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Old 09-15-2018, 03:15 PM
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Atrial Fibrillation... Sigh.....


Anybody here successfully treat their A-Fib with medication alone? For years even?
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Old 09-15-2018, 03:33 PM
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Anybody here successfully treat their A-Fib with medication alone? For years even?
What do you mean by 'successfully'? Staying out of afib by using meds? Keeping the rate controlled with meds? Yes, both can occur, but the latter is more likely than the former.

But for more informed discussion, can you tell more about your particular situation/concerns?
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Old 09-15-2018, 03:50 PM
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I suffered a bout of AFib earlier this year. I spent two nights in the hospital but they could not stop it with meds, only slow it down. They ended up using a "cardio-version" treatment, a trickle of electricity from front to back of my chest right through my heart. That zapped me back into proper rhythm. Ever since then (about seven months) I've been taking beta-blockers, which keeps me pretty much in normal rhythm. I also cut way down on my caffeine intake, and stopped carrying my cell phone in my shirt pocket (just in case).

(I was already on anticoagulants for other purposes, so that wasn't an issue.)
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Old 09-15-2018, 03:59 PM
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I suffered a bout of AFib earlier this year. I spent two nights in the hospital but they could not stop it with meds, only slow it down. They ended up using a "cardio-version" treatment, a trickle of electricity from front to back of my chest right through my heart. That zapped me back into proper rhythm. Ever since then (about seven months) I've been taking beta-blockers, which keeps me pretty much in normal rhythm.
Very similar experience. Mine was almost 2 years ago, and I was put on medication for several months with the expectation that that might do the trick. It didn't. Did the cardioverion thing and it worked like a charm. Been good ever since.

Prep time and check in for the procedure gook several hours, but the actual procedure is done in a matter of seconds, or less. I was sedated, although not general anesthesia. Prior to the procedure, my resting heart rate was about 80 - 90 bpm. Afterwards, it's been 50 - 60. The change was, literally, like flipping a switch.

I did not get any info from my cardiologist about how common it was for medication alone to get you back in good rhythm, so I have no idea whether it's a realistic option.
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Old 09-15-2018, 05:21 PM
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My AFib acted up over 10 years ago. They tried to reboot my heart, and failed. My cardiologist gave me something to reset it (though it hardly ever worked) and rescheduled me for another go. When I came for it, my AFib was gone, temporarily at least.
Since then I'm on Dilitaizem and Warfarin, and I'm down to cardiologist visits only every two years. I have no symptoms except very occasional fibrillation that I can feel. I get my INR checked every 6 weeks, and it is always right in the middle of the acceptable range.
My blood pressure and everything else is very good, I'm not over weight, and my LDL cholesterol is way low without medication.
So don't despair. It doesn't have to mess you up.
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Old 09-15-2018, 05:55 PM
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Originally Posted by Qadgop the Mercotan View Post
What do you mean by 'successfully'? Staying out of afib by using meds? Keeping the rate controlled with meds? Yes, both can occur, but the latter is more likely than the former.



But for more informed discussion, can you tell more about your particular situation/concerns?


By “success” I mean stopping (or substantially reducing) episodes of A-fib.



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Old 09-15-2018, 06:59 PM
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Mine cured itself. I canít really explain it. It would happen periodically for seconds up to minutes. Then one time it wouldnít stop and I went to the hospital. I was there overnight and in the morning it was gone. I canít tell you exactly when it went away but it did. Now maybe a couple of times a year at most I will feel a couple of irregular beats and thatís it.

Always make sure your potassium intake is enough. Lack of potassium can lead to irregular heartbeat. When I was in the hospital that one time the only thing they found that was wrong was that my potassium level was very low.
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Old 09-15-2018, 09:32 PM
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I underwent an ablation. It worked. So far. It has been three years since ablation.
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Old 09-15-2018, 09:54 PM
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I had heart valve repair 2 years ago and apparently I go into Afib without knowing it. I ended up with a 3.5 inch blood clot in my heart. I found this out after a piece broke off and went to my leg. It clotted the entire length of the leg and I was in the hospital for 2 weeks getting rid of it as well as the clot in my heart.

