Managing Atrial Fibrillation

Managing Atrial Fibrillation

Posted on September 11, 2014 by ECR Louisville in Blog, Caregiver Education

The editorial team at Everyday Health, a sister company to MedPage Today, produced an Afib Assessment Quiz, which asks patients to indicate how well they are managing their atrial fibrillation. The completion rate was 81%. We asked Philip Green, MD, Assistant in Clinical Medicine, Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, to respond to some of these findings.

Insight #9

Almost one third of patients who took the Fact versus Myth quiz on atrial fibrillation (AF) agreed with the statement “Atrial fibrillation is common but not dangerous.”

We asked Dr. Green:

Are you surprised, or is this attitude common among patients with AF? When talking to patients with AF, how do you describe the risks associated with the condition? Do you adjust your remarks based on the patient’s age, the presence of comorbid conditions, or other factors?

Dr. Green’s Response:

The experience of being diagnosed and living with atrial fibrillation varies dramatically from patient to patient. In some, the first symptom of atrial fibrillation is stroke, the most dreaded complication. In others however, atrial fibrillation is diagnosed on a routine electrocardiogram, and never causes symptoms or problems. I am therefore not surprised that many patients see atrial fibrillation as a benign condition. Of course, the thromboembolic risks of atrial fibrillation are well described, and I discuss the presence of this risk to all patients with atrial fibrillation. My explanation of thromboembolic risk hinges on the CHADS-VASC score, which estimates the risk of a thromboembolic event based on the presence of congestive heart failure, hypertension, age, diabetes, prior stroke, vascular disease, and gender. For those with CHADS-VASC scores that merit anticoagulation (usually 1 or above), I discuss the risk of stroke in atrial fibrillation in the context of my recommendation to initiate anticoagulation. In contrast, when a patient has lone atrial fibrillation, I usually don’t recommend anticoagulation. I explain that while a comparison of stroke risk and serious bleeding risk favors deferring anticoagulation, a small risk of stroke still exists. In those patients, I emphasize the need to prevent the development of diabetes and cardiovascular disease to keep the stroke risk low.




Insight #8

We asked Everyday Health users with atrial fibrillation to describe their physical activity levels, and nearly 60% said that they don’t make an effort to exercise other than just doing chores and engaging in hobbies.

We Asked Dr. Green:

In your experience, is this typical? Should people with AF be getting regular aerobic activity? Do you think that some patients with AF are afraid of exercise? Should they be? Do elite athletes with AF face special hazards?

Dr. Green’s Response: Despite the known health benefit of exercise, up to a quarter of Americans report doing no physical activity outside of work. This percentage is considerably higher among those with atrial fibrillation who responded to our survey. Unfortunately, this is not atypical as cardiovascular disease is more common in those who are sedentary and the diagnosis of cardiovascular disease causes many to avoid strenuous physical activity. As physicians we need to do what we can to reverse this trend. Regular exercise should be encouraged in patients with cardiovascular disease, and rate control medications should be optimized to allow for meaningful workouts without fear of tachycardia. On the other end of the spectrum, endurance trainers and marathon runners may suffer from atrial fibrillation more frequently than the general population. While the underlying mechanism is poorly understood, the relationship between atrial fibrillation and high levels of physical exercise should not serve as a deterrent for those with atrial fibrillation to reverse their sedentary lifestyles.

Insight #7

We asked Everyday Health users with atrial fibrillation to describe their weight and weight goals, and less than half (43%) said they were maintaining a healthy body weight.

We Asked Dr. Green:

Are most of your AF patients overweight, as well? What do you tell patients about body weight and AF? Do you strongly encourage them to lose weight? Why or why not?

Dr. Green’s Response: Many of my patients with AF are overweight or obese, so I face the challenge of managing patients with both conditions quite often. In fact, because of emerging evidence, my perspective on the relationship between the 2 conditions has changed. In the past, I advised patients with AF to lose weight as part of an overall healthy lifestyle. I assumed the cardiovascular benefits of weight loss would translate into improved heart health, which may have an impact on AF. Recently we have learned that compared to lifestyle advice, an intensive weight loss program translates into less AF, fewer symptoms from AF, and perhaps structural changes in the heart that lower the predisposition to AF.1 This new evidence needs to be confirmed in larger trials, but should serve as additional motivation for obese patients with AF to lose weight.

1. Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA. 2013;310:2050-2060.

Insight #6

In our survey, nearly half of patients with diagnosed atrial fibrillation (AF) reported drinking caffeinated beverages during the day and that this causes their heart rate to increase.

We Asked Dr. Green:

Is this dangerous? What do you tell patients about drinking caffeinated beverages? Is it a blanket recommendation, or do you tailor your advice according to their response to caffeine? In other words, is caffeine bad for everyone with AF?

What do you tell AF patients about alcohol consumption?

Dr. Green’s Response: Among those with paroxysmal AF, caffeine and alcohol should be avoided if they’re known or suspected to be triggers for AF episodes. In general, small amounts of caffeine and alcohol are well tolerated, but can be detrimental in larger quantities. There’s no specific recommendation regarding caffeine intake, as intake should be tailored to each patient’s sensitivity and response to caffeine.

Alcohol in small amounts is often safe, but in larger amounts can be cardiotoxic by triggering arrhythmia, directly damaging heart muscle, and by raising blood pressure. Therefore, because those with AF also have other cardiac comorbidities, alcohol consumption should be limited to small amounts to avoid the possible deleterious cardiac effects.

