Doctors & patients are saying about ''...

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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. 

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

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Baltimore, MD

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

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

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

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

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

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

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

Drug Therapies

Develops A-Fib After Appendectomy Surgery; Lifestyle Changes and Meds Restore Normal Sinus Rhythm

My A-Fib Story at A-Fib.comby Richard from Florida, April 2020/May 2021

My name is Richard, male, and born in 1945. I am 5′ 9’’, weigh 167 lbs., and am a non-smoker. My exercise is walking about 1.5 miles a day, and I have a healthy diet.

Complications from an Appendectomy Surgery―Develops A-Fib

In April 2018 I was in the hospital for three weeks. I had two surgeries, first an appendectomy and 10 days later correction of a problem caused by the first surgery.

After the second surgery I developed A-Fib, with no prior history of it.

Surgery is a form of trauma, and this shock depletes magnesium and can lead to heart arrhythmias.

The only drug to bring me back to sinus rhythm was Amiodarone. I left the hospital with prescriptions for Amiodarone 100 mg a day and Metoprolol Tartrate 25 mg twice a day.

Amiodarone Damages Thyroid

Everything was under control for several months until I had blood work that revealed my Thyroid was not functioning.

Amiodarone was removed, and Metoprolol Tartrate was increased to 50 mg twice a day.

Everything was fine for a while when I started having irregular heartbeats periodically. Metoprolol Tartrate was increased to 75 mg twice a day.

Life-Style Changes: Reduced stress with L-Theatine & Kava Tea

At that time, I made some life-style changes. I eliminated caffeine and added the supplement L-Theanine 200 mg three times a day.

The purpose of the supplement was to manage my anxiety, which I believe contributed to the problem. I also replaced coffee with Kava tea and Honey Lavender Stress Relief tea, having one of each a day.

I still had an irregular heartbeat periodically.

A-Flutter, Too! Considered an Ablation But…

I had an EKG, and Atrial Flutter was detected.

I was considering an Ablation but wanted to try a different drug that was not in the antiarrhythmic family.

We finally settled on Diltiazem 120 mg daily plus Metoprolol Tartrate 25 mg twice a day.

I was able to manage anxiety without use of antidepressants or other drugs.

Drug Therapy & Supplements Work: Normal Sinus Rhythm Restored

I have now been symptom free for over 7 months. I attribute my success to the Beta Blocker plus Channel Blocker combination and L-Theanine plus Kava tea to reduce anxiety.

A key point is that I was able to manage anxiety without use of antidepressants or other drugs.

Update: May 2021

Since my initial story I had some episodes of an irregular heartbeat. My prescription for Metoprolol Tartrate was increased from 25mg to 50mg twice a day.

Generally everything is fine now, with an occasional irregular heartbeat when under stress. This is usually short lived.

Lessons Learned

Lessons learned about life with A-Fib

When dealing with a medical condition always consider alternative treatments before selecting invasive procedures (such as catheter ablation).

In this situation alternatives include life-style changes, supplements, and prescription drugs.

If the alternative fails you may always revert to the invasive procedure.

