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Complete Transcript from the February 21, 2011 Live Online Q&A
Session on"Atrial Fibrillation"
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| 11:54 |
LG Health Admin:
Hello, and welcome to our live online Q&A session on “Atrial Fibrillation” with Dr. Douglas Gohn. The session will begin at noon. If you have a question that you would like Dr. Gohn to answer, please feel free to send it to him now. He will be answering the questions in the order in which they are received. |
| 12:02 |
LG Health Admin:
Thank you for joining us this afternoon for a live online Q&A session on “Atrial Fibrillation” with Douglas Gohn, MD. |
| 12:02 |
LG Health Admin:
Dr. Gohn is an eminent cardiologist and researcher with extensive expertise in pacemaker and defibrillator procedures, as well as ablation procedures. Board certified in internal medicine, cardiovascular disease and cardiac electrophysiology, he has served as director of electrophysiology at Lancaster General Hospital and has given presentations on pacemaker, electrocardiogram and radiofrequency catheter ablation topics. He has been the lead author or co-author of more than 20 manuscripts and abstracts published in medical journals and a clinical research investigator at The Lancaster Heart & Stroke Foundation. |
| 12:03 |
[Comment From Kevin: ]
What are good guidelines for heart rate during exercise? |
| 12:04 |
Dr. Douglas Gohn:
A general guideline is that heart rate should not exceed 80% of maximum predicted heart rate. The maximum predicted heart rate can be calculated by taking 220 minus your age. |
| 12:05 |
[Comment From Carolyn: ]
How does a doctor know when AFib needs to be treated? |
| 12:05 |
Dr. Douglas Gohn:
The need for treatment of AF is based on a variety of factors. Two treatment strategies exist. The first strategy is “rate control.” This approach is utilized when a person has minimal symptoms related to the AF. Drug therapy is directed at controlling the rates of the AF(and allowing the AF to persist) and maintaining anticoagulants. |
| 12:05 |
Dr. Douglas Gohn:
The alternative strategy is that of “rhythm control.” This approach involves therapies directed at maintaining normal rhythm with either drugs or ablation. This approach is best for patients who have symptoms associated with their AF. All AF should be evaluated and treated. The intensity of that treatment is variable. |
| 12:07 |
[Comment From Ursula: ]
How long does a patient have to take Coumadin after they have had atrial fibrillation? |
| 12:07 |
Dr. Douglas Gohn:
The need for anticoagulants in AF is dependent on the circumstances. If the AF episode occurred as the consequence of a significant precipitating event (for example, a severe pneumonia), the treatment with anticoagulants may be short-lived (weeks to months). |
| 12:08 |
Dr. Douglas Gohn:
However, if the AF is a primary problem, the need for anticoagulants is determined by a variety of risk factors. Previous stroke, age greater then 75, hypertension, heart failure and diabetes are things that are associated with an increase risk of stroke with AF. If a patient has any of these risk factors, they may be best served with long-term therapy with anticoagulants such as Coumadin. |
| 12:09 |
LG Health Admin:
Do you experience heart flutters on a regular basis?
Yes ( 62% )
No ( 38% ) |
| 12:09 |
[Comment From Mary: ]
Is Asprin 325 mg a good replacement for coumadin? |
| 12:09 |
Dr. Douglas Gohn:
Aspirin can be utilized to reduce the risk of stroke in patients with afib in a very selected group of patients.
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| 12:10 |
Dr. Douglas Gohn:
These patients generally are young, have no history of hypertension, diabetes, or heart failure, and have not had previous stroke. |
| 12:13 |
[Comment From Kevin: ]
Any tips for tall endurance athletes? |
| 12:13 |
Dr. Douglas Gohn:
Endurance training with a training volume of 10-15 hours per week has been associated with increased incidence of atrial fibrillation. There are no specific recommendations for taller endurance athletes. |
| 12:14 |
[Comment From Anita: ]
I’ve been taking Metoprolol for Atrial fibrillation for about three years, and I continue to have many instances of “break through”, which are brought on by a moment of anxiety... |
| 12:14 |
[Comment From Anita: ]
Should I expect this is how it will continue to be, or should I be searching for more answers… ie, a higher dosage, or finding the root cause, or treating the anxiety that seems to bring on the episodes? It even causes me to be leery of exercising, as I am afraid of bringing on an episode. Should I be concerned about this… or should I just accept that these episodes are occurring? Are they causing any harm or not? |
| 12:14 |
Dr. Douglas Gohn:
Metoprolol is a drug that is designed to control the rates of afib and rarely has much effect on the recurrence of afib. If you having frequent episodes, I would suggest you seek evaluation that would include an echocardiogram, appropriate blood studies, and possibly a stress test.
