—Continue reading—for the rest of our answer along with a few takeawys.
FAQs A-Fib Drug Therapy: Natural Blood Thinners
FAQs A-Fib Drug Therapy: Natural Blood Thinners
“Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”
There are a number of foods and supplements that are known to thin the blood. These include foods with high amounts of aspirin-like substances called salicylates, omega-3 fatty acids, vitamin E supplements, and foods with natural antibiotic properties.
Healthy adults can greatly reduce the risk of blood clots and cardiovascular disease by modifying their lifestyle and adding nutritional supplements proven to support cardiovascular health. But this site is not recommending or advising that people switch from prescription anticoagulants to natural blood thinners.
No Studies that ‘Natural’ is as Effective as Warfarin
As of yet, there aren’t any double blind studies which demonstrate any natural alternative (or combination) is as effective against stroke as warfarin (Coumadin) or the new NOACs.
Certain foods and supplements may be “natural” and thin the blood, but there’s little research on their effectiveness to prevent clots in those at high-risk for stroke, such as A-Fib patients.
What’s more, there isn’t a way to track their effectiveness in the same way doctors can monitor the action of warfarin through routine blood tests.
If considering a switch to natural blood thinners, do not stop taking your anticoagulation medication. Talk to your doctor first.
Patients with Lone Atrial Fibrillation
Natural blood thinners may be considered for patients with “lone” Atrial Fibrillation, that is, patients who have had A-Fib occur only once or twice, are young, and have an otherwise healthy heart (normal size, no enlarged chambers or leaky valves, not otherwise prone to blood clots or other heart risk factors like diabetes, etc.). These low-risk patients may be candidates for natural alternatives to warfarin (Coumadin). (Historically, these patients may have been put on aspirin.)
If considering a switch to natural blood thinners, do not stop taking your anticoagulation medication. Talk to your doctor first. (But realize that your doctor isn’t likely to tell you to stop taking your warfarin or NOAC prescription.)
Seek Holistic-Minded Practitioners
Instead, you may want to seek out doctors who are holistically-minded and have knowledge of natural medicines; for example, a doctor who practices complementary or integrative medicine or a naturopathic physician. They can partner with you to pursue natural alternatives to prescription medicines. For a listing of such doctors in your area, go to http://www.ACAM.org.
For example, on his website, the Integrative Cardiologist and anti-aging specialist Dr. Stephen Sinatra discusses combating blood clots with this regimen of natural blood thinners:
• Fish oil (2–3 grams daily)
• Garlic (1–2 grams daily in capsule form)
• Nattokinase (100 mg daily)
• Vitamin E as mixed tocopherols (200–300 IU daily)
• Bromelain, an enzyme derived from pineapple (600 mg daily)
For additional advice on natural ways to prevent blood clots, visit www.drsinatra.com.
Talk to Your Doctor: Supplements Can Interfere with Coagulation
Always talk to your doctor before adding any supplements to your treatment plan. Some ‘natural’ supplements may interact with your prescription meds (when taken alone or in combination) or interfere with coagulation and increase your bleeding risk.
Return to FAQ Drug Therapies
Last updated: Monday, June 18, 2018
FAQ: “Which is the better to prevent A-Fib-related stroke—warfarin (Coumadin), a NOAC or aspirin?
FAQs A-Fib Drug Therapy: Stroke Prevention
“For A-Fib patients, which is the better to prevent A-Fib-related stroke—warfarin (Coumadin), a NOAC or aspirin?”
Updated: June 2018. For decades, patients more at risk for A-Fib-related stroke have been on warfarin (Coumadin). In the last few years, many of these patients have switched to the newer NOACs. A-Fib patients with low or no risk factors for stroke are often put on aspirin, or nothing at all.
Differences with the Same Goal
Aspirin is an antiplatelet drug that decreases the stickiness of circulating platelets (small blood cells that start the normal clotting process), so that they adhere to each other less and are less likely to form blood clots. (Cost: dirt cheap.)
