#006 Six Strategies to Reverse Inflammation and Chronic Pain

May 27th, 2014 by

I thought I would never live another day without pain. Every step hurt. Like 100 million other Americans I lived with chronic pain.

Something always hurt. My left knee was always in pain, my neck hurt to turn, and my lower back hurt.

I could only take a few doses of ibuprofen or naproxen before my stomach would start to hurt. Celebrex (a non-steroidal anti-inflammatory drug or NSAID) was my answer at the time for the pain. I took Celebrex daily and my autoimmune disease was very active. Although I was just in my mid-40s at the time, I just kept wondering, if the pain is so bad now how on earth am I going to survive to retirement?

The Dangers of NSAIDs

While Celebrex did raise my blood pressure 5-10 points, fortunately I did not have any severe complications from taking my daily NSAID. NSAIDs will not only raise your blood pressure but they are also known to increase your risk of bleeding, strokes, kidney failure, and ulcers.

NSAIDS May Cause Heart Attacks and Atrial Fibrillation

It has been known for quite some time that taking these anti-inflammatories increase the risk of a heart attack. Depending on what study you look at, this risk is any where from a 2-4 fold increase.

While it is not clear exactly how NSAIDs cause heart attacks, it is likely due to their effect on how our blood actually clots or the increased blood pressure that is a known side effect of these medications.

Recently there was yet another study published linking atrial fibrillation to the use of NSAIDs Yes, that little ibuprofen, Aleve, Motrin, etc. pill can also cause atrial fibrillation. In this study, NSAIDs increased the risk of atrial fibrillation by 76%. Even more frightening is that there was an increased risk of atrial fibrillation for up to one month after taking the NSAID!

Is there anything else I can take for pain?

Unfortunately, the other pain medications are not without risk either. There are now increased warnings of potentially life-threatening liver complications from acetaminophen. Not only can the opiate pain killers cause addiction issues but they can also cause people to die from a cardiac arrest due to prolonging the QT interval on an EKG.

When I was in severe pain, I did not see any other way to fight the pain than to take my Celebrex. I knew I was increasing my risk of heart problems but if I did not take Celebrex there was no way I could have even gone to work. Today, I realize that there are lifestyle changes that you can make now to prevent the pain so that there is no need for NSAIDs. Fortunately, everything turned around for me over time. This turn around did not happen over night. It took many, many months for the pain to finally go away. I have not taken anything for pain in a long, long, time. I never thought this was even possible.

How do we know if our bodies are inflamed?

There is a simple blood test which measures the level of inflammation in our body. This test is called C-reactive protein or CRP. High levels of CRP have been linked with many chronic diseases such as atrial fibrillation, heart attacks, and Alzheimer’s Disease. This is a test that can be easily ordered by your physician.

6 Ways to Reduce Inflammation and Pain

How can we reduce the inflammation in our bodies so that we don’t need anti-inflammatory drugs? Let me give you 6 ways we can reduce our inflammation.

1. Stay Physically Active

Physical activity helps to reduce inflammation. If something hurts, there are physical things like stretching, yoga, or strength training that we can do to help relieve the pain. Withdrawing from all physical activity just because something hurts only makes the pain worse long-term.

2. Avoid Foods That Cause Inflammation

We know what these are. Sugar, processed foods, wheat flour, and excessive amounts of animal meats can all cause our body to become inflamed and hurt. By eating real food we can allow our bodies to heal over time.

3. Eat Foods Which Reduce Inflammation

Did you know there are many anti-inflammatory foods? Yes, fruits and vegetables, legumes (beans, lentils, etc.), oily fish, nuts, seeds, and whole grains except for wheat flour can all help to reduce inflammation and pain.

4. Maintain An Ideal Body Weight

Fat cells secrete many hormones and other substances which cause inflammation throughout our bodies. Also, the extra weight causes a lot of wear and tear on our joints over time. As you get lighter the pain the pain will lessen or even go away.

5. Get Your Stress Under Control

Stress causes inflammation and magnifies any pain in your body. Make sure you do something each day to help you get your stress under control.

6. Discuss Alternative Treatments For Pain With Your Physician

There are many anti-inflammatory supplements, like fish oil, or herbs will not only make your food taste even better but they can also reduce inflammation. Also, acupuncture and massage therapy can be extremely helpful for long-term pain challenges.

What have you found that works for managing pain? You can leave a comment by clicking here.

#005 Get Your Energy Back Now

May 27th, 2014 by

The number one complaint I hear from my patients in my cardiology practice is that they feel so tired. Why is this the case? With power drinks and other energy drinks all around us, why have we become so tired? Do we have to live fatigued?

I get it. I used to feel this way as well. I would easily go through more than 32 oz of Diet Coke each day just to get through my day. I was so tired between surgeries and procedures that I had to make my way to the nearest nurses station or the Doctor’s Dining lounge where I could find a free, nice and cold Diet Coke. While I was always dragging through the day, ironically I just could not fall asleep at night. It never even dawned on me at the time that my processed food, sugar loaded, stress filled life could have anything to do with a lack of energy.

Could our modern lifestyle be driving all of the fatigue patients we are now seeing? By changing my lifestyle the energy has come back and I no longer need Diet Coke to get me through the day.

If you suffer from chronic fatigue, please also work with your primary care physician. It is possible that your fatigue could also be due to anemia, an under active thyroid, diabetes, nutritional deficiencies, or a myriad of other hormonal and metabolic problems. For those without an underlying medical problem causing their fatigue, it is completely reversible.

Let me suggest 10 ways you can get your energy back now!

1. Get a Good Night of Sleep

It seems basic but is often neglected. If you do not sleep well or have sleep apnea you will be tired during the day.

People with sleep apnea generally snore and stop breathing in the middle of the night. Usually their spouse can make this diagnosis.

For men, if your neck size is 17 or more there is a good chance you have sleep apnea. For women, it is a neck size of 16 or more.

Sleep apnea is also a big cause of atrial fibrillation. Fortunately, most cases of sleep apnea are totally reversible with weight loss. Until you can get the extra weight off, if you have sleep apnea, please use your CPAP machine. If you suspect you might have sleep apnea, please contact your physician to order the necessary testing to determine whether or not you have this condition.

If it is insomnia you are struggling with there are things you can do to improve your sleep. Have a set sleep and waking time schedule. Fasting 4 hours before going to bed at night can be tremendously helpful. Avoid computer, TV, or other screen lights that activate our brains and suppress our natural sleep hormone, melatonin, before bed. Get outside and stay physically active. A clean, dark, cool, and quiet room will do wonders for sleeping as well.

2. Get Off As Many Medications As Possible

Most of the medications we take can make us tired. While you cannot just stop taking your meds, you can work with your doctor to get off as many medications as possible. Bring your medication list each time you meet with your doctor. Discuss each medication. Is there anything you can stop?

By faithfully following our lifestyle, most of you will be able to get off your blood pressure and cholesterol pills. You may even be able to get off any pain pills you may be taking as well.

3. Get in Sync With the Sun

Make sure you get outside and get plenty of natural light each day. Likewise, when the sun goes down start wrapping up your day’s activities. Work with your body and the sun’s natural rhythms. Night owls may suffer from more depression and fatigue during the day. If you try to fight the natural rhythms of life you will be fatigued.

4. Eat a Healthy Breakfast

Breakfast is the most important meal of the day. Make sure you get in the right foods to start out your day. This will give you energy and set you up for success later in the day. Conversely, a big meal at the end of the day just sets us up for poor sleep, weight gain, and fatigue the next day.

5. Stay Hydrated

When we get dehydrated it makes us tired. Drink plenty of water for more energy. Carry your BPA free water bottle with you and make sure you are never without water.