Richard from Florida

Editor’s Comments

Editor's Comments about Cecelia's A-Fib storyNew Onset A-Fib After Surgery: Unfortunately, it’s not unusual to develop A-Fib after both cardiac and non-cardiac surgery. In particular, after bypass surgery new onset A-Fib is reported to occur in 12 to 40 percent of patients.
It’s much less common in cases of non-cardiothoracic surgery such as Richard’s appendectomy (2.5%). Something complicated must have happened to operate on Richard a second time. An appendectomy isn’t a walk in the park. The complication rate is about 18%.
Surgeons often give meds like beta blockers, amiodarone or sotalol to patients before cardiac surgery to prevent new onset A-Fib.
Amiodarone Very Toxic: In Richard’s case, he had life-threatening A-Fib in the hospital, and the use of Amiodarone was justified. But as happens in all too many patients, prolonged use of Amiodarone destroyed Richard’s thyroid. If at all possible, you should try not to take Amiodarone. For more, see Amiodarone Effective But Toxic. For more, see Amiodarone: Most Effective and Most Toxic.
Anxiety Relief: Kudos to Richard for discovering the natural way to reduce his anxiety.
L-theanine is an amino acid found in green and black tea and in certain mushrooms. It’s considered to affect the levels of certain chemicals in the brain such as serotonin and dopamine that  influence mood, sleep, and emotion.
Kava Tea (Kava Kava) is a member of the nightshade family of plants, Kava has relaxing and stress-reducing properties and reduces anxiety.
Caution: Kava it has been linked to health concerns. There is some research which indicates that Kava may injure the liver. See LiverTox: Clinical and Research Information on Drug-Induced Liver Injury.
A-Fib Free with Beta Blockers and Calcium Blockers: Beta blockers and calcium channel blockers like Metoprolol and Diltiazem are designed and intended to be rate control meds to keep the heart from beating too fast while remaining in A-Fib.
For Richard they worked to keep him A-Fib free. Maybe they can work for others as well.

We are grateful to Richard for sharing his experience.

Resource for this article
Ryu, Jae Kean. Postoperative Atrial Fibrillation After Noncardiothoracic Surgery: Is It Different From After Cardiothoracic Surgery? Korean Circ J. 2009 Mar;39(3): 93-94.

Comparing the Effectiveness and Safety of the Direct Oral Anticoagulants (DOACs) in Patients With A-Fib

Anticoagulants are used with high-risk Atrial Fibrillation patients for the prevention of clots and stroke. FDA approved in 2010, Direct Oral Anticoagulant (DOACs) quickly became attractive alternatives to warfarin, the long‐standing standard of care in anticoagulation.

DOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). (Edoxaban [Savaysa] approval came later.)

The use of the term “Direct Oral Anticoagulants” (DOACs) has replaced the term NOACs (Novel Oral Anticoagulants), but it means the same.

When the FDA approved DOACs (Direct Oral Anticoagulants), they relied on 3 different clinical trials. But these trials only compared a DOAC, like Eliquis, to warfarin, not to the other DOACs.

Someone like myself had to dig deep into the research to find evidence of which DOAC actually tested better/safer of the three. (I found that Eliquis tested better and was safer.)

For more about the DOACs, see my articles: Warfarin and the New Anticoagulants, and my report from the AF Symposium: The New Anticoagulants.

DOACs: Finally a Head-to-Head Comparison

Today there is clinical data comparing the DOACs against each other. (And support my original reports.)

A comprehensive review of 36 randomized control trials and observational studies included over 1 ¼ million patients. The DOACs compared were apixaban, dabigatran, rivaroxaban, and edoxaban. The reviewers found:

▪ For major bleeding: Eliquis (apixaban) “tended to be safer” than Xarelto (rivaroxaban) and Pradaxa (dabigatran) based on both direct and indirect comparisons;

▪ For best treatment: Eliquis had a higher probability of being the best treatment of decreased risk of stroke/systemic embolism;

▪ Highest benefit: Eliquis had the highest net clinical benefit and smallest NNTnet (Number Needed to Treat for net effect, i.e., how many people were helped by it, how many were harmed.)

Reviewers Conclusions

The researchers wrote: “Apixaban (Eliquis) appeared to have a favorable effectiveness-safety profile compared with the other DOACs (NOACs) in AF for stroke prevention, based on evidence from both direct and indirect comparisons.” (Translation: Eliquis was found to be more effective and safer than the other DOACs).

Editor’s Comments:

Editor's Comments about Cecelia's A-Fib storyIn the world of scientific statistics and cautious conclusions, this is about as big an endorsement as you will find: Eliquis is superior to the other anticoagulants.
If you’re on a different DOAC, talk to your doctor about switching to Eliquis.
Know the Risks of Taking Anticoagulants (Blood Thinners): Taking almost any prescription medication has trade-offs. In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding and other problems. Bleeding events are common complications of anticoogulants.
Is an Anticoagulant Necessary for Me? Be certain you should be on an anticoagulant in the first place. Doctors assess an A-Fib patient’s risk of stroke using a rating scale (called CHA2DS2-VASc). Ask your doctor what’s your risk-of-stroke score. If your score is a 1 or 2 (out of 10), ask if you could take a non-prescription approach to a blood thinner.
Remember Anticoagulants Are High Risk Drugs: Be aware that all anticoagulants are considered high risk drugs.