Long story short I'm on blood thinner for the rest of my life.
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Old 09-15-2018, 10:42 PM
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Magiver, just out of curiosity was the clot in your leg like a sudden thing like you woke up one morning and your whole leg was discolored or did it start small and spread. Just curious. Did you feel anything odd prior to the clot appearing?
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Old 09-15-2018, 11:19 PM
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Magiver, just out of curiosity was the clot in your leg like a sudden thing like you woke up one morning and your whole leg was discolored or did it start small and spread. Just curious. Did you feel anything odd prior to the clot appearing?
It was progressive. Exactly this time last year I had trouble walking any distances. It would start in my calf muscle and the entire lower leg would then ache like the worst shin splints. I thought it might be a clot and had a scan of my leg done. They only scanned the vein side of the leg because that is where blood clots usually start. It got worse to the point a walk of 100 feet would require laying down for 30 minutes yet I could walk 15 feet with reasonable success. The pain would get rapidly worse with the distance traveled. I eventually had the artery side of the leg scanned and by that time there was no discernible pulse in my leg. That was 2 months later so there's your time line.

4 days of repeated surgery for the leg and 10 days of drug therapy to dissolve the clot in my heart.

There was no discoloration just an ever increasing amount of pain when walking. If I wasn't walking it didn't hurt.

Just as an aside, if it gets that bad your leg will be colder than the other leg. You should also be able to easily feel your pulse by pressing your fingers across the top of your foot.
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Old 09-16-2018, 10:21 AM
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I did not know there was any treatment for it. Maybe there weren't in 2005 when mine was diagnosed. I have been on blood thinners since. First warfarin, now something call eliquis. Which I had to suspend for two days before a colonoscopy.
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Old 09-17-2018, 07:16 AM
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I've had paroxysmal atrial fibrillation for at least 10 years now. I call it "wonky heart syndrome". I'm on Bisoprolol Fumarate, Flecainide Acetate, and aspirin. I still get occasional wonkiness but it's mild and lasts from a few minutes to several hours.
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Old 09-19-2019, 09:46 AM
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Since last posting in this thread almost exactly a year ago my at-fib has become more frequent and longer lasting. The dosage of the medications I'm on can't be increased so I'm going in for an ablation next week.
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Old 09-19-2019, 10:10 AM
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There are a few things that matter a lot when considering how to treat atrial fibrillation. In addition to age, presence of diabetes, high blood pressure, 'congestive heart failure", and history of a stroke or TIA, there's also patient preference and quality of life, with both the atrial fibrillation and its treatment affecting the latter.

By the way, the risks of stroke from atrial fibrillation - the big risk that gets most of the attention - is no different whether you are fibrillating continuously or intermittently (or even 'occasionally').

This is not a one size fits all disease. What works and what is best for an otherwise healthy 50-year-old with atrial fibrillation is likely very different than what works in an 80-year-old whose a fib is just one of his problems.

Off topic somewhat, and I am not asking you to respond, but I predict that many of the folks around here with a fib are also using thyroxine. Even very mild degrees of over-supplementation can precipitate atrial fibrillation. It's not even clear to me that we shouldn't be monitoring the heart in patients on thyroxine and not their TSH.

Last edited by KarlGauss; 09-19-2019 at 10:13 AM.
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Old 09-19-2019, 11:56 AM
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I was on Propafenone for afib for around 5 years, had no problems. It came back, so I had ablation. Been good for another 5 years. Mine seemed related to alcohol use / abuse (Holiday heart). Gave up the booze prior to the ablation.
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Old 09-19-2019, 12:08 PM
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Mrs. Watering has Afib pretty much all the time. She did undergo cardioversion, but it didn't work. Her cardiologist put her on Eliquis, and he's asked her to consider the Watchman procedure, which is a method for closing off the left atrial appendage to prevent clots/stroke.

I'm wondering why he doesn't recommend ablation.
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Old 09-19-2019, 10:18 PM
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I had a bout of it several years ago, but Amiodarone (spelling sort of guessed at) stopped it within two days. It came back last year, but in a much milder fore, called A-Flutter), which has been controlled with another pill, and all seems to be ok.

A-fib is not a death sentence, even if the doctors are unable to control it. A very good 50 YO friend of mine has had a bad case since he was an adolescent, and has been zapped with electricity eleven times without any improvement. Pills do nothing. He gets along fine, and has been working as a caretaker on an island in the Washington San Juan Islands for the past four or five years. Lots of physical exercise doing that, I guarantee.
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Old 09-19-2019, 11:42 PM
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Not related specifically to the OP's question about meds only, but related to the clot risk: just in the past week or so I heard about a new implanted device called Watchman - which as I understand it blocks off the part of the heart where clots are most likely to form. My father-in-law (age 83) had this done yesterday.