6. Keep Moving

It seems counter intuitive, but those who are the most fatigued are the people who need to start moving the most. As we stay physically active it will energize us.

7. Focus on the Fruits and Vegetables

Fruits and vegetables give us life and vitality. Make sure you get in your American Heart Association recommended 9 servings of fruits and vegetables each day. This is not hard to do if you make this part of every meal. Your body will thank you.

8. Avoid Large Meals

Big meals wreck havoc on the body. They make you tired, put a big stress on the body, and paradoxically set you up to be hungry again soon. Eat lighter to keep your energy levels up.

9. Avoid the Biggest Energy Draining Foods: Sugar, Excessive Animal Meats, and Processed Foods

While sugar may give you a very short energy boost, the crash will leave you more fatigued than ever. Also, the foods that have the same effect as sugar in the body (high glycemic index foods) like wheat flour will also drain your energy. Excessive amounts of animal meats can also leave you tired. Rather than indulge in processed foods, which will only leave you feeling worse, focus on real foods.

10. Live Happy

When we are happy we feel alive. Depression and feeling down can rob us of our energy. While tips 1-9 all help us to live happier, I find that if I also review what I am grateful for each day, look for ways to help others, find some time for myself, and am progressing in my personal goals I feel very happy.

What things work for you to give you more energy? Please drop me a line and let me know what works for you. You can leave a comment by clicking here.

#004 The Scientifically Proven 4 Ways to Reverse Aging

May 25th, 2014 by

The Scientifically Proven 4 Ways to Reverse Aging

No one wants to grow old.  Is there a way that we can stay forever young?  Read on to find out the proven 4-step process to reverse aging by a Nobel prize-winning scientist.

Birthdays

I recently turned 50.  Birthdays used to be very depressing for me. Each new candle seemed to represent one step closer to having my body breakdown.

Perhaps this was because for years my patients had told me not to grow old or that the so-called golden years aren’t that golden.  And, watching their progressive decline, I started to believe them.

It was almost like the “nocebo effect.”  The nocebo effect is the opposite of the placebo effect.  With the nocebo effect, you think that something bad will happen and then it becomes a self-fulfilling prophecy.

I distinctly remember my 40th birthday. Turning 40 was something I had been dreading for a long time.  Forty years seemed like a marker to me that I was getting older.

At that time, I was 35 pounds heavier and was on multiple medications. I did not feel well and was very depressed to be 40. I was taking Celebrex twice daily to help with neck pain, and I had such weakness in my C5-C6 nerve root that I could not even pull my laptop out of my computer bag with my right hand.

Through a series of events in my life, which I describe in our book The Longevity Plan, I reversed aging.  Interestingly, many of the things which helped me were also found to be quite helpful in the first study to show that you can reverse aging by Nobel Prize-winning scientist, Dr. Elizabeth Blackburn.

Today I feel fabulous. I have not taken any pills, not even a Tylenol or ibuprofen, in a long, long, time. It is almost as if I am 30 all over again.  And I no longer dread birthdays.

Quest for Youth

Who doesn’t want to be forever young?  When I think of the quest for immortality, I think of Emperor Qin who was born in 260 BC.

He was a ruthless emperor who conquered all of China for the first time. He unified China and even constructed the Great Wall to protect his new kingdom.

Emperor Qin also wanted to live forever. He sent thousands of people on quests throughout Asia to find the secret elixir that would make him young again. Sadly, Emporer Qin never found it. In fact, he died at the young age of 50 likely from Mercury poisoning which was being given to him by his physicians to make him young again.

As a result of mercury poisoning, Emporer Qin was buried with his thousands of terracotta soldiers to protect him in the after-life.  When you think about it, Emperor Qin’s quest for youth was not much different than our search for lotions, potions, and plastic surgery that can do the same for us today.

The Reverse Aging Study

Fortunately, we now have scientific proof that you actually can reverse aging. Recently, the famous cardiologist, Dr. Dean Ornish from the University of California, San Francisco, published a medical study with Nobel Prize-winning scientist Dr. Elizabeth Blackburn which gained worldwide attention.

In this study, Doctors Ornish and Blackburn included 35 men with early prostate cancer who opted not to undergo surgery or radiation.  Some of these men committed to making healthy lifestyle changes, and some chose to continue to live the way they had always lived.  The lifestyle changes prescribed in this study consisted of just four simple things that the motivated men did faithfully for the five years of this study.

1. Eat a plant-based diet

Eating a plant-based diet in this study means they didn’t eat added sugars, processed carbohydrates, or added oils.  They completely cut out processed foods.  Rather they ate a diet extremely high in real foods like fruits, vegetables, nuts, seeds, and legumes.

2. Exercise daily

These study participants all became physically active.  It was a daily habit, and they did everything possible not to sit too long at any time.

3. Did something for stress each day

While yoga was the preferred way to manage the daily stress in this study, these study participants also did other stress-reducing activities as well.  For example, meditation, nature walks or hikes, prayer, or exercise in any form may be a mindful way to manage stress.

4. Social connection

Study participants met weekly for the five years of this study.  During these meetings, friendships formed with the researchers and fellow members of the study.  Even outside of these weekly meetings, study participants encouraged each other to continue living this healthy lifestyle.

Results of the Reverse Aging Study

After living this way for five years, Drs. Ornish and Blackburn found that the telomere length of the group who adopted these lifestyle changes was 10% longer than it was before they started five years earlier. In contrast, the control group, who did not make any lifestyle changes, experienced a 3% shortening of their telomere length which is typical of growing five years older.

What is a telomere?

Telomeres are the caps on the end of our chromosomes. The telomeres protect our DNA through the aging process.

Over time, as our cells divide our telomeres shorten. When they get too short, they can no longer protect our DNA which can then lead to the usual diseases of aging and ultimately death. Short telomeres equate to a high risk of heart disease, cancer, and many other chronic diseases.

Practical Tips

This study is remarkable in that it showed for the first time that you could reverse aging.  After five years, the group of men who adhered to this lifestyle turned back the aging process by 10%.

To reverse aging doesn’t require any expensive lotions, potions, or plastic surgery.  All you have to do to reverse aging is eat a real food plant-based diet, stay physically active every day, embrace stress, and connect socially with people who also value health and happiness.

The power is up to us! We can reverse aging!

#003 (UPDATED) Can Too Much Exercise be Bad for You?

May 24th, 2014 by

Can Too Much Exercise be Bad for You?

The modern day marathon was inspired after Pheidippides, a long distance running courier in ancient Greece. During two days he ran a total of 175 miles. On the last leg of his run, a 25 mile distance from the battlefield near Marathon to Athens, he died suddenly.

Can the same thing happen to us if we run too much?

Recent Headlines: Too Much Running is Dangerous

Did you see the recent news reports that too much running is dangerous?  What is the science behind these headlines?

These headlines came from a recent study published in the Journal of the American College of Cardiology.  In this study, researchers from Copenhagen reported their findings of 5,048 joggers and non-joggers who they had followed for 12 years.

Results of the The Copenhagen City Heart Study

Here are the key findings of this study which caught the attention of the news media:

1. The most intense runners had the same risk of dying as the coach potatoes.

2. Light joggers who jogged between 1 and 2.4 hours each week, for no more than 3 times each week, at a slow to moderate pace were the least likely to die.

3. Moderate joggers did not survive as well as the light joggers.

4. Running faster than 7 mph, jogging for 2.5 hours or more each week, or jogging more than 3 times per week increased the risk of premature death in this study.

Can we believe the results of the Copenhagen City Heart Study?

For the runners reading this article, like me, our first question is how reliable are these data?  And, just what is the optimal dose of running?