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| 12:15 |
Dr. Douglas Gohn:
There are other drugs that are more effective at controlling atrial fibrillation. These episodes more than likely are not causing you harm, however, they may predispose you to an increased risk of stroke. |
| 12:15 |
LG Health Admin:
Have you been treated for atrial fibrillation?
Yes ( 73% )
No ( 27% ) |
| 12:16 |
[Comment From Tom: ]
Dr. Gohn, I have read that Tikosyn should not be a long term medication. Will you please comment? |
| 12:17 |
Dr. Douglas Gohn:
Tikosyn is difficult to use for a variety of reasons. The drug requires a 72-hour hospital stay to start the drug. A small percentage of patients are adversely affected by the drug initially and require dose reduction or discontinuation of the drug in the first several days. After the initial period, the difficulty persists because of frequent drug interactions. |
| 12:17 |
Dr. Douglas Gohn:
I think Tikosyn is an adequate long-term medicine for selected patients who get past the initial “challenge” and do not require a significant number of other medicines. |
| 12:18 |
[Comment From Kevin: ]
Is it possible that past intense exercise prior to diagnosis damaged the heart (heart rate over 200)? |
| 12:18 |
Dr. Douglas Gohn:
The cause of the association between endurance training and atrial fibrillation has not been clarified. |
| 12:18 |
Dr. Douglas Gohn:
This may potentially be related to changes in the autonomic nervous system, or simply related to changes in the heart associated with the need for increased cardiac output that occur with this type of training. There is no data to suggest that is related to heart damage. |
| 12:20 |
[Comment From Sue: ]
Before you get to treatment strategies, can you discuss diagnosis factors, as Carolyn asked? |
| 12:20 |
Dr. Douglas Gohn:
The evaluation of atrial fibrillation should include an echocardiogram, which is used to assess heart muscle function, the status of the heart valves, as well as the size of the left atrium. A 24-hour heart monitor, may be utilized to assess heart rates during afib, as well as normal rhythm. Thyroid blood tests should be checked and occasionally a stress test is appropriate. |
| 12:21 |
Dr. Douglas Gohn:
Often times this initial evaluation will yield a likely association with heart disease that may be causing afib.
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| 12:22 |
[Comment From Guest: ]
I was diagnosed w/ AF several years ago, was on med for a while but it lowered my pulse rate. Eventually (after follow up visits I was taken off meds. Recently, I have had several episodes of what feels like "missed" beats. Should I go back to DR? |
| 12:22 |
Dr. Douglas Gohn:
Repeat evaluation is appropriate. Afib rarely goes away on its own, and the “missed” beats may be a sign that you are developing recurring atrial fibrillation. |
| 12:23 |
[Comment From Tony: ]
I have had heart flutters for years, but last year I had 2 that lasted for hours then back to short ones, off and on. Now I have high blood pressure (220/118) I have no insurance. What can I do to try to help this? My HDL is 83, LDL is 45. I’ve lost weight but it’s so high I am getting scared. Thanks! |
| 12:24 |
Dr. Douglas Gohn:
The first step is to get your blood pressure treated and find out what type of rhythm is responsible for your flutters. Your family doctor should be able to provide you with a low cost drug for BP and a monitor to record the heart rhythm when you feel symptoms. |
| 12:25 |
[Comment From Kevin: ]
Can you comment on Pradaxa? |
| 12:25 |
Dr. Douglas Gohn:
Pradaxa is a new anti-coagulant (blood thinner) that has just been released in November. |
| 12:25 |
Dr. Douglas Gohn:
It is as effective as Coumadin for the reduction of stroke in atrial fibrillation. We participate in a clinical trial of this drug for three years prior to its release and had good anecdotal results. |
| 12:25 |
Dr. Douglas Gohn:
It does not require monitoring of blood work like Coumadin. |
| 12:26 |
[Comment From Joe: ]
I am on beta-pace. What determines how long I will be taking the medication? |
| 12:27 |
Dr. Douglas Gohn:
Drugs like Betapace are drugs that typically are used for long-term suppression of atrial fibrillation. Unless you had a obvious precipitating cause for atrial fibrillation that was reversible, I suspect you will be on this drug long-term. |
| 12:28 |
[Comment From Carolyn: ]
I am on 81mg of aspirin and 150mg of Pradaxa 2 times daily. How do I know if my blood if too thin? |
| 12:28 |
Dr. Douglas Gohn:
There is no good way to monitor “how thin” your blood is with Pradaxa. The combination of Pradaxa and low dose aspirin is considered safe. If bleeding should occur then aspirin should be discontinued. |
| 12:28 |
LG Health Admin:
Are heart palpatations having an impact on your daily life?