In theory, this should allow a patient to come off of warfarin after about 6 weeks (dunno if FIL was on that, but he's got so many health issues it wouldn't surprise me).
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Old 09-20-2019, 10:46 AM
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I guess I don't know what acute a-fib is. I was diagnosed with a-fib in 2005 and have taken blood thinners since. But I have been totally symptomless. It was diagnosed with a cardiogram and an ultrasound. I also have a pacemaker, but that is unrelated AFAIK.
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Old 09-20-2019, 11:46 AM
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My heart keeps the rhythm of a bad jazz band. I had an ablation procedure performed in 2014 and just recently the missed beats have come back.

Testing showed that my occurrences were twice as frequent as the recommended threshold for acceptable.

I find out next week whether my new meds are working. If not I'm scheduled for my next ablation procedure set for the end of October.
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Old 09-20-2019, 03:33 PM
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I guess I don't know what acute a-fib is. I was diagnosed with a-fib in 2005 and have taken blood thinners since. But I have been totally symptomless. It was diagnosed with a cardiogram and an ultrasound. I also have a pacemaker, but that is unrelated AFAIK.
Same here. No symptoms (still, from my last post a year ago.) I can walk for miles in San Francisco and it does not affect me.
I got diagnosed when I was trying to donate blood and got rejected because of a racy pulse. I get a Holter Monitor and ultra sound every couple of years. I only see my cardiologist every other year, and get my INR checked every 6 weeks.
No quality of life issues at all.
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Old 09-20-2019, 03:56 PM
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. . . I was diagnosed with a-fib in 2005 and . . . I also have a pacemaker, but that is unrelated AFAIK.
Quite possibly related. The development of atrial fibrillation can sometimes be an early, if not the earliest, manifestation of disease of the heart's electrical conduction system. 'Degenerative' disease of the conducting system is very common, especially in older people. It can also develop for other reasons such as scarring from heart attacks or from heart inflammation.

Although a fib is characterized by a rapid and irregular heart rhythm, people with disease of the conduction system may also have times where no electrical impulse is generated by the atrium (upper heart chamber). This is called 'sinus arrest' and may require insertion of an "artificial pacemaker" (with the sinus node, sitting at the top of the atria, being the natural default pacemaker that we're born with).

In addition, people with conduction system disease often have blocks in the conduction of electricity from the sinus node through the atria (upper heart chambers) to the ventricles. These blocks can be transient or permanent. If such a block becomes permanent or is deemed to be at risk of persisting, a pacemaker is often inserted and will directly stimulate the ventricle when required, i.e. when no impulse from above has been detected*.

*there are much fancier options as well

Last edited by KarlGauss; 09-20-2019 at 03:58 PM.
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Old 09-21-2019, 07:33 AM
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Thanks for the informative discussion.

Based on what I've read here, I just set-up my Apple Watch 4 to do A-Fib checks on me. I've had the watch (and the ability) since Christmas and never bothered using that feature.

My first test showed "No Signs".
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Old 09-21-2019, 10:22 AM
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A-fib is not a death sentence, even if the doctors are unable to control it.
Depends on your species. A guy we know owned a racehorse that repeatedly was first out of the gate, ran beautifully, then slowed down in the stretch. The horse was certified as a bleeder, so got Lasix to race. Tests showed he had bouts of a-fib exacerbated by potasium depletion from receiving Lasix.

The horse was put down. Racehorses that don't/can't win are a poor return on investment. Selling/giving away the horse was considered, but a horse with heart disease could collapse and injure humans.
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Old 09-21-2019, 12:21 PM
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My late grandmother had several rounds of A-Fib. Her pulse would race to 150+ with a very unstable rhythm. We could not get a BP reading during those episodes. However most of those episodes of A-Fib would settle on their own, and her heart would return to its normal rhythm in a few hours time. She did not seem uncomfortable or in any way affected by the incident. Her oxygen saturation would remain normal - as measured with a pulse oximeter after the episode was over. She was prescribed a small dose of Sotalol which kept it under control until she passed away, years later. I think it is ventricular fibrillation that is considered serious / possibly fatal.

ETA: She was also on Clopidogrel and Aspirin.
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Old 09-21-2019, 03:34 PM
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. . . most of those episodes of A-Fib would settle on their own, and her heart would return to its normal rhythm in a few hours time. She did not seem uncomfortable or in any way affected by the incident . . . I think it is ventricular fibrillation that is considered serious / possibly fatal.
Indeed. Unlike ventricular fibrillation which is often lethal, atrial fibrillation is seldom an emergency or acutely life threatening. And that's a good thing since almost 10 percent of people over the age of 65 have it.

