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St. Jude Medical

February 18th, 2018
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Hi Doctor,Iam 68 yrs old. When i am 51 had a triple by-pass and at 59 for a heart attack.In my family,my father when he was 41 expired of a heart attack and his brother dropped dead from a heart attack at 27. When I am just sitting down reading or looking at T.V. I some times have jaw pain that is extremely painful it happens on both sides of my jaw at the same time.I have woke up in the middle of the night with it. I take Nitro for the pain. My other systems that I have had is getting extremely hot breaking in to a sweat. One time I woke up gasping for air. About a month ago I was sitting down and my right arm and the right side of my face when completing num. This all lasting for no more that 10 seconds. I thought that I was having a stroke but the doctors said no That it was to short of time for a TIA. I never have trouble when I am exercise or cutting the lawn. This all happens when I am at rest. The only thing that I do know is that I have one blockage that is at 50 percent.What could be my problem? Please explain??
2013-07-22 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Many thanks for your email. Your family history is certainly concerning, and so while your symptoms could represent many things I recommend you see a Cardiologist and a Neurologist for these symptoms. The chest pain and shortness of breath may need to be evaluated using a stress test by your cardiologist, while your right face/arm numbness may warrant screening of the arteries that supply your neck and also a quick screen for an irregular heart rhythm called atrial fibrillation. To avoid unnecessary delays, I would try to get these referrals soon. Please remember that we physicians always say that if you have chest pain at rest - particularly if it does not go away - please go to the ER. Similarly, if you have numbness again, please go to the ER.

Why leaning backward seated at my desk chair suddenly trigger a succession of skip beats, but resuming right away my initial normal seated position stopped them. If I kept that incline position those skip beats would rapidly transformed into Afib. Same thing in bed. Getting up right away stopped the Afib trigger mechanism. On two occasion I sat at a my desk all night (working or watching tv seated normally) with absolutely no symptoms but as soon as I got back in bed the same trigger mechanisms started again! I think I know what was the trigger behind it , but I do not understand why leaning backward or taking the flat laying position in bed trigger afib to kick in.
2013-08-01 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

This is fascinating. The first point is that rotational movement of the neck (from side to side) and a few other movements are known to trigger heart rhythm disorders - but usually slow heart beats. The second, question is - are we sure that you are having Afib (that is, have you recorded it on a monitor such as a mobile phone app?). This is worth checking with your doctor to do a full workup, including checking the arteries in your neck and the reflexes triggered by neck movement. Thanks for sharing the very interesting story.

Hi Dr. Narayan- My dad is 84, diabetic, double stroke survivor with A-fib. His last stroke occurred 5 years ago after hip surgery. Surgery demanded his being taken off coumadin 4 days prior to surgery. A heperin drip was used as a bridge and/or after surgery. He is now a candidate for Provenge treatment to slow the spreading of his prostate cancer. Unfortunately they will need to put a cathader/line in above his pectoral as the veins in his arms are not sufficient to receive the Provenge infusion. It is apparently mandatory to take him off his coumadin again and start bridging with Lovenox before and after the cathedral procedure. MY QUESTION: With my dad\'s history of stroke, are the risk factors for another stroke increased or higher when bridging from coumadin/warfarin to Lovenox? It\'s a fine line i know with my dad\'s INR and being diabetic, a-fib and 84, I\'m concerned about the stroke risk yet again. Thank you Dr. Narayan - your thoughts are much appreciated.
2013-07-21 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Thanks for the interesting question. In general, your father\'s physicians are doing the right thing to bridge him with heparin and lovenox. These things are a fine line, but since he cannot have full blood thinners while they place the new line, this is a very reasonable plan and would be followed by many physicians since it minimizes the time that he is without a blood thinner.

Hello Dr Narayan. In my early childhood I remember describing the feeling of a butterfly fluttering in my heart to my grandmother. When I was about 35, my pcp made me wear a holter monitor for 24 hours. I was referred to cardiologist for tachycardia and arrhythmia. Cardiologist eventually referred me to EP and I was told I had an Accessory Pathway. I quit going to EP because he mentioned ablation and possibly pacemaker if medication could not get arrhythmia under control. 3 yrs ago, before Sinus surgery, I was referred for Cardiologist for risk assessment. Cardiologist made me wear holter and discovered that I had A Fib. I am now 53 yrs old and I am on Flecainide, Propanolol and Aspirin. The EP that I go to now said that the previous EP couldn\'t have possibly known I that I have an Accessory pathway without doing a EP study. The previous EP based the Acc Pthwy dx on patterns on my ECG. Is it possible to dx Accessory Pathway without EP study? I still have episodes of fluttering, weakness, dizziness and confusion. Should I be on Coumadin? I do not have hypertension or diabetes, but both my mother and father had/have chf, htn & a fib. Thank you,
2013-07-21 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Thanks for the interesting questions. Yes, it is possible to diagnose an accessory pathway from the ECG without doing an EP study - if it is a clear pattern and under the right circumstances. Based on what you are experiencing, I would go with your Cardiologist\'s advice based on the results of your Holter. If you have ever had a blackout or near blackout, you should tell you cardiologist straight away. Decisions about coumadin depend on many factors, and should be made by you with your doctor after a proper discussion. Thanks.