Yes ( 39% )
No ( 33% )
They did before I was treated ( 0% )
Not sure ( 28% ) |
| 12:29 |
[Comment From John: ]
When taking Coumadin and you have a high I&R around 3.5, what affect can that have on they way you feel ? |
| 12:30 |
Dr. Douglas Gohn:
An INR of 3.5 should not effect the way you feel, but may predispose you to increased risk of bleeding. |
| 12:30 |
[Comment From Shirley: ]
I was diagnosed w/ AF after tilt table test many years ago (8?). Treated w/ med that made my heart rate go too low. Eventually taken off meds. No problem until a couple of weeks ago, and now seem to have "missed" beats. |
| 12:31 |
Dr. Douglas Gohn:
It sounds like you need to return to your physician for repeat evaluation to determine what is causing your “missed” beats. |
| 12:32 |
[Comment From Gene: ]
If you have had only one instance of A-Fib what is the chance that you will experience another and...how long should you stay on an anticoagulant like Pradaxa after the episode? |
| 12:33 |
Dr. Gohn, MDO:
The likelihood of experiencing another episode of AF is dependent on a variety of factors. The presence of hypertension, heart failure or valvular heart disease makes it very likely that another episode may occur. This likelihood also increases with age, with the incidence of AF increasing significantly over 70. |
| 12:34 |
Dr. Gohn, MDO:
Obesity and sleep apnea are two other factors that may predispose to recurrent events. The decision to maintain drugs like Pradaxa are based primarily on the risk factors associated with stroke. If someone has had a previous stroke, hypertension, diabetes, heart failure or is over 75, long term therapy may be appropriate. |
| 12:35 |
[Comment From Paul: ]
The FDA recently removed Darvon from distribution which I was taking long-term to control headaches. I was diagnosed with A-Fib about 8 years ago. Could that have been a significant contributor to A-Fib? |
| 12:35 |
Dr. Douglas Gohn:
The likelihood that Darvon was a precipitating cause of your afib is low. If the incidence of your afib decreases coming off the drug, this would suggest that you may be one of the unanticipated patients who have this association. |
| 12:37 |
[Comment From Dennis: ]
Is there a limit of cardio intensive exercise one should engage in after atrial ablation? |
| 12:38 |
Dr. Douglas Gohn:
The goal of the ablation is to cure or limit the AF so a normal lifestyle can be enjoyed. After the first few weeks to months post ablation normal activity can be resumed. |
| 12:39 |
[Comment From Audrey: ]
Dr. Gohn. What do you know about the new drug that is available that does not requre the 4-5 week blood tests which is required when taking warafin/coumadin? |
| 12:39 |
Dr. Douglas Gohn:
The latest anti-coagulant (blood thinner) is Pradaxa. This drug is as effective as Coumadin at reducing the risk of stroke in atrial fibrillation. It does not require routine blood testing. |
| 12:40 |
Dr. Douglas Gohn:
It is a twice-a-day drug that is generally well tolerated. It was just released in November and we have been utilizing the drug frequently. |
| 12:40 |
[Comment From Earl: ]
I have a pacemaker and expierenceing skipped heart beats. What should be done? |
| 12:40 |
Dr. Douglas Gohn:
Pacemaker is a great tool to track down the nature of these skipped beats. The pacemaker can be interrogated and important information about the etiology of your symptoms can be found. |
| 12:41 |
Dr. Douglas Gohn:
Once the cause of your symptoms is known drug therapy, or changes in your pacemaker program, may help your situation. |
| 12:42 |
[Comment From Ed: ]
What is the best treatment for A-fib for a person with multiple myeloma? |
| 12:43 |
Dr. Douglas Gohn:
This is dependant upon the stage of your multiple myeloma, and the complications of the myeloma. In situations like this often we’ll not perform ablative therapy because of concerns of complications with the myeloma. |
| 12:44 |
[Comment From Chris: ]
I'm currently on a 30 day monitor where I "call in" each day. Can you tell me what this type of test shows? |
| 12:44 |
Dr. Douglas Gohn:
This type of monitor typically will collect information on any abnormal heart rhythms, either fast or slow, and also allows you to record your heart rhythm when you are having symptoms. This information is then used to guide therapy for your abnormal rhythm. |
| 12:46 |
[Comment From Guest: ]
Are frequent PVC's/PAC's a precursor to Afib? I have been told to ignore them as they are benign (EKG, echo neg) |
| 12:46 |
Dr. Douglas Gohn:
PAC’s can be a precursor to atrial fibrillation, however, there is no data to suggest that suppressing these reduces the risk of developing afib. PVC’s are generally not thought to be associated with afib. It sounds like careful monitoring is appropriate at this point. |