Like most medical studies, this study was definitely not perfect.  For example, there were only 47 joggers in the group that jogged the most (more than 4 hours a week).

In this small group of 47 joggers in this study who ran more than 4 hours a week there was only one death.  Had that one person not have died during the study then the results would have been completely different.

Interestingly, this study did not even report what this one runner even died from.  For all we know he could have died in a car crash that had nothing to do with his love of running.

While we can certainly poke holes in the conclusion of this study, this study is in line with a growing body of research that shows that extreme levels of exercise may be dangerous to our health.  The only difference between this study and the other studies is that this study reported that even low levels of exercise (jogging for more than 2.5 hours per week) conferred an added risk of death.

Can what happened to Pheidippides happen today?

For better or worse, too much exercise is something that 99% of the American public never needs to worry about. In fact, knowing that less than 5% of Americans even get enough exercise according to pedometer studies I hesitated even writing this article.

I recently read the epic masterpiece by Christopher McDougall entitled “Born to Run” (affiliate link) which reignited within me my passion for marathon running.  A number of years ago during my health crisis I had to give up running due to severe knee pain.  Since completely changing my lifestyle I was able to reverse my knee pain in addition to many other medical conditions.

Prior to becoming a cardiologist, I had run 5 marathons including the legendary New York City Marathon twice. You will notice the photo of my 1992 New York City Marathon finish.

Yes, I am the totally depleted guy without a shirt at the finish line. I remember as a child running in our neighborhood and dreaming of winning the Olympic Marathon for USA, however, from my marathon time you will notice that I never quite qualified…

Now that I have completely regained my health and am able to run again I would love to train for another marathon.  However, as a cardiologist, I have to question if marathon running, or any ultra endurance event, is really the best thing for my health. Outside of the wear and tear on our joints from marathon running, just what is happening to the heart?

Phidippides Cardiomyopathy

Interestingly, there is now a cardiac condition called Phidippides Cardiomyopathy. In this condition, the heart enlarges, weakens, and becomes very susceptible to a cardiac arrest after extreme levels of exercise.

Indeed, studies have shown that marathon runners experience transient enlargement of their hearts after a marathon.  Other studies have shown that 13% of marathon runners permanently “scar” their hearts.

It is not just marathon runners who are at risk. Studies have also shown endurance cyclists and cross-country skiers are also at risk of cardiac complications.  For example, endurance athletes often have cardiac enzymes, from cardiac cell death, in their blood following an endurance race.  It should be pointed out that cardiac enzymes in the blood is an ominous finding and is one of the ways we diagnose a heart attack when anyone, usually non-athletes, when they present to the emergency room with chest discomfort.

Fortunately, the vast majority of these cases of Phidippides Cardiomyopathy completely resolve. However, in a small subset of people they actually go on to develop heart failure. In addition to Phidippides Cardiomyopathy, endurance athletes also appear to be predisposed to developing a dangerous arrhythmia called atrial fibrillation.

Tragically, one of the key characters in Christopher McDougall’s book, Caballo Blanco, an ultra marathoner, died of a cardiac arrest while running just 3 years after the book was published.  At autopsy he was found to have an enlarged heart and likely also developed Phidippides Cardiomyopathy after a life-time of ultra marathoning.

They Don’t “Exercise” in China’s Longevity VillagePeasants on their way to work in the morning in the village of Poyue

When we discussed the concept of exercise to the residents of China’s Longevity Village on our last visit, they found the whole Western concept of exercise quite strange.  In fact, if you ask them they will tell you that they “never exercise.”

How can they escape most of the Western diseases like heart disease, dementia, diabetes, obesity, etc. and yet never exercise?  The answer is really quite simple.  They are physically active all day, every day farming by hand.  They do experience short periods of high intensity training like when they need to carry a 50-70 pound basket of produce on their backs while walking up the side of a mountain.

Their form of “exercise” is very gentle and does not stress the joints.  Could this be why none of them had undergone joint replacement surgery but yet could walk without a limp even at an age of more than 100 years old?

How Much Should We Exercise?

Just how much exercise should we aim for?  Let me share with you four simple strategies that I recommend for my patients.

1. Make it a daily habit.

Commit to 30 minutes of moderate intensity exercise or 15 minutes of high intensity exercise each day.  If you think about it, 15 minutes over the course of a day really is not much time.  Even the busiest of people can carve 15 minutes out of the day to protect their health.

2. Find an exercise you enjoy.

It doesn’t matter what you do for exercise as long as you enjoy it. Unfortunately, half of all people who start an exercise program quit within 6 months.

The key, therefore, to making exercise stick is to find something that you enjoy.  Exercise does not mean just going to the gym.  Personally, I hate the gym and have not spent anytime in a gym for years.

Rather, exercise could be dancing, walking, skiing, hiking, or just about anything that moves your body.  Even better is to mix up your exercise routine to minimize the risk of injury and work different muscle groups.

3. Have a Work Out Partner or Track Your Work Outs

Studies show that those who exercise with others are more likely to be successful.  If you don’t have anyone you can exercise with then track your work outs.  Studies show that either approach will increase your chances of making daily exercise a lifelong habit.

4. 10,000 Steps

In addition to exercise, it is also just as important to remain physically active throughout the day. Studies have shown that people who sit for most of the day (i.e. desk jobs), cannot reverse the ill effects of sitting all day even if they exercise vigorously each day.

For example, if you sit more for more than 3 hours a day then you lose 2 years of life according to this study.  When we sit our large muscle groups are at rest which leads to changes in our body’s metabolism and how we process glucose.

10,000 steps represent the equivalent of walking approximately 5 miles.  I have found that even my elderly patients can log 10,000 steps a day.  Just the act of tracking your steps causes you to take an extra 2,000 steps (1 extra mile) without even knowing it.

With thoughts of the Copenhagen City Heart Study and Phidippides Cardiomyopathy in my mind, I think I will hold off on training for any more marathons. Do you agree?

What is your preferred form of exercise?

Please note that this article was revised and updated on February 6, 2015.

#002 Does it Matter What Time of the Day We Eat?

May 18th, 2014 by

Does it really matter what time of the day we eat? At the end of the day it is all about the total number of calories taken in, right?

My philosophy in the past was a calorie is a calorie. I remember as a teenager or even in college sometimes eating a whole pizza right before bed. I was hungry so I ate right before bed. A calorie is a calorie, right?

Wrong! The timing of when we eat really does matter. Even if we eat the same number of calories, depending on what time of the day they are consumed can help to determine whether we are able to maintain a normal weight or become obese.

Eating Time of the Day Study

In a recent issue of the prestigious heart medical journal, Circulation researchers from Harvard’s Brigham and Women’s Hospital report their findings on nearly 27,000 American men from the Heath Professionals Follow-Up Study. At the beginning of this study, none of these men had coronary heart disease, however, after 16 years of follow-up, 1,527 of them developed coronary heart disease. Coronary heart disease is where the arteries feeding blood to the heart become plugged up with plaque and put people at risk of a heart attack or even a cardiac arrest.

In this study, the researchers asked the question as to whether or not these men skipped breakfast or ate late at night had any impact on their development of coronary heart disease or not. Interestingly, 13% of the men routinely “skipped” breakfast and 1% reported eating late at night. When they looked at the risk of coronary heart disease, those men that skipped breakfast were 27% more likely to develop coronary heart disease and 55% of those who ate late at night were more likely to develop coronary heart disease.

How do we explain these findings?

Paradoxically, many studies have shown that those people who skip breakfast are much more likely to become obese. In addition to carrying extra weight, skipping breakfast has also been shown to affect insulin and lipid metabolism which likely also leads to increased plaque build up in the arteries of the heart. Likewise, eating late at night also had a deleterious effect on the heart. Our body’s metabolism is highest in the morning and lowest just before bed. Thus, consuming calories earlier in the day with steady meals seems, in harmony with natural body rhythms, seems to optimize the way our bodies burn fuel.