They aren’t like taking vitamins, though they are certainly better than having an A-Fib (ischemic) stroke. To learn more see: Anticoagulants Increase Risk of Hemorrhagic-Type Strokes.

Resource for this article
Zhang, J., et al. Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis. Eur J Epidemiol (2021).

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

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

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

Here is the actual wording of the guidelines:

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

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

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

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

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

2021 AF Symposium: New Technologies and Drugs―Flecainide Inhaler by InCarda

2021 AF Symposium

New Technologies and Drugs―Flecainide Inhaler by InCarda Therapeutics

Jeremy Ruskin, MD, Mass. General Hospital and AF Symposium

Jeremy Ruskin, MD

Dr. Jeremy Ruskin of Massachusetts General Hospital gave a 5-minute Spotlight Session talk on InCarda Therapeutics’ flecainide inhaler. InCarda is a privately held biopharmaceutical company in Newark, CA.

Dr. Ruskin described the InCarda inhaler which uses flecainide, a well-established antiarrhythmic agent.

Flecainide Inhaler from Carda Therapeutics

When a patient with recent onset A-Fib self-administers the breath-activated inhaler, it produces a flecainide-containing aerosol when the patient inhales. This results in a rapid absorption of flecainide via the lungs into the heart. An A-Fib attack can be terminated in as little as 8 minutes.

By contrast, if flecainide is taken as a pill-in-the-pocket, it often takes much longer for the pill to work (20-30 minutes).

Aside from the problems associated with flecainide, this inhaler is generally safe and well tolerated.

“Cmax ” is a pharmacology term meaning the peak serum concentration of a therapeutic drug. 
It’s “Cmax dependent” which means its peak plasma concentration is a function of dose and speed of administration, but primarily determined by dose.

According to Dr. Ruskin, “Inhaled Flecainide has the potential to be a practical, cost effective option for rapid conversion of AF to sinus rhythm.”

Editor’s Comments

The InCarda flecainide inhaler is already in FDA Phase II trials. But it will probably still be a couple of years before it’s generally available to doctors and patients.
InCarda Inhaler Better Than Pill-In-The-Pocket: The InCarda flecainide inhaler is or will be a welcome addition to Pill-In-The-Pocket therapy where patients only take a drug when it’s needed, not all the time. Today’s antiarrhythmic drugs can have bad side effects and be poorly tolerated if taken all the time. Think of how  liberating it would be to just use an inhaler to quickly get out of an A-Fib attack.

One wonders if the InCarda inhaler can be developed for anticoagulants as well. Anticoagulants are high risk drugs especially for older patients. 

f you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021

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2021 AF Symposium: ATTEST Trial—Catheter Ablation to Modify Progression of AF

2021 AF Symposium

ATTEST Trial: Catheter Ablation to Modify Progression of AF

Dr. Karl-Heinz Kuck

Dr. Karl-Heinz Kuck of the Asklepios Klinik St. Georg in Hamburg, Germany, gave a presentation on the findings from the ATTEST Trial. (He also spoke on this topic at the 2020 AF Symposium).

Patient Risk: Progressing from Paroxysmal to Persistent A-Fib

Dr. Kuck pointed out that within one year, 4% to 15% of paroxysmal A-Fib patients become persistent.

In addition: they are at a higher risk of dying, they have more risk of stroke, and it’s more difficult to restore them to normal sinus rhythm. (In the Rocket AF trial, the mortality rate of persistent A-Fib was triple that of paroxysmal patients.)