Insight #5

In our survey of patients with atrial fibrillation (AF), 59% reported that they sometimes feel as if their hearts are “pounding,” “beating very fast,” “fluttering,” or “skipping.”

We Asked Dr. Green:

How do you handle symptom reports in patients with AF?

Dr. Green’s Response:

Symptoms are an important aspect of AF. Any amount of symptomatic AF affects quality of life. Therefore, in certain patients, symptom management is the justification for a rhythm-control strategy. Some, albeit a minority of patients, with paroxysmal atrial fibrillation can reliably feel their AF and therefore may be candidates for a “pill in the pocket” approach to self-managed chemical cardioversion. In many patients, however, symptoms of “pounding,” “beating very fast,” “fluttering,” or “skipping” don’t correlate with the burden of AF and therefore don’t translate into an increased risk of thromboembolic events. In fact, many patients without documented AF report similar symptoms. Furthermore, many patients with persistent or paroxysmal AF don’t feel their AF at all.

To summarize, it’s essential to minimize bothersome symptoms caused by atrial fibrillation. But in most cases, symptom reports due to AF don’t lead to a reclassification of risk or to modification of an earlier decision about anticoagulation for stroke prevention.

Insight #4

Nearly 50% of respondents said they either don’t pay attention to what they eat or “often give into temptation.”


We Asked Dr. Green:

What do you tell patients who have an elevated stroke risk because of atrial fibrillation about nutrition?

Dr. Green’s Response:

Eating well is an essential component of a heart-healthy lifestyle. Many people, even those with the best of intentions, don’t always make healthy eating a focus, or they may give in to temptation. The first component of making positive food choices is learning the nutritional value of the food we eat. I remind patients to read the labels and to look especially at the sodium and sugar content. This can help them appreciate the difference between, say, fresh fruits and vegetables and those that are canned or processed. A second piece of advice is to substitute healthy foods for those that are less nutritious—for example, switching out refined grains for whole grains, or selecting fish and chicken instead of other meats. The third thing I tell them is to avoid eating when they’re not hungry. That may seem obvious, but many people binge, usually in response to emotional triggers, or eat excessively at night. By minimizing those behaviors, they can limit their excess calories.

Insight #3

Only 30% of patients who responded to the survey said that their body weight was “healthy.” The remaining 70% indicated that they were slightly overweight, overweight, or obese.

We Asked Dr. Green:

How important is body weight in atrial fibrillation (AF) and stroke risk reduction? Where does body weight reduction rank on your list of issues that you pursue with patients, along with blood pressure control and others?

Dr. Green’s Response:

As a population we struggle to maintain healthy weights, and as healthcare providers we are constantly called on to combat the effects of obesity. While not officially part of the CHADS2 risk score that we traditionally use to calculate stroke risk in patients with AF, obesity is associated with components of CHADS2, including congestive heart failure, hypertension, advanced age, diabetes, and prior stoke. Specifically, obesity is closely linked to diabetes and hypertension.

Therefore, in my AF patients who are overweight or obese, weight reduction is key. Weight loss may prevent the development of, or reverse, hypertension and/or diabetes. It may also lower stroke risk for these high-risk patients. Certainly, the positive health effects of a weight loss program that includes a healthy diet and regular exercise cannot be emphasized enough for our patients with AF.

Insight #2

We found that more than 70% of these afib patients did not exercise at all, or exercised just 1 or 2 days a week.

We Asked Dr. Green:

How do you motivate your patients with afib to get a reasonable amount of healthy exercise?

Dr. Green’s Response:

Sedentary lifestyle is highly prevalent in our society and affects those with and without chronic diseases. In addition to emphasizing the general health benefits of activity, I try to motivate my patients with atrial fibrillation to exercise by directly linking physical activity to their atrial fibrillation management plan. This is true for my rhythm control and rate control patients. I emphasize to them that an optimal medical regimen for atrial fibrillation is effective during exertion. A rate control strategy should allow for reasonable heart rate increases in response to exercise, and rhythm control should maintain sinus rhythm at peak exertion. The patients then need to demonstrate the effectiveness of our treatment plan during exercise.

Insight #1:

We found that the respondents, all of whom have atrial fibrillation, are evenly split between those younger than 60 and those between 60 and 70 years of age.

We Asked Dr. Green:

Does a patient’s age per se influence your approach to atrial fibrillation treatment or stroke risk reduction? If yes, how does age affect treatment?

Dr. Green’s Response:

Age is probably the first and most important factor I consider when deciding on an approach to stroke prevention in atrial fibrillation. Aging and cardiovascular disease are closely linked epidemiologically and pathophysiologically. Aging is associated with vascular calcification, cardiac chamber stiffening and enlargement, and increased risk of thrombosis. Consequently, advanced age is an important risk factor for thromboembolic stroke in patients with atrial fibrillation.

Therefore, in elderly patients with atrial fibrillation, even in the absence of other stroke risk factors, I favor anticoagulation for stroke prevention. In younger patients with no other stroke risk factors, I tend not to use anticoagulant therapy. From my perspective, there is no ‘lone’ atrial fibrillation in the elderly and, as such, older adults with atrial fibrillation should receive anticoagulant therapy to prevent stroke.

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 Medpage Today
Published: 08/26/2013