I have lone afib and have had it for about 5 years. I have tried most of the drugs with no success and experienced bad side effects. Last year I was having about 3 events a month. This year I started taking ginger capsules (500mg) before meals and so far have been mostly afib free except for a couple of occasion when I forgot to take them. As you can appreciate I am keen to share this news with you. Do you know why this works? I have read that ginger works the same way as ibuprofen in reducing inflammation.
2013-07-15 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Many thanks for this interesting and enlightening observation. If you search the internet, you can find several reports that raw ginger (or drinking ginger tea) has helped others to reduce their AF. However, there are very few, if any, scientific studies on this subject yet. Thus, it is now clear how ginger may work. However, if it works for you please continue (in moderation!). Watch the literature for further developments, and thanks again for your email.

I am a 63 yr old male with asymptomatic, paroxsymal atrial fibrillation and chads2vasc of 0. My cardiologist prescribed dilitiazem and low does aspirin after echo, stress echo, 24 hr holter, ecg. Recently I consulted with an ep and he administered a 7 day holter that showed I am in afib 30% of the time, with longest episode of 12 hours. The ep recommended that I start anticoagulants. . My cardiologist had previously told me he would start me on anticoagulants when I was 65. I would like a second opinion. Thanks.
2013-07-15 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

This is a very important question. In general, most practitioners anticoagulate based on the CHA2DS2VASc score, and not based on AF burden per se. Thus, since your CHA2DS2VASc score is zero, most practitioners would agree with using no agent or aspirin - even though you are in AF 30% of the time. The opposite argument is also true - in a patient with a high CHA2DS2VASc score (2 or more), most practitioners would recommend anticoagulation with warfarin or a newer agent regardless of the precise amount of AF. In summary, based on this information your cardiologist\'s opinion seems sound.

I am a 63 year old male with asymptomatic, paroxysmal atrial fibrillation. My cardiologist prescribed diltiazem and low dose aspirin. My CHADS2VASc is 0. I recently went to an ep who did a 7 day holter monitor which showed I am in Afib 30% of the time with longest episode of 12 hours. The EP recommended anticoagulation. I wanted to know if there are any studies on anticoagulation recommendations and AF burden and if not are their guidelines that ep\'s use or is it based on personal experience. In addition I would like a second opinion if possible. Prior to going to the EP I discussed anticoagulation with my cardiologist and he said he would start when I was 65.
2013-07-14 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

This is a very important question, and Yes, there are several studies on this topic. In general, most practitioners anticoagulate based on the CHA2DS2VASc score, and not based on AF burden per se. Thus, if your CHA2DS2VASc score were high you would be anticoagulated with warfarin or a newer agent regardless of the precise amount of AF you have. Accordingly, since your CHA2DS2VASc score is zero, many would consider placing you on no agent or potentially aspirin even though your AF is 30% of the time. Thus, your cardiologist\'s opinion seems very sound.

When you feel a skip beat how do we know it has originated from the Atria ...or the Ventricle... or it is a PAC with a ventricle response.? I have from time to time felt them inside the upper stomach level just below the last left or right rib. I have had event monitor recorder hooked but to no avail even though I have marked the precise time of the day when they occur.
2013-07-14 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Many thanks for this question. The short answer is that you may never be fully accurate in determining if your skipped beats come from the atria or ventricles. There are some \"classical\", \"old school\" tips, but these are not fully reliable. For instance, if the beats go away when you are exercising, they were previously felt to be ventricular. However, this is not always true, and one could have atrial and ventricular beats. It is odd that the event monitor has not picked these up. It is worth going through the tracings and your diary log (of symptom times) with your Doctor. Please make sure that the time on the event monitor is the same as the time on your watch. If, after checking all of this, your \"skipped beats\" do not correlate to any rhythm irregularity, then your symptoms are likely from something else.

Dr. Narayan, can you tell us what FIRM studies are currently underway and when you expect to release additional results from these studies. Also, do you suspect FIRM procedures are best used in conjunction with PVI ablation or that they will be equally effective as a stand alone procedure.
2013-07-14 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

Thanks for the question and the interest in FIRM. Actually, several FIRM studies are underway, with the major ones at the moment led by Dr. John Miller, Chief of Arrhythmia Medicine at Indiana University. Several more are expected in the near future. FIRM is being used by several groups with PVI, but also as standalone FIRM-only. Both appear very successful. Since new data is being gathered, it is worth each patient discussing these options with their doctor to ensure the most up-to-date decisions.

I am 18 years old. I have been getting palpitations and they occur frequently. I donít smoke, don t drink coffee or alcohol very much. When I go to gym the heart monitors on the cardio equipment always flash with warnings that my heart rate is too high. It averages at about 184 beats per minute when i power walk. Am I in risk of heart attack? Kindly suggest me?
2013-07-10 Answered By : Dr. Sanjiv M Narayan, MD, PhD, FHRS

This is something that your doctor should advise you about. First, it is important to know if you have any other symptoms when you have your palpitations, or when your heart rate goes up to 184. These symptoms may include chest pain, shortness of breath, dizziness, lightheadedness or if you have blacked out or nearly blacked out. Second, you should record what was happening when you get palpitations. When you see your doctor, this information will be useful. I would definitely try cutting out caffeine and alcohol completely, to see if that makes things better. Third, these symptoms may reflect many things: they may be normal (at your age, your maximum heart rate with exercise may be up to 200 beats/minute), they may reflect a heart rhythm abnormality, or they may represent one of several problems with other parts of your body that are causing rapid heart rates. I would avoid going to the gym or pushing yourself too much with exercise until you have discussed this with your doctor.

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