| 12:47 |
[Comment From Tina: ]
When should I be concerned about palpitations . I have a new right bundle branch block. |
| 12:48 |
Dr. Douglas Gohn:
The presence of a new right bundle branch block suggests that further evaluation is appropriate. This would include an echocardiogram, as well as some form of monitor to determine the etiology of your palpitations. |
| 12:49 |
[Comment From Nancy: ]
What is the difference between the skipped beats felt with MVP, and the missed beats connected with A-Fib? Thanks. |
| 12:49 |
Dr. Douglas Gohn:
Afib is a very specific abnormal rhythm that may occur in the presence of MVP. However, often times patients with MVP will have single extra beats that are not atrial fibrillation and are benign. A heart monitor should be used to sort this out. |
| 12:50 |
[Comment From Guest: ]
What is ablation? |
| 12:51 |
Dr. Douglas Gohn:
Catheter ablation is a procedure where one or more flexible, thin tubes (catheters) are guided via x-ray into the blood vessels and directed to the heart muscle. A burst of radiofrequency energy destroys very small areas of tissue that give rise to abnormal electrical signals that cause heart rate and rhythm issues. |
| 12:51 |
Dr. Douglas Gohn:
This procedure is done in an EP Lab by an electrophysiologist who is a cardiologist who has experience in treating electrical conduction system issues in the heart. |
| 12:51 |
LG Health Admin:
There are still about 10 minutes remaining in this session Before you leave today's Q&A session, please take a moment to let us know what you thought of it by answering a few questions on our brief Q&A survey. We appreciate your help...thanks! http://bit.ly/Survey_QA |
| 12:52 |
[Comment From John: ]
What do you know about a drug called Multac / ( not sure of the spelling) |
| 12:52 |
Dr. Douglas Gohn:
Multaq is a relatively new drug that is utilized to suppress atrial fibrillation. The drug is not given to patients with heart failure. It seems the drug is relatively well tolerated by our patients. Multaq is not any more effective then the other drugs available and can be started as an outpatient. |
| 12:54 |
[Comment From Shirley: ]
I have an under active thyroid, take levothyroxin, and had a blood test (6 weeks ago; confirmed that it was in appropriate range) but continue to have extremely dry skin, "slow thinking", lethargy, etc. Am wondering if I should have it rechecked, and whether there could be a connection of that to fluttering that I have begun to re-experience. Assume that should be ruled out before going back to heart dr to check on recurrence of AF? |
| 12:54 |
Dr. Douglas Gohn:
Your thyroid should be normalized before approaching any treatment of your atrial fibrillation. Your symptoms sound like you may still be low in thyroid hormone, however, the blood tests should be used to guide therapy. |
| 12:56 |
[Comment From John: ]
Can you comment on diet and exercise as it relates to Afib? |
| 12:56 |
Dr. Douglas Gohn:
Obesity has been associated with increased incidence of atrial fibrillation, subsequently maintaining a normal weight is important. |
| 12:57 |
Dr. Douglas Gohn:
Factors in diet may trigger episodes of afib. These would include caffeine, alcohol, or other stimulants. |
| 12:57 |
Dr. Douglas Gohn:
Exercise is important in helping maintain normal body weight and may be helpful. |
| 12:57 |
Dr. Douglas Gohn:
There are no specific dietary therapies that will cure afib. |
| 12:59 |
[Comment From Marilyn: ]
When is the optimum time to have an ablation? When a fib episodes are very infrequent (every 6 months) or when they have become very frequent to constant? |
| 12:59 |
Dr. Douglas Gohn:
If atrial fibrillation becomes persistent, the likelihood of success of ablation is reduced. My personal bias is to pursue ablative therapy early in patients who are young and have no other significant cardiac history. |
| 12:59 |
Dr. Douglas Gohn:
It was great being here with you today. Please take a moment to fill out the Atrial Fib online survey to give us feedback so we can provide better quality educational sessions. http://bit.ly/Survey_QA |
| 1:00 |
Dr. Douglas Gohn:
Thank you for your extremely thoughtful questions. I apologize if I was unable to answer your question during this time. I will review those questions and add my responses to the archived version of this Q&A session. Thanks to you, we had a very lively discussion here today, and I hope that you found my responses adequately addressed your concerns. |
| 1:01 |
LG Health Admin:
Writer: Dr. Douglas Gohn
Heart Disease and Stress Management |
| 8:12 |
LG Health Admin:
Writer: Dr. Douglas Gohn
LIVE Atrial Fibrillation Q&A with Dr. Gohn |