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Atrial Fibrillation |
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Atrial Fibrillation |
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Videos on Atrial Fibrillation: (link to the McGill Continuing Medical Education Web Site, Cardiology Section)
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Aug 1998 -J. T. @worldnet.att.net
I am a 54 year old school librarian in good health.
On May 1,1997, I had an atrial myxoma removed. I was told that it had been the size of a small pear and had involved the right and left atria. The convalescence was complicated by an inability to tolerate digoxin and I had to return to the hospital for an additional week to regulate medication. I have been told the the nature of the surgery impaired my heart and that atrial fibrillation will continue. (There was a possibility that the heart rate would become normal, but this is not to be).
I had numerous atrial fibrillation episodes following the surgery, that last, and most worrisome, was 5/12/98 that lasted a week and caused me to miss work. Sotolol failed. In May,1998 I went into atrial fibrillation that lasted for a week. 4 verapamil a day finally slowed the heart beat and now I am on Rythmol and Aspirin.
Yes, use my question on the journal.
Thanks, J.T.
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Cardiac tumors are rare, and of these atrial myxomas are the most common. Most of the patients with this condition are over 50 years of age and are women.There is a right atrium (blue) returning blood from the body to the right side of the heart and then to the lungs (to be oxygenated), and a left atrium that feeds the left side of the heart with the oxygenated blood from the lungs. Atrial myxomas are most often found on the left side of the heart and are attached to the septum that divides the atria. |
Atrial myxomas vary in size and can grow to several centimeters in diameter.
See the case report of a 47 year old computer technician with a one year history of painful skin lesions on his palms and soles. Each episode lasted 1-2 weeks. The patient had embolic events which included episodes to both feet and to the right arm. The patient had shortness of breath bending forward or sitting up, which resolved when lying back. (This report shows an echocardiogram as well as an angiogram showing the myxoma in motion)
Atrial myxomas are rare, but clinicians ( e.g. Fisher , Cardiovasc. Rev. Rep. 9:1195, 1983. ) have reported the signs of a myxoma can include: shortness of breath, weight loss, fever, coughing up blood, passing out, sudden death (rare), stroke, heart attack, and atrial fibrillation.
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Some of these symptoms are not unexpected as the myxoma is a soft mass that is mobile and which can block the mitral valve or release release emboli into the blood stream. These emboli can block vital arteries and cause damage(strokes occur with blockages in the brain, heart attacks with blockages in the arteries going to the heart) |
Most of the myxomas occur on the left side of the intra-atrial septum and the treatment is the removal of the myxoma and usually part of the septum. The removal of tissue around the origin of the myxoma is felt to be important to prevent the recurrence of the tumor, and in most cases the recurrence rate is less than 2%. This being said, cardiac surgery in general and surgery which involves the atrial septum (including operations the repair holes in the septum) are associated with atrial fibrillation (see a representative electrocardiogram) and atrial flutter. Often this resolves over the months following the operation. An important question is where or not one should anticoagulate a postoperative patient with an agent such as warfarin as opposed to giving Aspirin.
In general there have been five randomized clinical trials compared warfarin with no medication for the prevention of strokes in atrial fibrillation patients in general. They were:
The average combined risk reduction with warfarin for all five studies was 68% (95% C.I. 50% to 79%). Three trials compared aspirin and warfarin:
and found that warfarin was more effective in preventing strokes. The combined risk reduction for the combined three studies comparing warfarin to aspirin was 47% .
The choice of Warfarin verses Aspirin depends on whether the doctor feels the patient is in a high or low risk group for an embolism.
Therapies that control, terminate and prevent atrial fibrillation or flutter include medications and electrical treatments including external cardioversion (see Recording of a series of shocks for Atrial Flutter), atrial pacing (see representative EKG of atrial pacing) or implantation of an atrial defibrillator. Rhythmol is an effective medication and is a class I anti-arrhythmic. This class includes other medications such as Tambacor, Procan, Quinidine and Norpace. Most Class I anti-arrhythmic work better with a beta-blocker, which in addition may prevent fast conduction of atrial flutter to the ventricle. Rapidly conducting atrial flutter can resulting in heart rates faster than 270/min (see recording of fast conduction to the ventricle).
