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St. Jude Medical

February 10th, 2016
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I am a 55 y/o male with paroxysmal Afib. I have htn. and am on atenolol and lisinipril. I have sleep apnea and use CPAP. I have a Chads score of 1. I have seen 2 EP in past with one saying that it was my choice to either use ASA or warfarin. Either is reasonable. The other EP said that I should just use ASA. I just saw a patient education TV show on dicscovery channel concerning Afib and stroke risk with a number of specialists. They all seemed concerned that patients should get appropriate anticoagulation. Hugh Calkins stated that with chads score of 0 , kthe risk is low with no need to anticoagulate and with chads 2 they highly recommend anticoagulation. With a chads score of 1 he said they tend to recommend anticoagulation. What should I do in my case? My understanding is that with a chads 1 the risk of ischemic stroke is equal to the risk of intracranial or GI bleed. Pick your poison, although the use of ASA may decrease ischemic stroke (I\'m not sure how much) it also increases bleeding risk, but not nearly as high as warfarin. Which risk is worse to have? Thank you.
2013-04-08 Answered By : Dr. Nitish Badhwar, MD, FACC, FHRS

CHA2DS2 VAsc score is a better score to use than CHADS score. The usual practice is to anticoagulate with a score of 2. We tend to use ASA with lower scores but the data on stroke prevention with ASA is not very robust. The newer anticoagulant drugs like dabigatran, rivaroxaban and apixaban have a better safety profile than warfarin. I use them in patients with score of 1 who are worried about risk of stroke.

I am a 55 y/o male, 215 lbs. with paroxysmal afib. The Afib started 6 years ago with a few episodes lasting 1-7 hours each. Testing revealed no cardiac abnormalities. Started on atenolol 25 mg./day. On daily baby ASA for a number of years. Afib stopped as suddenly as it started and was gone for 3.5 years. At that time I had a number of episodes each lating 1-7 hours each over 3- 4 months. Increased atenolol to 25 mg 2x/day. Additional testing unremarkable. Consult with EP. since Chads 1 stay on ASA although increase to 182 mg. Also added lisinipril for better control of mild htn. Tested for sleep apnea was positive and now on CPAP nightly. Lost 10 pounds ( 220 at the time). added a number of natural anti-inflammatories and antioxidants seen in AFIB REPORT. Episodes stopped for 1.5 years until last June. Had 3 episodes. Then 3 more in October and 5 more this Feb./March. Most episodes lasted 2-3 hours with a few lasting 5 hours. EP gave me flecainide to use as PIP. I am symptomatic with the episodes with palpitations, slight lightheaded, and uneasy feeling. I can check my pulse and know every time I have an episode. I have not used the flecainide yet as each episode has spontaneously converted. Is there any harm in waiting to use the flecainide and after how many hours can I waity before using it as PIP. I\'m a little concerned with its proarrythmic potential although I suspect that occurs in ly a small percentage of patients.When do I decide to go on flecainide daily instead of PIP. Is this all a personal choice or are there other paramaters. Is it OK to use PIP method or should I go directly to daily use. Then, at what point do I decide about having an ablation? I have heard that the longer you wait to have an ablation the less successful it is. Is that true? Up until now my Afib burden is relatively low.Is it still a personal choice when to have an ablation (too many episodes to tolerate)? However, this would seem to contradict the previous statement , if true, that the longer you wait (the longer you have afibe epsodes and are remodeling the leart) the less successful the ablation will be? Or is it true that if I go on daily flecainide which works and I stop having episodes or only very infrequent episodes, then my heart is not being remodeled and the delay is OK? Thank you.
2013-04-08 Answered By : Dr. Nitish Badhwar, MD, FACC, FHRS

Flecainide works well as an antiarrhythmic drug for paroxysmal a fib patients who do not have CAD. You should have a stress test done before taking it. I ask my patients to take the first pill in pocket drug in the ER or the office depending on when they have the episode. It can take 1-1.30 hour for its effect to work and should not be taken for shorter lasting episodes. You should tasking daily flecainide if you have frequent episodes and consider catheter ablation as it is more effective than drugs. I agree with early ablation as more frequent episodes of afib can lead to atrial remodeling and more sustained a fib.