Warfarin (brand name Coumadin) is an anticoagulant that works by slowing the production of blood clotting proteins made in the liver. Warfarin is highly effective, reducing the annual risk of stroke by approximately two thirds, but does require periodic lab tests to maintain the proper therapeutic level. (Cost: dirt cheap + lab tests.)
NOACs stands for Novel Oral AntiCoagulants. NOACs are alternatives for vitamin K antagonists (e.g., Warfarin). NOACs don’t require periodic blood testing as with warfarin. The clinical trials indicate NOACs work as well as warfarin. (Cost: Very expensive.)
Takeaways
The FDA approved the NOACs without any recognized method of determining their clot preventing effectiveness (as with warfarin, i.e. INR).
Warfarin has been successfully used for stroke prevention in A-Fib patients at high or intermediate risk for stroke. It’s readily available and inexpensive.
Aspirin is no longer recommended as first-line therapy for Atrial Fibrillation patients according to the 2014 AHA/ACC/HRS Treatment Guidelines for Atrial Fibrillation. And has been downgraded to a class 2B drug.
Microbleeds: We obviously don’t have any data on the long-term effects of taking NOACs for years. Some people on long-term warfarin have been known to develop micro bleeds and dementia. Will this happen with the NOACs? We simply don’t know. But intuitively one would expect the same thing to happen, though probably not to the extent of warfarin.
Weighing the various risk/benefit ratios is a decision for you and your doctor. And should be re-evaluated as you grow older.
Return to FAQ Drug Therapies
Last updated: Monday, June 18, 2018
FAQ: Are Anticoagulants and Blood Thinners the Same Thing? How do they Work?
FAQs A-Fib Drug Therapy: Warfarin
“Are Anticoagulants and blood thinners the same thing? How do they thin the blood?”
Since A-Fib increases your risk of clots and stroke, blood thinners are prescribed to prevent or break up blood clots in your heart and blood vessels and thereby reduce your chance of an A-Fib-related stroke.
Although referred to as “blood thinners”, they don’t actually affect the “thickness” or viscosity of your blood.
Anticoagulant Warfarin
There are two main types: anticoagulants and antiplatelet agents. They work differently to accomplish the same end effect.
Anticoagulants work chemically to lengthen the time it takes to form a blood clot.
Common anticoagulants include warfarin (Coumadin), Heparin and the NOACs such as apixaban (Eliquis).
Antiplatelet Aspirin
Antiplatelets prevent blood cells (platelets) from clumping together to form a clot.
Common antiplatelet medications include aspirin, ticlopidine (Ticlid) and clopidogrel (Plavix) .
Final answer: An anticoagulant doesn’t really thin the blood or make it less viscous, but it does help prevent a stroke like blood thinners do.
Note: To read about ‘clot buster’ drugs or treatments that could save you from a debilitating stroke, see my article: Your Nearest ‘Certified Stroke Center’ Could Save Your Life.
Return to FAQ Drug Therapies
Last updated: Tuesday, June 19, 2018
Good News for A-Fib Patients!―FDA Approves Reversal Agent for the NOACs Xarelto and Eliquis
Background: One of the problems for Atrial Fibrillation patients taking anticoagulants is the risk of life threatening or uncontrolled bleeding, particularly if one is injured. Since the introduction of the NOAC anticoagulants, there’s been an increase of hospital admissions and deaths related to bleeding, one of the major complications of anticoagulation.
In the U.S. alone in 2016, there were about 117,000 hospital admissions attributed to factor Xa inhibitor-related bleeding and nearly 2,000 bleeding-related deaths per month. An estimated 4 million people are taking factor Xa inhibitors.
Anticoagulant Reversal Agents
Up to now, only the anticoagulants Pradaxa (dabigatran) and Coumadin (warfarin) had a reversal agent or antidote.
As an example, if you were taking Pradaxa and were injured in an auto accident, doctors in the ER could administer ‘Praxbind’ (idarucizumab), the Pradaxa reversal agent, to stop any uncontrolled bleeding and (probably) save your life.
Many patients with Atrial Fibrillation were put on Pradaxa rather than Xarelto and Eliquis because Pradaxa has had a reversal agent since 2015.