And although blood thinners are usually mandatory, its very high prevalence suggests that the abnormal rhythm itself, once the stroke risk has been addressed, may not confer much harm to many people. In fact, there seems to be no difference in outcomes (including death) whether you simply control the heart rate in atrial fibrillation or convert ('cardiovert') the person out of atrial fibrillation. (Here is a systematic review of the issue with basically the same conclusion).
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Old 09-23-2019, 11:47 AM
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Anybody here successfully treat their A-Fib with medication alone? For years even?
Yes. I am. What's up?
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Old 09-23-2019, 11:52 AM
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I received the 'zap' and it didn't take. I went to another dr. who said I needed ablation. I managed to get into Emory to see the Chief of Cardiology; and I've been very happy.
I'm on Diltiazem and Eliquis.
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Old 09-23-2019, 06:20 PM
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Atrial fibrillation is pretty common and has many causes. It bothers some patients a lot, with symptoms like breathlessness or discomfort. And others donít really notice it.

The original goal of treatment was to return to sinus rhythm, and some cardiologists still prefer this. Some large studies suggest just getting the rate under control offers the same benefits in terms of mortality, and is much easier to do. At best, maybe 60% of patients given stronger medicine or cardioversion might be in sinus rhythm a year later. Ablation might increase this to 85%. But 25% of people on strong medicines like amiodarone canít tolerate it.

If it bothers you, more aggressive approaches might work. But they donít always work, and donít always stay effective.
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Old 09-23-2019, 07:33 PM
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If it bothers you, more aggressive approaches might work. But they donít always work, and donít always stay effective.
I'm not bothered about if I know it's not going to cause a heart a attack. However, It caused a massive blood clot in my heart post heart surgery.

The Cardiologist said it would always be a risk going forward and to stay on blood thinners.
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Old 09-30-2019, 07:39 AM
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Had the ablation on Thursday, and was released Friday afternoon. It seemed to go well and everything looked good in the echocardiogram afterwards. Still a bit sore at the catheter insertion site and have some epic bruising around the area. They reduced the dose of one of the medications and I'll stay on anticoagulates for at least 3 months when I'll have a follow-up with the cardiologist.
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Old 09-30-2019, 06:38 PM
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I underwent an ablation. It worked. So far. It has been three years since ablation.
Same here. My afib was treated pharmaceutically for 15 years, but worsened. Jumpstarts didn't help much. Ablation changed everything. Continued sinus rhythm is wonderful!
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Old 10-01-2019, 07:34 PM
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Cardiologist here. Not electrophysiologist (specialized cardiologist who would do afib ablation or Watchman implantations). As others have mentioned, afib treatment is not a one size fits all. For most people a rate control method, where we just treat with medications to keep the heart from going too quickly, is good enough. Many people are "fortunate" and don't feel the fibrillation. Plus, the risk of developing afib rises with increasing age, and thus even though an ablation or cardioversion may be successful now, there is no guarantee it will continue to stay that way. The first line of treatment is generally to restore normal heart rhythm with the idea that everyone deserves a shot, but there are certain characteristics like age, left atrial chamber size, chronicity of the afib, does the afib come and go (paroxysmal) or is it persistent, are there other comorbidities like sleep apnea, hypertension, heavy alcohol use, etc, that go into the decision process. They may try antiarrhythmic medications (some have been mentioned, like flecainide, propafenone, or amiodarone) to maintain a normal heart rhythm but they tend to have more negative effects and are usually only used if there is a really good reason for wanting the heart to stay in a regular (sinus) rhythm.
The Watchman device is a relatively newer device that occludes the left atrial appendage, which is the funny little hangy thing off the left atrium where most clots form. It looks sort of like a bottle cap and it basically plugs into the opening of the appendage and anchors itself in there with small hooks. The device eventually endothelializes (gets covered in a layer of cells) that makes it nice and smooth to the blood, and plugs off the opening leading to a lower risk of blood clot forming. It's reserved for people who really can't take blood thinners for long periods of time, usually because of a past history of bleeding or need for frequent procedures that would interrupt the time on blood thinners to the point that they are essentially ineffective. Definitely not for everybody.
I could go on for pages and pages but it gets boring pretty fast.
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Old 10-01-2019, 07:35 PM
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I should also add, generally speaking because of the relatively high rates of recurrence even after ablation, most electrophysiologist/cardiologists recommend continuing taking blood thinners to prevent stroke even if the ablation is successful. Assuming that the risk/benefit is there, I mean.
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Old 10-01-2019, 07:40 PM
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I should also add, generally speaking because of the relatively high rates of recurrence even after ablation, most electrophysiologist/cardiologists recommend continuing taking blood thinners to prevent stroke even if the ablation is successful. Assuming that the risk/benefit is there, I mean.
Any RCTs on this?
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Old 10-01-2019, 07:55 PM
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A quick search showed a meta analysis that showed continued OAC use after ablation therapy was associated with a decreased rate of thromboembolic events although as expected an increased risk of bleed.
https://www.ncbi.nlm.nih.gov/pubmed?term=31257677