The ATTEST Trial: RF Ablation vs Antiarrhythmic Drugs

The ATTEST clinical trial included 255 paroxysmal patients in 36 different study locations. They were older than 60 years and had to have been in A-Fib for at least 2 years (mean age 68). They had failed up to 2 antiarrhythmic drugs (either rate or rhythm control).

Patients were randomized to two groups: radiofrequency ablation (RF) (128) or antiarrhythmic drugs (127). They were followed for 3 years (ending in 2018).

ATTEST Findings

Significant data about the progression of A-Fib was learned from this trial.

• At 3 years, the rate of persistent A-Fib or atrial tachycardia was lower (2.4% ) in the RF group vs the antiarrhythmic drug group (17.5%).

• The RF group was approximately 10 times less likely to develop persistent A-Fib compared to the antiarrhythmic drug group.

• For patients in the antiarrhythmic drug group, 20.6% progressed to persistent A-Fib or atrial tachycardia compared to only 2.2% in the RF group.

• Recurrences occurred in 49% of the ablation group vs. 84% in the drug group. Repeat ablations were done on 17.1% of the ablation group.

Dr. Kuck’s advice: “Ablate as early as possible.”

Dr. Kuck’s Conclusions

Early radiofrequency ablation was superior to antiarrhythmic drugs to delay the progression to persistent atrial fibrillation among patients with paroxysmal A-Fib.

Dr. Kuck’s advice: “Ablate as early as possible.”

Editor’s Comments

The EAST-AFNET 4 Trial: The ATTEST Trial findings dovetailed with results from the EAST-AFNET 4 Trial.

Dr Paulus Kirchhof

In another ’21 AF Symposium presentation, Dr. Paulus Kirchoff (Institute of Cardiovascular Sciences, U. of Birmingham, UK) reported that EAST-AFNET 4 trial findings supported early initiation of rhythm therapy in cases of recent onset A-Fib. (See 2021 AF Symposium: EAST-AFNET 4 Trial—Early Rhythm Control Therapy in AF)
Research by both Dr. Kuck and Dr. Kirchhof came to the same conclusion: “ablate as early as possible” and the need for “early initiation of rhythm therapy.”
Why Risk Progressing into Persistent A-Fib? There are so many bad things that can happen to you when left in A-Fib. As Dr. Kuck points out, you’re at a higher risk of dying, there’s more risk of stroke, it’s more difficult to restore you to normal sinus rhythm.
And we haven’t even talked about heart damage from fibrosis, the risk of electrical remodeling of the heart, and the all-too-real dangers of taking antiarrhythmic drugs over time.
And what about quality of life? Who wants to live in A-Fib? There are few medical procedures so transformative and life changing as going from A-Fib to normal sinus rhythm.
Don’t Leave Someone in A-Fib―Ablate as Early as Possible: Dr. Kuck’s (and Dr. Kirchhof’s)  research answers once and for all whether or not A-Fib patients should be left in A-Fib, whether seriously symptomatic or not (e.g., leaving A-Fib patients on rate control drugs but still in A-Fib.)
These patients are 10 times more likely to progress to persistent A-Fib. That’s why today’s Management of A-Fib Treatment Guidelines lists catheter ablation as a first-line choice. That is, A-Fib patients have the option of going directly to a catheter ablation.
Research supports the same conclusion: “ablate as early as possible” and the need for “early initiation of rhythm therapy.”
Time for a Second Opinion? I occasionally hear of Cardiologists who refuse to refer patients for a catheter ablation, who tell patients a catheter ablation is unproven and dangerous. Not true!
When you hear something like that, it’s time to get a second opinion and/or change doctors.
Know Your Rights—Be Assertive: Your doctor may try to talk you into first trying antiarrhythmic meds before offering you the option of a catheter ablation.

As an A-Fib patient, know your rights and be assertive. According to the Management of Atrial Fibrillation Treatment guidelines, you have a right to choose catheter ablation as your first choice.