Andexxa: Antidote for Xarelto and Eliquis
Now both Xarelto (rivaroxaban) and Eliquis (apixaban) have the FDA-approved reversal agent Andexxa (Portola Pharmaceuticals) as of May 7, 2018. It probably won’t be available till early June.
Andexxa rapidly and significantly reverses ‘anti-factor Xa’ activity which is the anticoagulant mechanism of both Xarelto and Eliquis.
Should you Switch From Pradaxa?
If you are taking Pradaxa, you may want to discuss with your doctor whether you should switch to another NOAC. 
(Note: Eliquis tested the best and is the safest of the new anticoagulants. See my article: Pradaxa and the Other New Anticoagulants.)
Are you tolerating Pradaxa well ? Nearly two out of five people (35%) couldn’t― that’s a high rate of adverse reactions. A large number of patients on the 150mg dose of Pradaxa had an increased incidence of gastrointestinal adverse reactions (35%/yr) compared to warfarin (24%/yr). For more see my article: The New Anticoagulants.
Pradaxa’s own fact sheet states common side effects of Pradaxa include:
• Indigestion, Upset Stomach, or Burning
• Stomach Pain
Note: These statements don’t capture the actual human toll—burning throat, roiling intestines, diarrhea, burning anus, lasting intestinal damage, etc. that Pradaxa can produce in some people.
Even if you seem to tolerate Pradaxa well, it may cause permanent GI damage over time.
Anticoagulants are Still Considered High Risk Drugs
Even though Xarelto and Eliquis join Pradaxa with an antidote reversal agent, they are all still considered high-risk drugs.
Taking an anticoagulant is not like taking a multi-vitamin.
Anticoagulants work by causing or increasing bleeding. Though they are certainly better than having an A-Fib stroke, they carry their own risks. Read more: Bleeding Risk of Anticoagulants.
PODCAST: Marijuana—Good, Bad or Ugly for Patients with Atrial Fibrillation?
Note: If you prefer to read instead of listening to the audio, click below on the transcript graphic bar to roll down the printed version.
Podcast Introduction
Our friend, Travis Van Slooten is publisher of LivingWithAtrialFibrillation.com. With marijuana legal in a growing number of U.S. states, he invited Steve to join him on his podcast and share the latest about marijuana use by A-Fib patients. (About 18 min. in length.)
Here are the highlights of this podcast:
♥ Clinical data on marijuana and atrial fibrillation is limited and is often anecdotal at this point.
♥ A-Fib patients’ experience runs the gamut, it helps some, for others it puts them into A-Fib.
♥ General research: smoking marijuana might lead to the development of A-Fib; may affect the cardiovascular system; few confirming studies.
♥ For A-Fib, the best form is probably CBD in edible form.
♥ An unpublished study of 6 million heart failure patients: Non-dependent marijuana users were 18% less likely to develop A-Fib; Dependent marijuana users were 31% less likely to experience A-Fib.
Resources mentioned in this episode
♥ States Where Marijuana is Legal
♥ FAQs Coping with A-Fib: Marijuana
Travis Van Slooten was diagnosed with atrial fibrillation on Father’s Day in 2006. He would battle a-fib for nine years before having a successful catheter ablation in March 2015. He’s been a-fib-free since with no drugs! His blog covers his own journey and provides information, inspiration, and support for others with A-Fib. Visit his site.
Catheter Ablation Compared to Amiodarone Drug Therapy in Heart Failure Patients with A-Fib
Background: I previously reported on the ground-breaking CASTLE-AF study published in 2018 which compared treatment with conventional antiarrhythmic drugs (both rate and rhythm control) versus treatment with catheter ablation. I recently came across another, similar study. While the 2016 AATAC study pre-dates the CASTLE-AF study, it also contributes to our understanding of treatment choices for heart failure patients with A-Fib.
Treating Patients with Both Heart Failure and A-Fib
Heart failure is very common in patients with A-Fib (estimated at 42%). These are very sick patients. For people with advanced heart failure, nearly 90% die within one year.
