Why do these studies rely on how the patient feels instead of objective measures of cardiac output or exercise intolerance? My brother has significant exercise intolerance after a lifetime of athletic activity. He is 80 years old and has failed ablation.
you wrote: "But sometimes sinus rhythm does not make them better. In these patients, it makes little sense to proceed with further procedures like ablation." I would caution on reaching such a broad conclusion from relatively brief comparisons. I went into AFIB during the night and would not have known I was in afib the next morning if it weren't for my Apple watch, so your approach would suggest no ablation for me. However, I can tell you that my ability to exercise is enormously improved post ablation compared to when in afib, and that brings a lot of value to my life. Also, my reduced risk of stroke (and hence need for Eliquis) post ablation adds further value.
I am one who immediately was aware of my AF when it happened. I also could feel my PACs. I did not have a fast rate. My main symptom was anxiety, perhaps because I knew what risk AF was causing for stroke. It never lasted long enough for cardioversion and the usual drugs didn't prevent it from coming back. I was always amazed when I went to the ER to see a new stroke patient with AF and they told me they had never felt their heart acting up. I think many people don't have the right sensory nerve connections with the heart to feel arrhythmias. I was ablated 7 years ago and have had no further episodes of AF, fortunately.
I've had two cardioversions, the last one added a potassium drip for a couple of hours. No symptoms now for almost ten months, though my electro-physiologist suggested ablation. Because I've had two angiograms through the femoral artery, I asked what's the alternative? He gave me diltiazem to reduce my heart rate should another occurrence happen. Have not taken a single pill. Which reminds me of my mother-in-law who, at age 80, was diagnosed with afib, She's now 98. Her doc, however, urged a Watchman a few years ago. My wife and her siblings vetoed that idea. She's fine, though moves slowly.
Having trained before easy access to ablation we knew that most a fibbers couldn’t tell and didn’t care. And studies then showed that those we did ablate weren’t symptomatically better but spent more time in hospital and spent more money. There were a few who were exquisitely sensitive and symptomatic to a fib and you didn’t have a choice with them. I can count them on one hand, and I’ve seen a lot of a fib.
I think that today’s rush to ablation is driven by device manufacturers and $$$ for institutions and proceeduralists. To me there are only a few strong indications for ablation: the significantly symptomatic, those whose rate we can’t control and were we to achieve being able to cease continuing full anticoagulation that would be a good indication. The great majority of a fibbers are asymptomatic and they are too sedentary to notice 15 more seconds on a treadmill.
John Mandrola at his best! I greatly appreciate his attitude towards a phenomenon still not fully understood.
The discovery that the heart has a "little brain" that manages the organ's responses to external stimuli is relatively recent. I believe we have to include this in our understanding of atrial fibrillation.
Additional note: Lobotomy, also known as prefrontal leucotomy, was an archaic psychiatric surgical procedure that consisted of cutting the nerve connections between the frontal lobes and the rest of the brain. Created in the 1930s, the technique aimed to treat severe cases of schizophrenia, deep depression, and anxiety.
It eliminated the symptoms. Is ablation a new lobotomy?
I was under the assumption that ablation gets rid of irregular rhythm? Fortunately, I am very sensitive to my symptoms. But there are times when I cannot differentiate PACs versus AFib
Propofol alone can make people feel better so that’s another variable.
But the question “do you feel better after conversion” implies it’s binary. After hours of tachycardia, the patient may be relieved and better but still exhausted.
I know immediately when i go into AF because it dramatically jumps to over 170. I also know exactly when i convert to SR unless I’m asleep but i also feel like I’ve been dragged behind a truck for 20 miles.
I agree that assessing symptoms in and out of AF is important and can be very difficult and subjective. For a small percent it is overtly obvious, but even in those their “symptoms” even if dramatic can decrease over years.
I am a firm believer that objective peak exercise tolerance is better in NSR than in AF. All other things being equal.
A study with a simple ETT or better yet a CardioPulmonary Stress test; in AF and then again a few weeks after restoring NSR would be very enlightening.
One of the worst things we can do as clinical cardiologists is unnecessarily limit (directly or indirectly) patients functional exercise ability and activity level.
I give the sedation for these, and this study makes me think about how badly timed our usual symptom question is. The five minutes are propofol, and what someone says in the twenty minutes afterward is not clean data - they are relieved, a little euphoric, and often genuinely surprised it is already over. I have had patients tell me they feel wonderful before I have finished taking the monitors off. Three-times-daily recordings over weeks are a far better instrument than the question we ask at the bedside, and the third of patients who got worse is the finding I would not have predicted. The wider version of this is most of my job: what a patient reports and what my monitor shows are two separate measurements, and the trouble starts when someone treats them as one.
Why do these studies rely on how the patient feels instead of objective measures of cardiac output or exercise intolerance? My brother has significant exercise intolerance after a lifetime of athletic activity. He is 80 years old and has failed ablation.