If you find any errors on this page, email us. Y Last updated: Friday, April 16, 2021

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2021 AF Symposium Spotlight Session: Drug in Development from Acesion Pharma

2021 AF Symposium

Spotlight Session: Drug in Development from Acesion Pharma

At this year’s AF Symposium, there were 22 Spotlight Session talks 5 minutes long spread out over 3 days. Normally I don’t report on them in detail, since they usually aren’t currently available (and may never make it through development and regulatory hurdles into the marketplace). But here’d one that may be of interest to patients.
Dr. John Camm -

Dr. John Camm

Dr. John Camm of St. George’s Hospital in Oxford, UK discussed a drug in development from Acesion Pharma, a Danish biotech company.

This new drug (AP30663) is highly atrial specific and works as an SK channel inhibitor [to suppress A-Fib]. SK channel inhibitors are ion channels present in the heart which regulate the cardiac rhythm.

Acesion’s new drug is designed for IV cardioversion of A-Fib to normal sinus rhythm.

Editor’s Comments:

Just the fact that Acesion is working on a new antiarrhythmic drug is news in itself. It’s been years since any new antiarrhythmic drugs have come on the market. And the antiarrhythmic drugs currently available to patients leave a lot to be desired.

Plus, the Acesion drug being developed is highly atrial specific which is an important advantage over most other antiarrhythmics.

If you find any errors on this page, email us. Y Last updated: Monday, April 19, 2021

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

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

Delaying A-Fib Progression: Ablation vs Antiarrhythmic Drugs

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

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

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

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

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

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

Consider Working Aggressively to Stop Your A-Fib

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

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

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

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

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

A-Fib is Progressive infographic at

New Research: Rhythm vs Rate Control Drugs for Atrial Fibrillation

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

Results of Leaving Someone in A-Fib

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

Remember: A-Fib is a progressive disease. 

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

• Remodel your heart, producing more and more fibrous tissue which is irreversible. When the atirum is permitted to fibrillate without intervention, remodeling occurs.

• 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.

        • Even in asymptomatic patients, they unconsciously adapt to reduced physical activity when not in sinus rhythm.


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

Dr Andrea Natale

Dr Andrea Natale

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

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

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

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

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

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

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

New Study Confirms Rhythm Better Than Rate Control

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

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

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

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

Study Results: The early rhythm-control strategy proved superior to rate control and was associated with a lower risk of adverse cardiovascular outcomes than usual care. The study was stopped early, because the rythm control group did so much better than the usual-care group (3.9 negative events vs 5.0). As one would expect, sinus rhythm was more common in the rhythm control group (82% vs 61% at two years)

2020 ESC Guidelines: The updated 2020 ESC (European Society of Cardiology) guidelines consider catheter ablation of A-Fib to be a safe and superior alternative to AAD therapy for maintenance of sinus rhythm, reducing A-Fib-related symptoms, and improving Quality of Life.   

Added 7/22/22:

Around 80% of patients diagnosed with A-Fib in the UK are eligable for early rhythm control, according to an analysis of the EAST-AFNET 4 trial. Rhythm control, initiated soon after diagnosis of A-Fib, reduces cardiovascular complications without increasing time spent in hosspital and without safety concerns. “Early rhythm control should become a routine part of the clinical management of most patients with newly diagnosed AF.” (Kirchhof, P. et al)


Editor’s Comments:

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

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

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

Kirchhof, P. et al. Early rhythm-control therapy in patients with atrial fibrillation. (EAST-AFNET 4 trial). N Engl J Med., 2020 August 29.

Cardiac Rhythm News, July 21, 2022. Analysis sets out generalisability of EAST-AFNET 4 trial findings.

Debate “Catheter Ablation should be first line therapy in selected patients with A-Fib” Boston AF Symposium, January 13-14, 2006.

“Your A-Fib is Just Nerves”…”Try Not to Think About It”; At 72 Finally A-Fib & PVCs-Free After 2 Ablations, But Then a Setback

By Cecelia Hender, July 2020

Cecelia Hender and granddaughter

I have been asked to write my story about my journey with A-Fib. I have had arrhythmias since I was a young woman. I was about 20 years old when I first experienced irregular heartbeats. I had gone to my doctor back then and was told it was “nerves” and to relax. This was how most women were treated by doctors back then. Everything was “nerves”.