In patients with both conditions, a cardiologist’s first treatment is most often drug therapy with an antiarrhythmic drug. But is this an effective strategy? Is this really in the patient’s best interest? A 2016 study says NO!
AATAC stands for: Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD
AATAC stands for: Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD
AATAC: Catheter Ablation vs. Amiodarone Antiarrhythmic Drug Therapy
In the powerful AATAC multicenter worldwide randomized trial, catheter ablation was compared to drug treatment with amiodarone (the most effective but also the most toxic of the antiarrhythmic drugs).
The 203 enrolled patients had persistent A-Fib and heart failure with an Ejection Fraction of less than 40%. Patients also all had either a dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator.
All patients in the AATAC study were given optimal medical therapy for congestive heart failure such as ACE inhibitors, etc.
Patients were randomized to receive either a catheter ablation or drug treatment with amiodarone.
Note: The AATAC study should be read in conjunction with the more significant CASTLE-AF study which found similar results.
Note: The AATAC study should be read in conjunction with the more significant CASTLE-AF study which found similar results.
Group 1: Catheter Ablation
The first group received a catheter ablation of the pulmonary veins (PVI) along with roof lines and extensive ablations on the left atrial posterior wall; if non-PV potentials were found, the superior vena cava was isolated. At their discretion, EPs could ablate complex fractionated electrograms and non-PV triggers.
A ‘re-do procedure’ could be performed during the 3-month blanking period.
Group 2: Amiodarone (AMIO) Drug Treatment
The Amiodarone (AMIO) group was given 400 mg twice a day for 2 weeks followed by 400 mg each day for the next 2 weeks, then they were given a maintenance dose of AMIO 200 mg/day for the balance of the 24 month study period.
Study Follow-up and Results
All patients were followed for a minimum of 24 months. Recurrence was measured by the implantable devices with device interrogation at 3, 6, 12, and 24 months follow-up. Key findings at the end of the trial period include:
• Recurrence: 70% of patients in the ablation group were recurrence and A-Fib free (after an average of 1.4 procedures) vs. only 34% of the Amiodarone (AMIO) group.
• PVI with/without posterior wall isolation: Higher success was reported in patients undergoing PVI with posterior wall isolation compared to PVI alone (79% vs. 8%).
• Amiodarone therapy was found to be significantly more likely to fail.
• Cardioversion: During the 3-month blanking period 51% of the Amiodarone (AMIO) group needed cardioversion vs. 3% of the ablation group.
• The unplanned hospitalization rate was 31% in the ablation group vs. 57% in the AMIO group. This is a 45% relative risk reduction of hospitalization.
• A significantly lower mortality was observed in the ablation group: 8% vs. AMIO 18%.
Summary: Catheter Ablation Superior to Amiodarone Drug Therapy
Heart failure and A-Fib are common cardiac conditions that often coexist.
The AATAC study, the first randomized study of heart failure patients with persistent A-Fib, found that catheter ablation is superior to amiodarone drug therapy in achieving freedom from A-Fib long-term.
In addition, treatment with catheter ablation improved mortality in these patients, increased exercise capacity and Quality of Life (QofL) along with reduced unplanned hospitalizations.
Acknowledging My Bias
I admit to being biased against amiodarone drug therapy due to personal experience and from what others have shared. (For example, see Karen Muccino’s A-Fib story.) I am horrified that anyone would be put on such a high initial dosage of amiodarone as in this study. I would never participate in such a study. But obviously all doctors don’t share my concerns.
If a less potent (and less dangerous) antiarrhythmic drug had been used, it’s probable the study results would have been even more favorable for the ablation group.
What This Means to A-Fib Patients
These patients were in persistent A-Fib along with heart failure. These are some of the most difficult patients to make A-Fib free.
The EPs and A-Fib centers in this study were some of the best in the world. That there was a 70% success rate and no recurrences after 2 years is a testimony to the advanced mapping and ablation skills of these EPs. It’s remarkable how far catheter ablation strategies have improved over the years.
On the downside, not all EPs are equal. The single procedure success rate varied greatly from 29% to 61%. (See Huge Growth in Number of EPs Doing Catheter Ablations, But All EPs Are Not Equal.)