Sotalol is a class III anti-arrhythmic with about the same efficacy as Rythmol, the problem with Sotalol is that the medication can cause a life threatening arrhythmia (see recording of Torsade de Pointes with Sotalol) especially with high doses, in the presents of a low serum potassium or renal failure.
Verapamil is a class IV anti-arrhythmic but has a dual effect in atrial fibrillation. Theoretically it should increase the chance of atrial fibrillation as it decreases the refractory period of the atrium, and secondly it slows the conduction of the fibrillation to the bottom of the heart. This slowing of the heart rate is the best role for Verapmil. This approach of slowing and not converting the atrial fibrillation may be a reasonable choice as it makes the patient less symptomatic and does not carry with it major side effects such as sudden death. The same can be said for digoxin and most beta-blockers other than Sotalol. It is also important to realize that although at first a patient may feel unwell with atrial fibrillation, most adjust and function well with a drop of only 20% in their exercise capacity.
In the end, no anti-arrhythmic has been shown to prevent blood clots associated with atrial fibrillation. Further post-operative atrial fibrillation often does not recur and long term anti-arrhythmics may not be required.
Long term one expects patient who have had a successful operation to do well but remember:
From: J.W. Dec 1997
I am a 34 yr. old male and fairly active. About a year ago I was diagnosed with atrial fibrillation. Since then I have been treated with a few different medicines of which none seemed to help. I was an occasional beer drinker and after a night of a few beers I would occasionally go into an irregular rhythm and have to go to my cardiologist or the ER. I have stopped drinking altogether, its been about a month or so. The other night I went into a AF while folding laundry and had to be admitted to the hospital.
Why in am I still getting these rhythms? What is triggering them? My cardiologist has yet to give me a definitive answer. Since my stay in the hospital, I am now on coumadin added to the medicine that I am already taking, being Lanoxin, and Rythmol. Also Is there any kind of watch or small portable monitor that I can buy that will tell me my pulse rate at any time, and that I may wear all day long.
Please feel free to use my question on the Journal, and thank you for your response.
Sincerely J.W.
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Dear J.W.,
We see AF in younger persons with no clear reason for the arrhythmia. Alcohol can bring it on in some. In general we check to be sure that the thyroid gland is normal and the heart is structurally normal too (normal echo). If all is normal we often do not find a reason for the AF (this may change as we learn more about AF), but independent of the cause of the AF, most young people in this group are at low risk for a stroke, the major problem with AF. Most patients, once in AF for a few weeks settle down with simple medications and carry on with their lives. It is the changing from regular rhythm to AF that bothers most.
The choice of coumadin (warfarin) in an "idiopathic" young AF patient may be justified (see below) and this has to be accessed by the treating doctor. Medications to prevent AF may control the AF or may just delay the time when it will become permanent and have not been shown to protect against stroke. You are best to discuss the choices with your own MD or a specialist in arrhythmias (electrophysiologist).
There are watches that measure pulse and are intended for those doing sports. The only problem is that they may not work well in atrial fibrillation, so you will have to try one out to see if it works.
You may not feel good when your rhythm switches into atrial fibrillation, but the racing and irregularity of the heart is rarely life threatening. Atrial fibrillation though, can be associated with the generation of blood clots which can be dangerous.
What is the risk for blood clots/stroke with atrial fibrillation?
Most AF patients with significant heart disease, including those with heart valve replacements and those with echocardiographic signs of heart failure and/or an enlarged left atrium clearly are at higher risk of forming blood clots. Many AF patients, though, have only atrial fibrillation and no other heart disease and in this group the risk is less clear.
The Stroke Prevention in Atrial Fibrillation study -1 (SPAF) trial compared coumadin with no blood thinner in patients and enrolled a total of 568 patients and 46 events during the study. The Atrial Fibrillation Investigators' pooled analysis (AFI) recorded 81 events with a total of 1236 patients.
Both studies identified risk factors for patients who if not treated were at higher risk for a blood clot (greater than 5% or 7% risk of an event /year!). These factors included:
with SPAF also finding
AFI finding
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Therapies for Atrial fibrillation, Risk Reduction:
Therapies which might prevent blood clots forming in AF patients could include
On these choices, aspirin probably has some benefit and warfarin provides the most benefit for preventing blood clots.