Time passed, and the irregular heartbeats seemed to get worse at times.

In my 30’s, I remember going to another doctor and told him that when my heart would take off like a race horse, I could not breathe. And when it stopped, I felt I could climb a mountain again. He said, “try not to think about it.”  What ????

I fought with these irregular heartbeats for many years. I was on different blood pressure meds that also helped with heartbeats, but I was never told to see a cardiologist or have a doctor investigate just what was going on.

Once or twice, when I was younger, a doctor had me wear a heart monitor. It was a 24-hour monitor. And when it showed nothing for that period of time, he said I was fine.

Sent to a Cardiologist Almost By Accident―Hard to Document the Arrhythmia

I worked for a medical facility, and one day about 15 years ago a young doctor came in for an interview. He sat in my office for a good amount of time while they were preparing for the interview. During this time, I got to talk to him a lot.

When he said he was an electrophysiologist [cardiac specialist], I asked about my irregular heartbeats. He was so kind and intelligent and gave me a lot of information to think about.

It was this young doctor who told me that I should see a cardiologist. So, I did. And I was treated with medications and had many heart monitors.

But it was always hard to catch the arrhythmias on an ECG or heart monitor.

“You are in A-Fib”―Two Weeks of A-Fib Hell…

Finally, in 2017 I had another [heart] monitor, and it showed a series of irregular heartbeats.

But on this one particular day, I had a very irritating rhythm. It was very fast, then irregularly fast, and I could barely breathe. I went to my PCP [Primary Care Physician] office where they did an EKG and said, “You are in A-Fib”.

They sent me immediately to my cardiologist who confirmed this. I was put on a different kind of med (Metoprolol at first and also Coumadin). And “fingers crossed” I would convert on my own. 

I remember like it was yesterday, the moment my heart decided to go back into normal sinus rhythm. I was so happy and felt so strong…

…Then Blessed ‘Normal Sinus Rhythm!’

It took almost two weeks, but I remember like it was yesterday, the moment my heart decided to go back into normal sinus rhythm.

The feeling was like a major blessing had just descended on me. I was so happy and felt so strong in that very moment. I cried.

Dr. Seth McClennen―Successful Ablation! But PVCs Major Issue

I met with Dr. Seth McClennen, an Electrophysiologist, who decided I was a good candidate for ablation. I was so thrilled.

Finally, someone was going to help me be normal!

My whole life was spent afraid and never going anywhere alone for fear that my heart would act up and I’d be stranded someplace unable to breathe – unable to move. Finally, I found some help.

Dr. Seth McClennen is a well-known and most beloved Electrophysiologist here in the Boston area. He is the best in my book.

He told me all that I needed to know about ablation, and off I went for my very first A-Fib ablation in June 2017.

Although PVC’s don’t carry the risk of stroke as A-Fib but are just as debilitating.

It was successful! I went almost two years without an episode of A-Fib at all whatsoever.

However, my PVC’s were a major issue.  They still kept me house-bound for the most part. Afraid to go anywhere alone. Although PVC’s don’t carry the risk of stroke that A-Fib has, they were just as debilitating.

A Second Ablation for PVCs―Without General Anesthesia―No Big Deal

Dr. McClennen suggested a second ablation for the PVC’s in January 2019.  He said that it would be best if I could go through this without anesthesia, because with sedation, the PVC’s would “hide,” and the ablation would be difficult.

So, I did it … my trust in Dr. McClennen and his wonderful team outweighed any fear or apprehension on my part.

For another patient’s story about treating PVCs, see PVC-Free After Successful Ablation at Mayo Clinic by Dr. Mulpuru

My second ablation was in April 2019. The ablation without sedation was no big deal at all. Now I am talking about a PVC ablation. Seth McClennen was right there working, and I could talk to him any time. He kept me informed as to what was going on.