Hello Doctor: I am a 69 y.o. male with occasional afib(every 2 or 3 weeks) over the last 2 years. Episodes last 12-24 hours and consist of stumbling, irregular beats around 70 bpm( normal is low 50\'s). I take 75 mg. of Atenolol and Pradaxa and also have mild sleep apnea. Afib as confirmed by 2 week Cardionet monitoring. Is there any good treatment and do Viagra or Cialis aggravate the condition. Thanks
2013-03-27 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Treatment of AFib can consist of an antiarrhythmic drug such as flecainide or propafenone if you have no serious structural heart disease, or sotalol or dofetilide if you have underlying coronary artery disease, or amiodarone if you have a significant history of heart failure. If medications fail to control the Afib, then catheter or surgical ablation may be effective. This is something you should discuss with your cardiologist or an electrophysiologist. Finally neither Viagra or Cialis are known to aggravate Afib.

Do Viagra and Cialis cause afib?
2013-03-27 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

There is no evidence that either drug causes AF to my knowledge, and it has not previously reported as an adverse effect. The use of Viagra or Cialis is of course contraindicated if you are also taking nitrates.

I am in desperate need of finding a physician that can do surgical procedures to stop Afib as close to middle Tennessee as possible, although we will travel out of state for top notch doctor ;). My father was diagnosed as having Afib this past January and was given medication to stop it which didn\'t help, was given a pacemaker and it\'s helped to the point of keeping his heart rate from going below 60 for long (his heart was staying in the 30s at night and dropping in the 40s during the day some), 2 stints and a kissing balloon in his upper left artery and still now having problems to the point of not wanting to live. He is having episodes during the day where he will feel lightheaded, nauseous, shaking, shortness of breath (choking feeling) and heartburn. All of this he has had and all of the procedures he has had done over the past couple months. His quality of life is just not good right now. We need help! I\'m desperate to have my father back to normal. He was always the type of strong man to never miss work and never complain, so I know he is bad off. Also, he is on Plavix and the doctor told us he cannot come off for any procedure. Is there a way to come off for an extremely needed surgery?
2013-03-27 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Catheter ablation or surgical ablation can be done for Afib, but it may be best in some situations to try an antiarrhythmic drug first to control the Afib. Ablation procedures can be done on Plavix if required because of a recent stent. In your area you can check with the following EP doctors regarding treatment of Afib.

I am 67 yr old female. Just had ablation for a-fib a week ago. Episodes every day 15 minutes to 7-8 hrs. Not taking anti-arrhythmia drugs. Had failed propafenone. tolerated dofetilide before although it was ineffective. Dose after ablation showed some interval problems so now just taking Metoprolol. Are such freq episodes common in blanking period? More than I used to have. Also I have sharp pain on right side under ribs when taking deep breath or coughing. Am supposed to fly to Europe in a few days (12 days after ablation) EP dr said ok but now I am getting worried.
2013-03-24 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

In a small percentage of cases the frequency of episodes of AF may increase after ablation. These usually settle down after several weeks, but in some cases they do not, and a second ablation is necessary. I am not sure what ďinterval problemsĒ you had, but usually with dofetilide the QT is prolonged and with propafenone the QRS is prolonged, although the dose can be adjusted to allow continuation of the medication. The sharp chest pain could be due to a condition called pericarditis in which inflammation occurs around the heart after ablation. This is usually treated with ibuprofen 600 mg three times a day, but in some cases requires additional medication to control. If you continue to have frequent AF, especially if the episodes become more prolonged (>24 hours), it may not be safe to travel, unless you are taking an anticoagulant medication such as Coumadin or Xarelto to prevent a stroke, which I assume you are taking after ablation. I would certainly recommend you discuss these issues again with our EP doctor before travelling.

I\'m a 54 yr old male and was in afib (silent but all the time) for about 1yr 1st cardioversion at 3mths did not convert, taking amiodarone,Diltiazem,pradaxa, aticand plus, Prozac , 2nd cardioversion at 12mths converted still on all Meds. 6 wks after 2nd conversion started flipping in and out of afib every couple of hrs this lasted about a wk. had EKG and of course was not in afib at the time.still on all the same Meds had the loop on for 2wks and it only had 1count have not got the results on it yet. Scheduled to see EP in 7 mths from now do you think he will do an ablation? ( having many problems taking all this medication) and would like to get of some of them.also I was very over weight and 6\'4\" tall and have lost 110lbs since the start of all this. JC
2013-03-16 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Restoring sinus rhythm before an ablation has been shown to improve long-term outcomes after ablation. So it was reasonable to get you in sinus rhythm first to see how you feel in normal rhythm and whether the medications will work. Amiodarone is our most effective drug, but it does have the potential for long-term side effects. Not knowing who your EP doc is, I canít predict if he will recommend an ablation. However, if you are now having symptomatic paroxysmal atrial fibrillation on medication, ablation may be a reasonable next step to try to eliminate the atrial fibrillation from recurring, either with ablation alone or in combination with medication. It may also be reasonable to continue the amiodarone, which sounds largely effective at this time, until it either stops working or you get side effects, and then consider ablation.