The common saying, “eat breakfast like a king, lunch like a prince and dinner like a pauper” really is true. This study, along with many others, have all shown the same thing. Breakfast is important and should not be skipped. Earlier dinners are best and we should not eat after finishing dinner. Taking these simple steps not only lowers our risk of heart disease but also helps us to maintain a normal weight and avoid obesity.

My Simple Two Suggestions:

1. Never Skip Breakfast

This is the most important meal of the day. Get your body’s metabolism working properly from the start. Get your calories in while your metabolism is at its highest.

2. Don’t Eat or Drink After 7 pm

Your body does not know what to do with calories right before bed other than just store them as fat. You will sleep much better without a full stomach. Also, if you are not drinking right before bed you are more likely to make it through the night without having to get up to use the bathroom. A proper night’s sleep is also critical in optimizing your body’s metabolism.

A calorie consumed at 7 am is much more likely to be burned than a calorie at 9 pm. A calorie is not a calorie with regards to your body’s metabolism.

What about you? Do you ever skip breakfast or eat late at night? You can leave a comment by clicking here.

#001 Can You Really Prevent Alzheimers Disease By Not Retiring?

May 15th, 2014 by

Recently, I saw the news headlines from around the world—if you work longer you can help to prevent Alzheimer’s Disease.  Is this really the case? Do we really want to work forever?

For years I killed myself at work. I worked long hours. Like most Americans, I did not take my full vacation time. I burned out. My goal was to work as hard as I could, save our money, and retire early so that I could then kick back and relax.

Needless to say, this approach nearly killed me. My health suffered. The goal is to pace yourself at work and enjoy each and every day of life along the journey.

What does it mean to keep working and not retire?

Prevent Alzheimer’s Disease by Not Retiring Study

This controversial study was presented at the recent Alzheimer’s Conference in Boston.  As it was just a one page abstract, the actual study has not yet been peer reviewed or published in a medical journal.  Thus, the findings of this study can be considered preliminary at this time.

This study reviewed 430,000 French retirees and evaluated the risk of Alzheimer’s Disease based on the age of retirement.  Based on this study, the authors concluded that for each year you delayed retirement your risk of Alzheimer’s Disease decreased by 3.2%.

My Take on this Study

The findings of this study are in line with what we are seeing in other studies.  Namely, with regards to the mind the old adage “use it or lose it” really is important.

As a cardiologist, I am always worried when I hear my patients tell me they are ready to retire.  This is especially true for men as their job is often their reason to get up each morning and often the main source of their social interaction.  For a man, one of the most dangerous days of their lives is the day they “retire”.

My wife and I, along with our research team, have been studying a remote village in China near the Vietnam border. In this village people just don’t get sick and they live these amazingly long and healthy lives free of disease including Alzheimer’s Disease.

When we ask them if they look forward to their “retirement” they all laugh.  To them, there is no concept of retirement.  You never withdraw from the Village. You always contribute in some way.

Does Retirement Need to be Redefined?

Perhaps the problem is how we have defined retirement.  For many of us, while slaving away in the daily grind of our jobs, we dream of retiring and sitting next to the pool or playing golf each day.  For many of my patients who have “achieved” this dream life, they quickly find that it soon becomes old.  Many are looking for a new reason to live.

Perhaps retirement should be redefined as going from a “for profit” to a “non-profit” focus.  Instead of working for “the man”, perhaps it is time for us to work for ourselves, for our families, or for the community when it comes to “retirement.”

Thus, when it comes to retirement and preventing Alzheimer’s Disease let me suggest the following:

1. Enjoy Your Work Today

If you are in a job that you hate, what can you do to change things? Do you need to look for new employment? Can you get paid for doing what you love?

2. Take All of Your Vacation Time

Taking vacation time is critical to your health. Never let a day go unused. Pace yourself.

3. Never Stop Learning

To enjoy your current career, you can never stop learning. This will also keep your mind sharp and Alzheimer’s at bay.

4. Work Reasonable Hours

In the U.S. we work longer hours than the rest of the world. Studies show that when we work more than 40 hours a week we significantly increase our risk of heart disease. Are we really contributing the most when we are burned out and worked to the bone?

As you get further along in your career, perhaps you start scaling back the hours or even work part-time as a consultant.

Regardless, don’t neglect yourself in the name of your job. Make sure you have enough time to eat right, exercise regularly, and can spend meaningful time with your family and friends.

5. Find a Meaningful Second Career

When you are ready to move on to “retirement” find a meaningful second career. People who volunteer enjoy much more fulfilling and healthier lives. There is so much you can do to make the world a better place.

What do you think?  Do we have the concept of retirement all wrong in the U.S.? You can leave a comment by clicking here.

#AF-008 Does Sleep Apnea Cause Atrial Fibrillation?

January 8th, 2014 by

Does Sleep Apnea Cause Atrial Fibrillation?

Kathy never seemed to get a good night of sleep.  Her husband, John, told me “she snores like a train and then stops breathing.  After a pause, she gasps for air, and then goes back to sleep.”

Does this sound like someone you know?  If so, they likely have a condition called sleep apnea.  Not only does sleep apnea make people feel tired all of the time but it also puts them at high risk for high blood pressure, heart failure, sudden cardiac arrest, and atrial fibrillation.

In this article, I will discuss why sleep apnea is so dangerous and treatment options to avoid this risk.

What is Sleep Apnea?

Sleep apnea is a condition where people stop breathing while they are sleeping.  When this happens, not only is sleep disrupted leaving the person tired the next day, but this drop in oxygen levels can cause many different heart problems.

The most feared complication from sleep apnea is premature death.  For example, the risk of sudden cardiac arrest is increased up to three times in patients with sleep apnea.

How Do I Know if I Have Sleep Apnea?

I have found that the sleeping partner can usually make this diagnosis.  They will tell you that you snore and will often stop breathing throughout the night.

Another good way to tell if you have sleep apnea is to look at your neck size.  If it is 17 or larger for a man or 16 or larger for a woman, then there is a good chance you have sleep apnea.

For people at risk for sleep apnea, we typically order an overnight pulse oximetry test.  In this test, people sleep with a pulse oximetry meter on their finger during the night.  If they have frequent episodes of their oxygen levels dropping below 90%, then they likely have sleep apnea.  Patients with an abnormal overnight sleep oximetry test are then referred for an overnight sleep study to confirm the diagnosis.

What Causes Sleep Apnea?

Most cases of sleep apnea are from being overweight.  The extra tissue in the neck or the back of the tongue collapses the airway during sleep.  The key then, in treating sleep apnea, is to keep this extra body tissue from collapsing the airway at night.

What is the Risk of Atrial Fibrillation with Sleep Apnea?

The stress of going periods of time during the night without breathing takes a significant toll on the heart.  Sleep apnea has been shown to cause enlargement of the left atrium of the heart which is the usual source of atrial fibrillation.  This left atrial enlargement then causes disruption of electrical pathways leading to a four-fold increased risk of atrial fibrillation!

How is Sleep Apnea Treated?

For most people suffering from sleep apnea, it is initially treated with CPAP, or continuous positive airway pressure, to keep the airways from collapsing during sleep.  Some cases may require alternating pressures, BiPAP, to treat sleep apnea.  Your sleep doctor can help you to select the right treatment option for you.

What If I Can’t Tolerate CPAP?

While some people have no problems tolerating CPAP therapy, others cannot.  Particularly, for those with claustrophobia this can be very difficult.