At one point he said, “Think of something that irritates you so we can get these to come out, and I can follow the path.”  So something that irritates me or causes stress will bring these out …. Well, it worked, and he was able to ablate these PVC’s.

Successful PVCs Ablation―Living Without Fear

For the first time in my whole life, I was able to move about without fear.

I could go to the store and feel normal—I was not worried that my heart would go crazy and I would be left in a puddle somewhere with no one to help me.

(Being a widow, it is very hard to continue life alone especially where your health is concerned. My husband died eight years ago when he was only 60 years old. I have never recovered.)

A Setback: Respiratory Infection Triggers A-Fib

Life was good as far as my heart was concerned. For three months I had no A-Fib or PVC’s. Then suddenly in April 2019, I got an upper respiratory infection which kicked off an episode of A-Fib. Oh no!!!…This familiar awful feeling was something I remembered.

It woke me up, and I immediately took my heart rate. It was 198. No one to take me to the hospital. And with my nerves, I did not want to call an ambulance. That was a BIG MISTAKE. I won’t do that again….

Anyway, a few hours later, my cousin came and took me to the Emergency Room.

They tried Cardioversion TWICE, but it did not work; so, I was put on the antiarrhythmic Tikosyn (dofetilide).

Tikosyn Works, But “Can I Have Another Ablation?”

I had to stay in the hospital for a week to level out and make sure this antiarrhythmic would be okay for me. It got my heart in perfect order, but I don’t want to stay on this forever.

So, my next question for my wonderful Dr. McClennen was “Can I have another ablation”? He answered, “Yes, we will discuss it in the Fall.”

Is Another Ablation on the Horizon?

So, I am waiting eagerly for Fall 2020 when we can discuss another A-Fib ablation. In the mean time, let me share what I’ve learned so far about treating Atrial Fibrillation.

Lessons Learned

Lessons learned about life with A-FibAblation is a Blessing and Low Risk―Better Than Living in Fear

Why do I feel excited about ablation? I truly feel that having an ablation is a blessing. And this is why I am writing this story for you.

I know there are risks and I know people are afraid of ablations, but the risks are nothing compared to living each moment of your life afraid to live.

Find a Great Doctor!

The trick is finding a great doctor. Not just a good doctor, but a great doctor.  What makes a great doctor?  Well, to ME … it’s someone who listened to me. Dr. Seth McClennen listened. He cared.  He even wants me to email him when I have a concern or question. He always answers me. Always.

Kardia Device a Great Help

AliveCor with tablet at

Using Kardia with tablet; under $100.

I have a Kardia machine – it’s that little EKG tag that you can email to your doctor.  I have sent Dr. McClennen my EKG when I’ve had a question. More so now, with this antiarrhythmic drug, I am always tempted to take an EKG and send it to say “How am I doing?”  Some days I just need to know my heart is in good order.

Find a Great Pharmacist As Well

It helps greatly to have a wonderful pharmacist too. Someone you can confide in and who will help you. The particular drug I am on interacts with so many things that I have to check everything with the pharmacist. Lisa Cohen Szumita is a wonderful pharmacist who is there to answer all my questions.

So, my advice is to have a great doctor – and a wonderful Pharmacist who has that rare quality these days of “Caring” for their patients.

Your Attitude is Your Greatest Weapon

As far as ablations go…your attitude is your greatest weapon.

If you are told you need an ablation, be blessed. Be thankful and blessed.

It’s what we AFIBBERS have to help us live a normal life. Thanks be to God!  When you are going to have your ablation, go into that hospital thanking God and asking Him and His angels to surround you.

Are you in need of prayer? Positive thoughts? Read about our A-Fib Positive Thoughts/Prayer Group and how to send us your request.

Ask all of us here on the website to hold you in prayer and good thoughts. That is what we are called to do.

Leave fear behind you – don’t bring fear into your procedure. Bring FAITH and JOY and PEACE. I went into that A-Fib ablation with such excitement—to finally live a life where I was not afraid to be in the store alone. A simple thing … but I was unable to do it. After ablation, my life was restored.