Five randomized clinical trials compared warfarin with no medication for the prevention of strokes in atrial fibrillation patients. They were:
The average combined risk reduction with warfarin for all five studies was 68% (95% C.I. 50% to 79%).
Three trials compared aspirin and warfarin:
and found that wafarin was more effective in preventing strokes. The combined risk reduction for the combined three studies comparing warfarin to aspirin was 47% .
Unfortunately the best choice for preventing blood clots, warfarin, as it thins the blood also predisposes a patient to bleeding. This can result in life threatening events (bleeding into the brain, bleeding from the digestive tract). In properly selected and controlled patients less than 75 years of age, this risk is risk is less than 1% (INR of 2.0 to 3.0). The risk increases with age but warfarin therapy still probably shows benefit in the age group >75 but is usually used with a lower level of blood thinning (INR of 2.0).
Who should be treated with aspirin or warfarin:
One usually chooses the treatment with the least risk.
Subject: Atrial fibrillation and exercise
From D. M., September 1997
I am a 61 year old runner and have atrial fib. I have had it for at least 8 years, maybe more. I went for a check up in late 1980's and it was discovered I had the irregular heart beat, my previous check up was a few years earlier and my heart rate was normal . I ran marathons in my 40's(1980's) and have now gotten back in shape ( lost 30+ pound), and have been running for about a year , now I would like to start entering some 5K , 10K , etc. races.. do you think it is OK to race with the atrial fib?
I feel fine running and just have a little hesitation on taking the next step.( pushing my self more, speed work outs , etc. ).
Hope to hear from you ..Thank you .
Don
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Dear Don
Congratulations on your interest & enthusiasm about exercise!
People with atrial fibrillation often demonstrate a rapid rise in their heart rate during exercise, even when the heart rate is well controlled at rest.
Before taking on vigorous physical activity, I suggest that you visit your physician for a general medical evaluation including a review of any medications you may be taking. Further cardiac testing that might be considered include an electrocardiogram (ECG) to evaluate the resting heart rate & rhythm, Holter Monitoring (24 hr portable monitoring) to evaluate the heart rate & rhythm during daily activities, Echocardiography to evaluate the heart size & valve function, and Exercise Testing to evaluate the cardiac response to exercise.
Exercise testing can be helpful in providing safe exercise guidelines specifically for you. Look into the availability of Cardiac Rehabilitation services in your area. Many of these programs can provide the necessary expertise in individualized exercise prescription and exercise training.
Good Luck,
Mark Smilovitch, MD, FRCPC, FACC
Subject: Treatment of atrial fibrillation
From: S. K. 97 Oct
I am 70 years old and have had Atrial Fibrillation for a number of years. I was a pilot and I wanted to keep flying.
My Doctor prescribed a number of the standard pills to keep my heart beating regularly. The majority of these pills worked. I then went to San Francisco to be prepared to take Sotalol. After taking the drug, I was still fibrillating. I called the Doctor and notified him that the pills were not helping.
Thursday morning we started an increase in the dosage, both morning and evening. Friday night at 1:30am my wife was going to bed and she noticed me breathing irregularly. She tried to waken me and I would not respond. I then wakened and tried to get out of bed to go to go to the bathroom. My body would not respond. She called 911. The firemen arrived first and they gave me oxygen. I could then move normally. I was taken to the hospital and stayed there for 4 days. It took a week without oxygen to get my speech back. I had taken Tambacor. This Sotalol is worse. It should have close scrutiny.
I recently saw an article in Newsday about a small implanted defibrillator that has a better record that Sotalol.
S.K.
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Reply: Dear S.K.
I am sorry to hear that you are being dogged by atrial fibrillation but this is a common arrhythmia seen as we get older. Your doctor that knows you is your best guide for your therapy, and not knowing your case better all that can be made are a few general comments which may not apply to your situation.
There are few treatments that carry no risk when it comes to medications for regularizing the heart rate. We call these risks, adverse affects and they include proarrhythmia (the worsening or creation of new rhythm disturbances).
For Atrial fibrillation you have to ask if there is a need to stay in sinus or regular rhythm. Some patients are very unwell in atrial fibrillation but many after a while (maybe a month or so) and with relatively safe medications that only slow the heart rate and blood thinners live well with their fibrillation.