I know that I could never tolerate this therapy.  I have enough difficulties sleeping as it is and CPAP would only further complicate things for me.

If you cannot tolerate CPAP, your physician may elect to just give you oxygen at night.  While this does not solve the problem of the airway collapsing, at least the extra oxygen will help to keep your blood oxygen levels higher while sleeping.

Other patients have considered surgical options to treat sleep apnea.  These surgeries often focus on surgically removing the extra tissue that collapses the airways while sleeping.  Unfortunately, the long-term success rates for these surgeries are either lacking or are unimpressive–not to mention the surgical risks of these procedures.

Natural Ways to Treat Sleep Apnea

Another approach, which is seldom discussed, is a natural approach to treating sleep apnea.  For most people who suffer from this condition, it is much more likely to occur when they are sleeping on their backs.

A simple approach that many of my patients have tried is to sew a tennis ball into the back of a shirt.  These patients then wear this “tennis ball shirt” each night while sleeping.  Every time they roll onto their backs the tennis ball awakens them.  Over time, they subconsciously learn to sleep on their stomach or sides.

Probably the most effective natural treatment approach to sleep apnea is to just lose weight.  As the primary cause of sleep apnea is too much fat deposition in the neck and back of the tongue, weight loss can solve the underlying problem.  I have seen countless patients who have completely reversed their sleep apnea with weight loss alone.

Will Sleep Apnea Treatment Reverse A-Fib?

As sleep apnea and atrial fibrillation go hand-in-hand, many patients ask me if their atrial fibrillation will go into remission with sleep apnea treatment.

A recent study showed that treating sleep apnea decreased the risk of atrial fibrillation by 42%.  Even if sleep apnea treatment does not make your A-Fib go away, at least it will make your A-fib much easier to treat.

For example, if you and your physician ultimately decide on a catheter ablation procedure to treat your A-Fib, having your sleep apnea under control doubles your chances of a successful procedure.  In this study, if you had sleep apnea, and refused treatment for the sleep apnea, your chances of a successful ablation procedure was only 37%.

Clearly, if you want to successfully treat your A-Fib, you cannot ignore underlying sleep apnea!

Action Steps

What should you do if you have been diagnosed with A-Fib and are at risk for sleep apnea?  Below are my three action steps:

1. Get Tested

The screening test for sleep apnea is so simple.  You just sleep at home with a pulse oximetry device on your finger.  If you have not yet been tested then call your physician today to schedule this test.

2. Get Treated

If you have sleep apnea, get treated.  Many patients cannot tolerate CPAP on their first try.  Don’t give up.  Work with your sleep physician to find the right equipment for you.

3. Reverse Sleep Apnea

Even if you tolerate CPAP just fine, wouldn’t it be even better if you could just reverse this condition?  I have found that most patients can reverse sleep apnea naturally with weight loss and by not sleeping on their backs (the tennis ball in the back of the shirt trick works really well for this).

The important thing to remember is you cannot stop using CPAP until you are sure you have completely reversed the sleep apnea.  Work with your physician and, after sufficient weight loss, repeat the overnight sleep oximetry test to make sure your oxygen levels never drop at night.

Do you have sleep apnea and atrial fibrillation?  What has worked for you?

#AF-007 Can I Live with A-Fib?

January 7th, 2014 by

Can I Live with A-Fib?

“Can I live with A-Fib?” asked Jeff, a 63 year-old man recently diagnosed with atrial fibrillation (A-Fib).  Jeff felt fine.  In fact, he had absolutely no symptoms at all from his A-Fib.  He exercised regularly without any difficulties.

When his primary care physician picked up his A-Fib on a recent physical he was in a state of shock.  “Wouldn’t I feel it if my heart was out of rhythm?” he asked his physician.

Surprisingly, most people with A-Fib don’t ever feel that their heart is out of rhythm.  Do these patients need to undergo aggressive treatment for their atrial fibrillation?  Can they just live out of rhythm?

Rate vs. Rhythm Control of A-Fib

One of the first questions to answer when someone is diagnosed with A-Fib is whether to pursue a rate control strategy or a rhythm control strategy for managing their A-Fib.  Let me explain.

A rate control strategy is where no attempts are made to get the person back into normal rhythm.  The only goal is to make sure that the heart rate is not too fast and to prevent strokes.  This approach is often best for older patients who don’t have any symptoms and A-Fib is not causing any heart damage.

The other option is a rhythm control strategy to managing A-Fib.  With the rhythm control strategy, every attempt is made to keep the person in rhythm.  Initially this may involve medications and a cardioversion (electrical shock).  When medications or cardioversions are no longer effective, this strategy often means a catheter ablation procedure.  This approach is ideal for the person who feels poorly when their heart is out of rhythm.

Rate vs. Rhythm Control Studies

When it comes to which approach to managing A-Fib is best, you would naturally assume that a rhythm control strategy is best.  After all, shouldn’t people do best when their hearts are in rhythm?

Interestingly, a rhythm control strategy has never been shown to allow A-Fib patients to live longer or to prevent strokes.

In the most famous rate vs. rhythm control study, the AFFIRM Study, researchers enrolled 4,060 patients and divided them equally into a rate control group or a rhythm control group.  In the rate control group, no attempt was made to get these patients back into rhythm.  Rather, the rate control group was just treated with medications to slow the heart rate and with warfarin to help prevent strokes.

In contrast, the rhythm control group patients were put on potent rhythm controlling drugs and attempts were made to shock their hearts back into normal rhythm.  After following these two groups for an average of 3.5 years, researchers were stunned at the results.

There was no statistical difference in the risk of death or a stroke during the study.  Additional studies showed the same results.  It should be pointed out that there has not yet been a study comparing a rate control strategy to a catheter ablation approach for the management of A-Fib.

Lessons from the Rate vs. Rhythm Control Studies

What was the message from the rate versus rhythm control studies in managing A-Fib?  Whether you pursue a conservative (rate control) or aggressive approach (rhythm control) to A-Fib, here are the results of these studies:

1. There is no difference when in comes to survival.

2. There is no difference when it comes to stroke risk.

3. A conservative treatment approach (rate control) is best for older patients without A-Fib symptoms.

4. An aggressive treatment strategy (rhythm control) is ideal for patients with A-Fib symptoms.

Unfortunately, these studies did not include many younger patients.  Thus, the lessons learned from these studies do not apply to younger patients with A-Fib.  Also, catheter ablation was not included in these studies so we don’t know how a rate control strategy would stack up against a catheter ablation approach to managing A-Fib.

How Do I Know If I Am Having A-Fib Symptoms?

This is a question that many of my patients struggle with.  For many people, they have no idea when their A-Fib began.  They may feel tired or fatigued and it is hard for them to know if A-Fib is the cause of this or not.

For these patients I recommend a “trial” of normal rhythm.  In other words, I recommend an electrical cardioversion or a shock for these patients to see if they feel better in normal rhythm.

While cardioversions are not long-term solutions, they can at least help patients to know if they feel better in normal rhythm or not.  If they do feel better in normal rhythm then we opt for an aggressive treatment approach (rhythm control) to make sure that they stay in rhythm.  For those patients who don’t notice any difference in or out of rhythm, our focus is to just make sure their hearts don’t beat too fast and to prevent strokes.

Are There Any Dangers with a Rate Control Approach?

I am often asked if there are any dangers to a rate control strategy.  It is important to remember that when you are out of rhythm the upper chambers of your heart are not pumping any blood.  Thus, if you are out of rhythm, you are losing 20-30% of your cardiac output.

For sedentary people, losing 20-30% of your cardiac output probably will not be missed.  However, for athletes, they will definitely notice this lack of full cardiac output during a race or competition.