I was so very upset that an upper respiratory infection brought me down. But I am on the right track again. So for the time being, I will take this antiarrhythmic.  (Please don’t send me any scary emails about what I take.)  I’ve heard it all. I did all the reports at work that had any and all of these drugs listed. I know all about it. But for now, it’s what I have to do

When the Fall comes, if my cardiologist says I’m good for another ablation …. Well, thanks be to God !! …. And so it is.

P.S. I’ll update my story when I have something to share. If you want to write me, send an email to Steve and he will forward it.

Cecelia Hender
Abington, Massachusetts

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

Editor’s Comments

I can’t help but get angry reading Cecelia’s story. After repeated heart rhythm complaints to her doctors, I can’t believe she wasn’t referred to a cardiologist.

She’s not alone with doctors dismissing women’s symptoms.

Other female patients have reported being told: “You’re experiencing a type of panic disorder.” “You’re exaggerating.” “A-Fib is no big deal.” “Take a Valium.” “Just take your meds and get used to being in A-Fib.”

Consequences of Gender Bias: If you are female, be prepared to experience gender bias in the medical field (but less so among Electrophysiologists [EPs]).

Beware of condescending behavior. You don’t have to accept or put up with that kind of attitude. Anticipate gender bias! Don’t let it deter you! (For more see: Women with A-Fib: Mother Nature and Gender Bias—Or—Get Thee to an EP ASAP.) 

Don’t Just Live with A-Fib: Educate Yourself! Cecelia had irregular heartbeats for decades before she learned she should consult a specialist, a Cardiologist (an electrophysiologist to be exact). 

Don’t be afraid to get a second opinion. Don’t be afraid to fire your doctor.

Thankfully Cecelia finally got her Atrial Fibrillation diagnosed. She then found one of the best electrophysiologists (EP) in her area. She learned about A-Fib. She got the best and most up-to-date advice and treatment. She had lived in fear of her A-Fib but found her cure in spite of her fears.

Catching the Arrhythmias: Cecelia describes very well her frustration when doctors tried and failed to document her A-Fib. All too often when you have occasional (paroxysmal) A-Fib, you’ll be in the doctor’s office and your heart is in normal sinus rhythm (NSR). If you’re not in A-Fib, they can’t document it with an ECG. Frustrating!

(I remember spending all morning in a doctor’s office waiting for an A-Fib attack so that an EKG can document it. But no luck. Then when I went downstairs for lunch, that‘s when I had an A-Fib episode.)

iRhythm Zio patch

Advancements in Heart Monitoring. Today doctors have any number of monitoring and data recording devices to “catch” A-Fib episodes.There are patches such as a Zio Patch which looks like a big Band Aid and which you wear for 1 or 2 weeks.

Medtronic Reveal LINQ insertable heart monitor

Medtronic Reveal LINQ

Another is an implantable loop recorder like the Medtronic Reveal LINQ which is inserted under your skin in a very simple, fast procedure. (I’ve had one for the last 1 1/2 years). It lasts for three years and tells doctors (and you) what’s going on in your heart 24/7.

Today your doctors are much more likely to “catch” and document your irregular heartbeats.

Dealing with PVCs: We’re most grateful to Cecelia for describing how Dr. McClennen fixed her PVCs which are a major issue for some people with A-Fib.

Maybe the key to ablating PVCs is no sedation or conscious sedation rather than general anesthesia. (I’ll try to get more info on Dr. McClennen’s methods of ablating PVCs.)

Added 12/16/2022:

Cecelia Hender writes in an update that she had a Watchman implanted February 2022 at Brigham and Woman’s Hospital in Boston, MA. “Now I am off of the Tikosyn (dofetilide) and also off of Eliquis. No more blood thinners. I am feeling well. The implant placement was a breeze, and I came home the same day. I had a wonderful team there. I think God for all of this. Just wanted to bring you up to date.”

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Friday, December 16, 2022

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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

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.

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: Monday, February 22, 2021

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