I believe that the most recent 2019 update by ACC/AHA/HRS mentions that it's a discussion to be had but no hard recommendations for continuing indefinitely.
I'm not at work right now so I can't access the journals outside the abstracts, but talking to my colleagues it has generally been the consensus that due to the high rates of recurrence as well as the oftentimes decrease in symptomatic afib thus leading to silent afib, the benefit is to reduce the risk of stroke.
I treat it like I would perioperative afib. Many people post-CABG or other CT surgery will have afib in the post-op phase and likely never have it again. But many have a lot of risk factors for afib and the stress of cardiac surgery likely just unmasked an underlying predisposition.
I'll see what I can dig up tomorrow and ask some of my EP colleagues.
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Old 10-01-2019, 08:02 PM
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Here's another meta analysis that shows the opposite, that stopping after successful ablation is associated with similar risk of VTE but lower rates of bleeding.
https://onlinelibrary.wiley.com/doi/...1111/jce.13822
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Old 10-01-2019, 08:22 PM
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Much obliged, but I would be embarrassed dumping more of a search onto you.

Mostly I wanted to be sure that I hadn't missed any key trials - where I work, a lot of rhythm stuff, even atrial fibrillation, is the purview of the EP people and frankly I'm not sure what they do post ablation when sinus has been restored. On the other hand, I tend to see a very skewed, older population with lots of comorbidities where we almost always anticoagulate and simply assume they're in (or in-and-out of) a fib forever.

Thanks,
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Old 10-01-2019, 08:52 PM
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... The Watchman device is a relatively newer device that occludes the left atrial appendage, which is the funny little hangy thing off the left atrium where most clots form. It looks sort of like a bottle cap and it basically plugs into the opening of the appendage and anchors itself in there with small hooks. The device eventually endothelializes (gets covered in a layer of cells) that makes it nice and smooth to the blood, and plugs off the opening leading to a lower risk of blood clot forming. It's reserved for people who really can't take blood thinners for long periods of time, usually because of a past history of bleeding or need for frequent procedures that would interrupt the time on blood thinners to the point that they are essentially ineffective. Definitely not for everybody. ...
Why isn't it for many more than get it?

Anticoagulation is itself risky, and not just for active people. My sedentary father-in-law slipped backwards in his chair and died from a brain bleed which I doubt would have happened if he wasn't on anticoagulation. The device seems comparable for stroke reduction and lowers overall morbidity and mortality, and I am led to believe even cost over a fairly reasonable time frame (the high cost of stroke and bleeding complications care).

Am I wrong in my belief that it is likely underutilized with many reasonable candidates for it not being offered it? (Honest question to which I would not be surprised by an answer that yes I am wrong.)
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Old 10-01-2019, 09:37 PM
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Am I wrong in my belief that it is likely underutilized with many reasonable candidates for it not being offered it?
Looking at what I think was the seminal study, I am not confident the results are generalizable to many candidates.

Most subjects (85%) in the trial were not in permanent atrial fib and also had relatively low risk scores. And, critically, the majority of patients enrolled had normal LV function. Again, patient populations vary, but this doesn't sound like most atrial fib patients I see.

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Old 10-02-2019, 08:44 PM
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Sorry, it's fellowship interview season and then I was off site, but I'll get back to you about the use of OAC after ablation.
As far as Watchman, any invasive procedure is going to carry some risks, and in the case of the Watchman, they poke a hole through the wall dividing the atria to get to it. There's a risk of bleeding into the pericardial space as well as the risk that the device does not completely endothelialize or completely occlude the left atrial appendage leading to further thrombosis risk. It may be something like the TAVR/TAVI procedure which is now as good as if not better than a surgical aortic valve replacement, but that took many years and clinical trials and started in the highest of surgical risk patients before it got to that point earlier this year. It's implanting an irretrievable device into the heart so there's a lot of hurdles it has to clear before it could be considered a viable alternative to the much better studied oral anticoagulant therapies.
  #43  
Old 10-04-2019, 12:03 AM
audiobottle is offline
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So the guidelines AHA 2012, HRS 2012 recommend continuing anticoag post-ablation per risk score because of the risk for asymptomatic recurrence. CABANA 2019 was a RCT which looked at ablation vs chemical antiarrhythmics and showed no difference in stroke risk. There were some big problems with the study, primarily due to the hefty crossover, but it's the most recent big study that dealt with the topic.
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