Besides preventing strokes with blood thinners, it is important that the heart rate not be too fast with a rate control approach.  If the heart beats too fast for too long, people can go into heart failure.  For this reason, we used to be very concerned about controlling the heart rate in A-Fib.

However, based on recent research, a more lenient approach to managing the heart rate has also been shown to be safe.  In other words, if a faster heart rate with A-Fib is not causing symptoms or heart failure, then we can be much more relaxed in controlling the heart rate.

Can I Live With A-Fib and See How Things Go?

All too often, people think that they’ll just try to live with A-Fib and see how things go.  The trouble with this approach is that the longer you are out of rhythm the harder it will ever be to get you back in rhythm if you later change your mind.

Studies show that if you have been continuously out of rhythm for more than a year it is extremely difficult to get you back in rhythm and keep you in rhythm long-term.  Thus, if you opt for a rate control strategy this has to be a decision that you will feel comfortable with for the rest of your life.

Should Younger Patients Live with A-Fib?

Most cardiologists agree that our treatment approach to younger patients should be more aggressive.  Even though a 50 year-old may feel just fine living in A-Fib, they are so young that we don’t know what their long-term future holds in store for them.

For example, it is possible that these patients may later have a heart attack or other heart problems.  They might really miss the lost 20-30% of cardiac output from A-Fib when they get into their 70s.

Thus, even if younger A-Fib patients don’t have any A-Fib symptoms, we often still opt for a more aggressive strategy (rhythm control).

Jeff’s Experience

Returning back to Jeff, how should he manage his A-Fib?  Even though he feels fine in A-Fib he is still relatively young at 63.

If Jeff was in his 50s or 70s the decision would be very easy.  We would recommend an aggressive strategy (rhythm control) if he was in his 50s or a conservative strategy (rate control) if he was in his 70s.  As he is only 63, it makes this decision difficult.

We opted for a “trial” of normal rhythm to help him better decide what direction to go.  Once we got him back into normal rhythm with a cardioversion, he could not believe how much better he felt.  He had been out of rhythm for so long that he had forgotten what it felt like to feel so good.

This was the answer we needed.  We opted for an aggressive treatment approach (rhythm control) of his atrial fibrillation.  Three years later he is still doing well and maintaining normal rhythm.

Do You Feel Your A-Fib?

Do you know when you go out of rhythm?  Please leave your comments below sharing your experiences with either a rate or rhythm control strategy to managing your A-Fib.

Disclaimer

Please do not self diagnose or treat based on anything you have read in this article.  Please discuss with your cardiologist whether a rate or rhythm control strategy is best for managing your A-Fib.

#AF-006 Can Weight Loss Cure A-Fib?

January 6th, 2014 by

Can Weight Loss Cure A-Fib, Diabetes, High Blood Pressure, High Cholesterol, and Heart Disease?

Did you see the recent media reports about this study?  Not only did weight loss alone cure atrial fibrillation (A-Fib) but it also cure diabetes, high blood, pressure, high cholesterol, and reversed previous heart damage!

In my opinion, this was the biggest study to emerge from the largest cardiac medical conference in the world, the annual scientific sessions of the American College of Cardiology.  All of my colleagues at the meeting were actively discussing the implications of this study.

The Obesity and A-Fib Epidemic

The United States is at the epicenter of both the obesity and the atrial fibrillation (A-Fib) epidemic.  Carrying extra weight puts a significant stress on the heart which makes it very common for overweight patients to go into A-Fib.  Perhaps this is why A-Fib is 10 times more common in the U.S. than in Asia.

The LEGACY Study

In the LEGACY Study, my friend Dr. Prash Sanders from Royal Adelaide Hospital in Australia, enrolled 355 overweight A-Fib patients in this weight loss study.  To get into the study, you had to have a body mass index of 27 or higher (25 or higher is considered overweight).

To put this BMI number into practical terms, the average weight of the patients participation in this study was approximately 220 pounds.  They divided these patients into 3 groups depending on how successful they were at losing and maintaining the weight loss.  Specifically, I would like to focus on what happened to the 38% of the patients who successfully lost an average of 36 pounds and kept that weight off for one to two years.

Weight Loss Cures Half of Overweight A-Fib Patients

The biggest message of the LEGACY Study is that half of A-Fib patients can be cured by weight loss alone.  Indeed, with just a 36 pound weight loss, 46% of A-Fib patients had their arrhythmias go into remission without medications or procedures.  Even in those who were not able to drive their A-Fib into remission, those who could lose an average of 36 pounds had a 6-fold decrease in their A-Fib burden.

7 Other Benefits of Losing 36 Pounds

In addition to a 50/50 chance of putting their A-Fib in remission, those who lost an average of 36 pounds in this study also had the following 7 additional benefits.  These benefits may even be more beneficial for their health and longevity than just putting A-Fib into remission.

1. 18 Point Reduction in Blood Pressure

Considering that the average blood pressure medication only lowers your blood pressure by 5 t0 10 points (mmHg), dropping your blood pressure by 18 points with simply losing 36 pounds is amazing.  What is even better is that patients dramatically lowered their blood pressure without the nasty side effects that often come from medications!

2. Inflammation Reduced by 76%

C-reactive protein (hsCRP) is a blood test that measures inflammation in the body.  Inflammation is a major cause of heart disease, dementia, and aging.  With a 36 pound weight loss, these patients were able to drop their average dangerous CRP level of 5.1 mg/L to a much safer value of 1.2 mg/L.

The goal CRP level for everyone is less than 1 mg/L.  While these patients did not quite hit this target, their average CRP came very close.  To help put things in perspective, someone with a CRP of 3.0 mg/L or higher has 3 times the risk of a heart attack than someone with a CRP of less than 1 mg/L.

3. 88% Cured of Diabetes

Diabetes is one of the most disabling conditions.  It causes blindness, amputations, kidney failure, heart attacks, dementia, and takes about 8 years off your life.  The good news is that, according to the LEGACY Study, 88% of the time people can be cured of diabetes with just losing 36 pounds!

4. Significant Cholesterol Reduction

The primary treatment for people with high cholesterol is to take a statin drug.  Considering that this recent study showed that statin users are 46% more likely to develop diabetes, this is enough to make anyone reconsider.

An even better way to achieve all of the benefits of statins, without any of the side effects, is to simply lose 36 pounds if you are overweight.  From the LEGACY Study, losing 36 pounds resulted in a 16% reduction in LDL (bad cholesterol) and a 31% reduction in triglycerides.

5. Cure an Enlarged Heart

An enlarged heart can be very dangerous.  An enlarged left atrium can lead to A-Fib.  An enlarged left ventricle can lead to heart failure and cardiac arrest.  Losing 36 pounds resulted in the left atrium shrinking by 18% and the left ventricle coming down 8% in size.

Once again, this is very good news.  It shows that it is never too late to reverse heart damage!

6. Reverse a Thickened Heart Muscle

We like big muscles everywhere in the body except for the heart.  If the heart muscle becomes to big the heart thickens and may have difficulties pumping.  In this study, patients were able to decrease the thickness of their hearts by 14%.

7. Better Quality of Life

At the end of the day the real goal in treating A-Fib is to prevent strokes and improve quality of life.  In this study, losing 36 pounds not only cured half of the patients from A-Fib but also resulted in a 200% improvement in their quality of life!

Can Weight Loss Cure A-Fib?

To get back to our original question, can weight loss cure A-Fib, I hope the answer by now is a resounding “yes.”  This well designed clinical study published in the Journal of the American College of Cardiology showed that there is indeed hope for A-Fib patients!

Not only will half of overweight A-Fib patients be cured with just a 36 pound weight loss but most will also be cured from high blood pressure, diabetes, high cholesterol, and other forms of heart disease.