Catheter Ablation Group: Improved Ejection Fractions
Among the 203 enrolled patients, it’s not surprising that there were 26 deaths during this study. These were very sick patients with congestive heart failure and Ejection Fraction below 40%. (An EF below 50% indicates a weakened heart muscle that is no longer pumping efficiently; an EF in the normal range is 50% to 75%.)
The good news is that for many in the catheter ablation group, their ejection fraction was significantly improved and they were no longer in heart failure.
Catheter Ablation Outperforms Antiarrhythmic Drugs
We now have 2 studies which demonstrate that compared to antiarrhythmic drug therapy, catheter ablation lowers death rate among A-Fib patients (with heart failure), improves QofL and lets patients live longer and healthier lives. Other major benefits of ablation include reduced unplanned hospitalizations and increased exercise capacity.
Take-Away for A-Fib Patients
I think we can draw conclusions from the AATAC and the CASTLE AF studies that also apply to A-Fib patients (not in heart failure).
Rather than a life on antiarrhythmic drug therapy, the AATAC and CASTLE AF studies encourage A-Fib patients to seek a catheter ablation (including a second “re-do ablation”, if necessary.)
Bottom-line: Hard research data shows that a catheter ablation is the better choice over drug therapy. An ablation can rid you of your A-Fib symptoms, make you feel better, and let you live a healthier and longer life.
Don’t just live with A-Fib. Seek your cure.
Anticoagulants, Dementia and Atrial Fibrillation
The prevalence of dementia and atrial fibrillation (A-Fib) are both on the rise with the aging population and increasing burden of vascular risk factors.
The association between A-Fib and dementia is well documented. To describe that relationship, researchers use the term “strongly associated” rather than explicitly state that A-Fib causes or leads to dementia. That’s as far as they can go, because there might be other factors at play.
Patients with A-Fib lose 15%-30% of their heart’s ability to pump blood to their brain, and to the rest of their body.
A-Fib Linked with Dementia
As patients, we use more direct language. All things being equal, we say A-Fib leads to and/or causes dementia. It makes intuitive sense, doesn’t it? Patients with A-Fib lose 15%-30% of their heart’s ability to pump blood to their brain, and to the rest of their body. (See: Increased Dementia Risk Caused by A-Fib: 20 Year Study Findings)
Research confirms that older adults with dementia had significantly reduced blood flow into the brain compared with older adults with normal brain function or young adults.
Research Reveals: Anticoagulants Reduce Risk of Dementia
A Swedish study investigated the effect of anticoagulation on the development of dementia among A-Fib patients. Research data was collected on patients diagnosed with and treated for A-Fib in Sweden between 2006-2014. This included 444,106 patients, and over 1.5 million patient-years.
The retrospective registry study compared the incidence of dementia developed in A-Fib patients with and without ongoing anticoagulation with warfarin or direct oral anticoagulation (DOAC) (i.e. dabigatran, rivaroxaban, apixaban and edoxaban).
This study of A-Fib patients found that anticoagulant treatment was associated with a 29% reduced risk of dementia. There was no difference in dementia risk between patients treated with warfarin and those treated with direct oral anticoagulants.
It’s encouraging to know that, if you have A-Fib and must take anticoagulants, they may reduce dementia to a limited degree.
The authors concluded that the risk of dementia is higher among A-Fib patients not treated with anticoagulation.
In fact, absence of anticoagulation treatment was among the strongest predictors for dementia along with age, Parkinson’s Disease, and alcohol abuse.
Anticoagulants May Reduce Micro-Clots
This study did not tell us how anticoagulation achieves this effect.
Some speculate that anticoagulants, while preventing macro-clots (strokes), also prevent or reduce micro-clots and smaller ischemic events which damage the brain over time.
Another Reason to Not Live with A-Fib
This study also raises another reason not to live in A-Fib if at all possible. Unlike macro-clots which cause strokes and which can kill or severely disable, A-Fib tends to produce micro-clots (smaller ischemic events or silent mini-strokes). The effect of micro-clots may not even be noticeable but, nonetheless, damages our brains over time.
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