The main risk of atrial fibrillation is that of having a blood clot which can cause a stroke. No therapy, to my knowledge, other than blood thinners (coumadin) decreases the rate of strokes. The medications that regularize the heart have yet to be proven as effective as blood thinners for preventing strokes.
Heart rhythm medications can create new arrhythmias some of which are life threatening. Sotalol is an example of a medication that can cause fatal arrhythmias. Sotalol is excreted mainly by the kidneys and the dosing intervals should be lengthened when the creatinine clearance is less than 60 ml/min. As with the anti-arrhythmic effect of Sotalol, Torsade de pointes, a potentially lethal arrhythmia, is dose dependent and occurs in 0.5 percent of patients who taking 160 mg/day, 1.6 % taking 320 mg/day, and up to 5.8% taking more than 320 mg/day.
The danger of Sotalol increase with the amount taken, and it is important to realize that a person who is unresponsive and "breathing funny" may be experiencing a life threatening cardiac arrhythmia (cardiac arrest) and if effective CPR is not given or the arrhythmia does not stop or is not corrected with-in three minutes (cardioversion) the result is usually irreversible brain damage and possibly death. It is important to recognize that a person is having a cardiac arrest, and to call for help and act immediately. A delay of 10 minutes is far too long! This is not easy to do if this is a loved one and one is faced with the situation for the first time.
A classic example of a medication that can cause loss of consciousness is Quinidine. This is an old medication that is still used today. Quininidine caused (and still does) loss of consciousness due to severe cardiac rhythm disturbances which can be fatal.
The latest therapies on the scene include the atrial defibrillator which gives you a shock to get you back to regular rhythm, and catheter ablation where the atrium is scarred to make atrial fibrillation more difficult to sustain. Both of these therapies are promising and may be of great value but both have yet to prove themselves. We look forward to future clinical trials of these therapies.
replyDear Dean,
-Atrial fibrillation (AF) is an irregular rhythm of the heart that results from the fast and irregular beating of the atria which in turn cause a slower and irregular beating of the ventricle. This can be seen in an electrocardiogram.
-AF is often seen with other problems such as congestive heart failure, hypertension, valvular disease and thyroid dysfunction. AF can be induced with alcohol in some people, is often seen in patients immediately after open heart surgery, and can be induced with some medications one of which is Adenosine (used to terminate fast heart rhythms). The place of digoxin in the treatment of AF is not certain. It tends to decrease the refractory period of atrial tissue which should promote the AF! Its best use is to slow the heart rate when a person is in AF chronically. Your episode may have terminated without any intervention. The value of oral digoxin therapy in a case like yours is not clear although the medication is inexpensive, well tolerated, and usually causes little harm if taken in the usual doses.
-There is a group of patients who have atrial fibrillation, are younger and have no detectable heart disease. The term for his type of atrial fibrillation is lone atrial fibrillation. In your case if your blood values are normal (including thyroid measures) and your echocardiogram is normal you are probably a lone atrial fibrillator.
-In answer to your questions:
1) There is some literature on chemically induced AF, and one reference that you might look at is Atrial fibrillation and sudden death related to occupational solvent exposure. Kaufman JD; Silverstein MA; Moure-Eraso R Am J Ind Med May 1994, 25 (5) p731-5. This report is of two cases of atrial fibrillation and one case of sudden death with exposure to a halogenated hydrocarbon CFC 113. I am not sure if your AF related to the adhesive you were working with but it is not impossible. If it was the adhesive, and if it acts like other agents (e.g. Adenosine) the inciting effect leaves with the agent and the arrhythmia does not tend to recur.
2) With your normal echocardiogram and I presume EKG, it would seem very unlikely that you have associated heart disease (you could confirm this with your own doctor). It is very possible that you are a lone atrial fibrillator and as such you might well have more episodes as time goes on, and as such pose little or no risk to you.
3) Your strong heart beat is probably normal (remember the digoxin probably had little or no effect on your rhythm). There is no strong relationship between lone atrial fibrillation and other heart disease. This seems to also apply to the generation of blood clots which are associated with other forms of atrial fibrillation and blood thinners are usually not required for lone atrial fibrillation. (again best to check with your doctor)
4) Atrial fibrillation has nothing to do with heart attacks. The odds are that you should keep running. You should confirm this with your own MD who might arrange an exercise stress test to reassure you that all is well.