Does the LEGACY Study inspire you to get down to an ideal weight?

Disclaimer

Please work with your physician to determine if you should lose weight and what your target weight should be.  Also, while weight loss may cure you of many chronic medical conditions, the results do not happen overnight.  It took 1-2 years for the patients in the LEGACY Study to experience these benefits.  Thus, continued medications may be required until your target weight is achieved.  Please do not self diagnose or treat based on anything you have read in this article.

#AF-005 A New Blood Thinner Alternative is FDA Approved! The Watchman Device

January 5th, 2014 by

A New Blood Thinner Alternative is FDA Approved! The Watchman Device

I recently saw a new patient, Lisa, who was stuck in a very difficult situation.  Last year while at dinner with her daughter she suddenly lost her ability to speak.  She told me that she knew what she wanted to say but the words just came out all garbled.

Fortunately, her daughter immediately recognized the signs of a stroke and dialed 911 from the restaurant.  Even though Lisa protested, the call was made.  She was rushed to the hospital, a clot busting medication was immediately given, and Lisa had a complete recovery from her atrial fibrillation (A-Fib) stroke.

She was then put on warfarin and did well until last month when she was hospitalized again.  This time it was a massive gastrointestinal bleed requiring 4 blood transfusions.  She now was in my office wondering what she should do.

She definitely did not want another stroke nor did she want any more life-threatening bleeding episodes.  At the time of this visit, my options were limited.  Now, hope is available!

The Watchman device was finally FDA approved after the FDA struggled with this decision for 6 long years.  Now that the Watchman device is finally available for A-Fib patients in the U.S., what is it and is it right for you?

The Left Atrial Appendage

Before we can discuss the Watchman device, we need to back up and talk about the left atrial appendage.  The left atrial appendage is a pouch in the left atrium of the heart.  Every heart has a left atrial appendage.

In atrial fibrillation (A-Fib),  the upper chambers of the heart (right and left atrium) just “quiver” and don’t pump any blood.  When this happens, the stagnant blood in this dead-end pouch can clot.  If one of these blood clots breaks free from the left atrial appendage and travels through the bloodstream to the brain it is called a stroke.

The purpose of blood thinners in atrial fibrillation is to thin the blood enough so that this stagnant blood in the left atrial appendage won’t clot.  The problem is that these blood thinners not only thin the blood in the appendage but they also thin the blood throughout the rest of the body as well.  For this reason, many blood thinner patients suffer from bleeding problems.

Surgical Removal of the Left Atrial Appendage

For decades now, cardiac surgeons have been surgically removing the left atrial appendage in A-Fib patients who require cardiac surgery.  The difference is that the Watchman device can accomplish the same thing without surgery. The Watchman device is a small umbrella that is used to plug up the left atrial appendage.  If the appendage is plugged, then blood cannot get in and blood clots generally don’t form in the heart.

This X-ray image shows us inserting the Watchman device in the left atrial appendage with a catheter.  This small device is inserted through a vein in the leg.

The entire procedure takes about an hour to perform and patients usually go home from the hospital the next day.  The goal of the Watchman device is to plug up the left atrial appendage so patients don’t have to take blood thinners and can still be protected from A-Fib strokes.

Why Did the FDA Struggle with Watchman?

You may be wondering why the FDA struggled for 6 years in approving the Watchman device.  Let me quickly recount the history.

In the first major study to evaluate Watchman, the Watchman device was shown to be as effective as warfarin in preventing strokes in A-Fib patients.  Where Watchman really shined was in the very low risk of bleeding.  This is likely due to the 3% annual risk of a life-threatening bleed with warfarin.

Sounds like an easy decision for the FDA, right?  Where the FDA struggled is that when cardiologists first started to implant Watchman in this study, there was a high risk of cardiac tamponade or bleeding around the heart.  Fortunately, later studies showed that most of this risk could be eliminated with experience.

As the FDA was not convinced with the first study, they asked for another study.  In this second study, not only was the risk of bleeding again low but the risk of cardiac tamponade was also low.  The concern with this second study was that after the study was published, there were a number of strokes in the Watchman group which tipped the balance of stroke prevention toward warfarin.

This left the FDA with a difficult decision.  Here is a new device that is difficult to learn.  Also, while it is much safer than warfarin, when it comes to bleeding, it may not be as good as warfarin when it comes to stroke prevention.

If you want to read more about this 6 year journey through the FDA, here is an excellent article from the Wall Street Journal.

The New Blood Thinners versus Watchman

At the time the Watchman was first submitted to the FDA, our only blood thinner for A-Fib was warfarin.  While the late night TV lawyers would have us believe that the new blood thinners (dabigatran/Pradaxa, rivaroxaban/Xarelto, apixaban/Eliquis, and endoxaban/Savaysa) are the most dangerous medications ever created, the truth is that they are much safer than warfarin.

Indeed, studies have shown that the risk of life-threateining bleeding with the new blood thinners is about 50% lower than warfarin.  The sad thing is that thousands of Americans have likely already suffered an A-Fib stroke because the lawyers scared them away from these potentially life-saving medications.

The reason why I bring up the new blood thinners versus Watchman issue is because the primary benefit of Watchman is a lower bleeding risk when compared to warfarin.  As the new blood thinners have a much lower risk of bleeding than warfarin as well, this bleeding reduction benefit with Watchman may not be as clear with the new blood thinners.

Our Experience with Watchman

At our center we have been implanting the Watchman device for most of the last decade as part of clinical studies.  We have implanted this device in hundreds of patients with minimal complications.  We have found Watchman to be extremely effective in preventing strokes and are excited to again offer this as an alternative to blood thinners for our high risk A-Fib patients.

What Should Lisa Do?

Lisa is the perfect Watchman candidate.  She has already had an A-Fib stroke and has had a life-threatening bleed from blood thinners.  For her, the decision is quite simple.

Is Watchman Right for You?

At the end of the day, is Watchman something you should consider?  First of all, I would only consider the Watchman device for patients at high risk of an A-Fib stroke.  To learn if you are at high risk of an A-Fib stroke, please read this article I wrote.

In addition to being at high risk of an A-Fib stroke, patients should also meet one of the following situations:

1. Unable to take blood thinners due to a previous life-threatening bleed.

2. Patients at high risk of a life-threatening bleed with blood thinners.

3. Patients with high risk occupations or lifestyles which would make blood thinners dangerous for them.

Are you considering the Watchman Device?

Disclosure

If you feel like you might be a good candidate for Watchman, please discuss this with your cardiologist.  Together, the two of you can decide if the potential benefits of Watchman outweigh the risks of this procedure.  Also, you can have an in-depth discussion about Watchman versus blood thinners.  Please, do not self diagnose or treat based on anything that you have read in this article.

#AF-004 When Should I Consider an Ablation for A-Fib?

January 4th, 2014 by

When Should I Consider an Ablation for A-Fib?

John had been struggling with atrial fibrillation (A-Fib) for years.  He had tried the medications but they all made him feel tired.  He just did not like the way he felt when his heart was out of rhythm.  Should he consider a catheter ablation procedure to manage his A-Fib?

In this article we will discuss when an ablation procedure should be considered for the treatment of A-Fib.

What is a catheter ablation procedure?

A catheter ablation procedure is a minimally invasive procedure where a cardiologist inserts thin catheters through your veins and advances them to the heart.  Once these catheters are in your heart, a 3D map is often created to see where these abnormal heart rhythms are originating from.  Once the rogue spots that are causing A-Fib are identified, these areas are then cauterized or frozen to keep the heart beating normally.