I am a 59 yr old female, CHADS of 1 for hypertension. I had ablation earlier this week for paroxsymal AF and flutter. I have tried 3 anti arrhythmics over the last year and a half. My EP said the procedure went well and no complications. I will remain on sotalol and pradax for the next 3 months. I was warned I could continue to have AF for 4-6 wk as the heart heals. My question is, can the frequency of the episodes increase before they improve ? i have quite a few episodes since the procedure.
2013-03-04 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

In most cases AF does not recur after an ablation, but it can in some cases, and rarely even be more frequent than before ablation, until it settles down permanently. There has been some research that shows that recurrent AF in the 90 day blanking period may predict a greater likelihood or recurrent AF, but we generally ignore AF that occurs during the blanking period. If you continue to have AF recurrences after the 90 day blanking period after ablation, this becomes concerning, and by 6 months a repeat ablation may be necessary.

I am a 56 year old Male. I was diagnosed with both A-fib and sick sinus syndrome. I am on my 2nd pacemaker first one implanted when I was 48 years old the first one malfunctioned so they change it out. Pacer tech from St jude tells me that my underlying heart beat some times beats when the pacer paces does causing me some double beats that drives me up the walls, I get some bad head aches from that. Do you have any suggestions I need help. Thank you.
2013-03-03 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

Since I am not aware of your pacemaker programming, I cannot offer you much helpful advice. However, if the pacemaker paces and you have premature atrial beats in response, then reprogramming your pacemaker or adding an antiarrhythmic drug may in some cases help. The atrial fibrillation may be prevented by pacing in cases with sick sinus syndrome, but again in some cases addition of an antiarrhythmic drug may be necessary. I recommend that you speak with your EP doctor about adjusting the pacemaker or trying an antiarrhytmic drug to suppress the extra beats that are bothering you.

Hello Dr: Iím a 52 year old male with symptomatic, paroxysmal afib for 30 years, but generally infrequent episodes (1-2 per year or less). I had an ablation in 2011. EP indicated that in addition to the PVís he ablated the atrial roof and some other areas of electrical activity. Due to recurrence, I had a second ablation in 2012. After the second procedure, EP indicated there was some PV reconnection, and also typical atrial flutter. Both were ablated, I was told that no further arrhythmias were inducible, even after the administration of an agent (donít know name) that is supposed to identify areas of even minimal reconnection. I did well for about seven months, but recently had a recurrence of afib. I am obviously very frustrated. What would be your opinion as to a reasonable next step? Should I consider a second opinion at this point? What about a third procedure? Is reconnection after two ablations likely? Or, should I wait for improvements in the procedure or technology. Iím getting a bit concerned about the cumulative fluoroscopy exposure. Any advice would be most appreciated. Thank you!
2013-03-03 Answered By : Dr. Gregory Feld M.D., F.A.C.C. F.H.R.S.

After two ablation procedures at one center, it would be reasonable to obtain a second opinion. A third ablation is sometimes warranted, if the AF recurs and is triggered by premature atrial beats on monitor, or if atypical atrial flutter occurs. If a third ablation is recommended it might be appropriate to ask for a referral to a center that does complex ablations or repeat ablations. Reconnection of the PVs is possible even after a second procedure, although it sound like testing with adenosive was done during the second procedure to demonstrate dormant (or as you put it \"minimal\") reconnections. A third procedure does increase the risk from fluoroscopy exposure, so you might want to have it done at a center that used 3-D mapping and minimizes fluoroscopy exposure. After a single or even multiple procedures, it is sometimes necessary to stay on an antiarrhythic drug to prevent AF recurrence. So that would also be an option in your case.

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