Could it be that the symptoms in some patients that converted and were in sinus rythm were due to atrial stunning?
you wrote: "But sometimes sinus rhythm does not make them better. In these patients, it makes little sense to proceed with further procedures like ablation." I would caution on reaching such a broad conclusion from relatively brief comparisons. I went into AFIB during the night and would not have known I was in afib the next morning if it weren't for my Apple watch, so your approach would suggest no ablation for me. However, I can tell you that my ability to exercise is enormously improved post ablation compared to when in afib, and that brings a lot of value to my life. Also, my reduced risk of stroke (and hence need for Eliquis) post ablation adds further value.
Good observational info.
After CDV, only some will remain in NSR. And only some among those will feel better. That should be the group to target for rhythm control.
The unknown is how hard to look for intermittent AF (with wearables) in the subset that has apparently “remained in NSR”.
I am one who immediately was aware of my AF when it happened. I also could feel my PACs. I did not have a fast rate. My main symptom was anxiety, perhaps because I knew what risk AF was causing for stroke. It never lasted long enough for cardioversion and the usual drugs didn't prevent it from coming back. I was always amazed when I went to the ER to see a new stroke patient with AF and they told me they had never felt their heart acting up. I think many people don't have the right sensory nerve connections with the heart to feel arrhythmias. I was ablated 7 years ago and have had no further episodes of AF, fortunately.
I've had two cardioversions, the last one added a potassium drip for a couple of hours. No symptoms now for almost ten months, though my electro-physiologist suggested ablation. Because I've had two angiograms through the femoral artery, I asked what's the alternative? He gave me diltiazem to reduce my heart rate should another occurrence happen. Have not taken a single pill. Which reminds me of my mother-in-law who, at age 80, was diagnosed with afib, She's now 98. Her doc, however, urged a Watchman a few years ago. My wife and her siblings vetoed that idea. She's fine, though moves slowly.
Having trained before easy access to ablation we knew that most a fibbers couldn’t tell and didn’t care. And studies then showed that those we did ablate weren’t symptomatically better but spent more time in hospital and spent more money. There were a few who were exquisitely sensitive and symptomatic to a fib and you didn’t have a choice with them. I can count them on one hand, and I’ve seen a lot of a fib.
I think that today’s rush to ablation is driven by device manufacturers and $$$ for institutions and proceeduralists. To me there are only a few strong indications for ablation: the significantly symptomatic, those whose rate we can’t control and were we to achieve being able to cease continuing full anticoagulation that would be a good indication. The great majority of a fibbers are asymptomatic and they are too sedentary to notice 15 more seconds on a treadmill.
Have anyone measured the potassium level in piasma during AF and between AF?
Low K+ is an inducer of AF, well known side effect of diuretics
John Mandrola at his best! I greatly appreciate his attitude towards a phenomenon still not fully understood.
The discovery that the heart has a "little brain" that manages the organ's responses to external stimuli is relatively recent. I believe we have to include this in our understanding of atrial fibrillation.
Additional note: Lobotomy, also known as prefrontal leucotomy, was an archaic psychiatric surgical procedure that consisted of cutting the nerve connections between the frontal lobes and the rest of the brain. Created in the 1930s, the technique aimed to treat severe cases of schizophrenia, deep depression, and anxiety.
It eliminated the symptoms. Is ablation a new lobotomy?
Should we be treating for symptoms or stroke mitigation?
Especially with intermittent afib!
I was under the assumption that ablation gets rid of irregular rhythm? Fortunately, I am very sensitive to my symptoms. But there are times when I cannot differentiate PACs versus AFib
Propofol alone can make people feel better so that’s another variable.
But the question “do you feel better after conversion” implies it’s binary. After hours of tachycardia, the patient may be relieved and better but still exhausted.
I know immediately when i go into AF because it dramatically jumps to over 170. I also know exactly when i convert to SR unless I’m asleep but i also feel like I’ve been dragged behind a truck for 20 miles.
I agree that assessing symptoms in and out of AF is important and can be very difficult and subjective. For a small percent it is overtly obvious, but even in those their “symptoms” even if dramatic can decrease over years.
I am a firm believer that objective peak exercise tolerance is better in NSR than in AF. All other things being equal.
A study with a simple ETT or better yet a CardioPulmonary Stress test; in AF and then again a few weeks after restoring NSR would be very enlightening.
One of the worst things we can do as clinical cardiologists is unnecessarily limit (directly or indirectly) patients functional exercise ability and activity level.
It decreases quality of life and longevity.
But if exercise seems to be the trigger for Afib how can you not limit their activity?
I give the sedation for these, and this study makes me think about how badly timed our usual symptom question is. The five minutes are propofol, and what someone says in the twenty minutes afterward is not clean data - they are relieved, a little euphoric, and often genuinely surprised it is already over. I have had patients tell me they feel wonderful before I have finished taking the monitors off. Three-times-daily recordings over weeks are a far better instrument than the question we ask at the bedside, and the third of patients who got worse is the finding I would not have predicted. The wider version of this is most of my job: what a patient reports and what my monitor shows are two separate measurements, and the trouble starts when someone treats them as one.