Patients may go home the same day or they may be observed overnight.  Typically just a band-aid is used for the puncture sites as stitches are not even required for this procedure.  To see video footage of an ablation you can watch this TV segment.

Do I have to take a medicine first?

Many patients who come to see me are disheartened to learn that I generally encourage them to try an antiarrhythmic medication first.  The reason is that this is the approach recommended by the A-Fib Treatment Guidelines and the fact that many insurance companies will not pay for the procedure unless an antiarrhythmic has been tried first.

On average, I find these anti-arrhythmic medications generally only work for a year or two.  For some patients they do not work at all.  For other patients I have found that they may effectively control A-Fib for more than 20 years!

One potential advantage to trying a medication first is that our technology for catheter ablation procedures just gets better with time.  Thus, if you can control your A-Fib for 3-5 years, we may have an even better treatment option for A-Fib at that time.

One thing to remember is that antiarrhythmics are not without risk.  Most of the antiarrhythmics studied have been shown to increase the risk of premature death.

Should I wait to have my ablation procedure?

Patients often ask me, “can I wait to have my ablation?”  My answer generally is that as long as you can maintain normal rhythm it is a reasonable option to wait for an ablation procedure.

There is a common saying that “A-Fib begets A-Fib.”  The reason is that episodes of A-Fib may lead to scarring of the heart.  This heart scarring then leads to even more episodes of A-Fib.

For patients who have been continuously out of rhythm for more than 1 year, the chances of a successful ablation procedure decrease significantly.  Indeed, we have published a study which showed that the longer an ablation is delayed the lower the chances of success.

What are the benefits of a catheter ablation?

In countless studies, the two clearly proven benefits of catheter ablation for A-Fib include the following:

1. To control A-Fib symptoms

2. To increase your chances of holding normal rhythm

While no one questions the role of a catheter ablation to control symptoms and increase your chances of holding normal rhythm, the question many have sought to know is will it prolong life, prevent strokes, and prevent dementia.

In our study of 37,908 patients at Intermountain Healthcare we asked this very question.  Our study showed that those patients who elected to have a catheter ablation procedure lived much longer and were much less likely to suffer from a stroke or dementia.

It should be pointed out that our study did not randomize patients to the two different treatments strategies, namely ablation versus drugs.  As it was not a randomized study, catheter ablation cannot yet be considered as a proven way to prevent premature death, strokes, and dementia.

To fully answer this question, there is an ongoing large multi-center study, called the CABANA Study, which will answer this question.  This study is funded, in part, by the National Institutes of Health.

Who is the ideal ablation candidate?

Another question I am frequently asked is “am I a good candidate for an ablation?”  After personally performing more than 4,000 catheter ablation procedures for A-Fib, these are the patients that I have found who are most likely to be “cured” from A-Fib.

1. They have paroxysmal A-Fib (A-Fib stops on its own)

2. Their left atrium is normal in size

3. They don’t have any other cardiac or medical problems

4. They have an ideal body weight

5. They are young

What are the risks of a catheter ablation procedure?

Unfortunately, catheter ablation procedures are not risk free.  Many complications can occur.  For example, patients could suffer the following complications: bleeding, infection, heart attack, stroke, tear in the heart, damage to the pulmonary veins, esophageal perforation, nerve damage, emergent open-heart cardiac surgery, or even death.

When it comes to the risk of a complication, experience does matter.  Like everything in life, the more you do something the better you get at doing it.

When it comes to catheter ablation, studies show that if your procedure is done by an inexperienced physician or hospital, you have a 1 in 200 chance of never leaving the hospital alive.  In this study, an inexperienced physician was defined as a cardiologist (an electrophysiologist or cardiologist specializing in heart rhythm disorders) who did less than 25 of these procedures each year.  An inexperienced hospital was defined as a hospital that did less than 50 of these procedures each year.

If your electrophysiologist has recommended a catheter ablation procedure for A-Fib, find out how experienced they are, how experienced the hospital is, and ask them to show you their complication rate data.  If they cannot show you these numbers you may want to consider looking elsewhere for a procedure which could have significant complications.

Should I have a radiofrequency or cryoballoon ablation procedure?

There are two general ablation approaches for atrial fibrillation, radiofrequency (heat energy) or cryo (cold energy).  Either approach can effectively eliminate the areas of the heart which are misfiring.  As there are no data showing which approach is best, the best approach for you is the technique your electrophysiologist is most comfortable with.

Is a surgical ablation procedure better?

In addition to the catheter approaches, there is also a surgical approach to treating atrial fibrillation.  If you need open-heart surgery bypass surgery or valve surgery, your surgeon could easily perform a MAZE surgery for atrial fibrillation while your chest is open.

Surgeons have now started doing less invasive surgeries for atrial fibrillation which involve much smaller incisions in your chest.  For many patients, these “Mini-MAZE” surgeries can be very effective in controlling A-Fib.

Certainly, the more invasive the procedure is the higher the risks.  Studies have not shown whether the surgical approach is more effective than catheter approaches in treating A-Fib.

The surgical approach for A-Fib could be a good option if you live in a region where you have an experienced surgeon and your electrophysiologist is inexperienced in performing catheter ablation procedures.

Should John consider an ablation procedure?

In John’s case, his atrial fibrillation has caused him significant symptoms.  When he is out of rhythm he feels very tired and short of breath with any activity.

John had also tried an antiarrhythmic medication to control his A-Fib.  Initially he tried flecainide.  When flecainide was no longer effective he tried sotalol.  Both of these medicines not only failed to control his symptoms but also caused him to feel very tired.  To be honest, John also did not like having to take medications for the rest of his life.

As he had symptoms from A-Fib and medications were ineffective, he clearly met the established criteria for a catheter ablation procedure.  Fortunately, his procedure went well and he is now drug-free and doesn’t have any more A-Fib.

Should I consider an ablation procedure?

At the end of the day, should you consider a catheter ablation procedure?  Regardless of whether you are an ideal candidate or not, the following are the people who should at least consider this procedure:

1. Your A-Fib causes you symptoms

2. Antiarrhythmics either don’t work or cause significant side effects

3. You have been in normal rhythm within the last year

Has your doctor recommended a catheter ablation procedure?

 

#AF-003 10 Ways to Cure A-Fib without Drugs or Procedures

January 3rd, 2014 by

10 Ways to Cure A-Fib without Drugs or Procedures

Atrial fibrillation (A-Fib) is up to 10 times more common in North America than in Asia according to a recent medical study published by my good friend, Dr. Sumeet S. Chugh, at Ceaders-Sinai based on a grant from the Bill and Melinda Gates Foundation.

Interestingly, according to research by Dr. Gregory M. Marcus from the University of California at San Francisco, when Asians immigrate to the U.S., they lose their protected status against A-Fib and soon develop rates of A-Fib similar to other Americans.

How can we explain the fact that A-Fib is 10 times more common in North America?  Is A-Fib under reported in Asia or is there something different about our lifestyles?

Is A-Fib Under Reported in Asia?

When most physicians hear Dr. Chugh’s work that A-Fib is up to 10 times more common in North America, they naturally assume that this condition is under reported in Asia.  While it is possible that there is a component of under reporting going on, other studies suggest that this may not be the case.

The easiest study to answer this question is to just do an EKG on everyone in a specified population and count up the cases of A-Fib.  If you don’t miss anyone with a screening EKG, then there will be no underreporting of the disease.  As A-Fib is more common as people age, why not just do an EKG on everyone over age 100 as these people will represent the highest rates of A-Fib in a population?

A-Fib in Centenarian Studies

When researchers did just this, an EKG on everyone over age 100, they came up with the following results.

1. A-Fib in U.S. centenarians: 27%

2. A-Fib in Danish centenarians: 17%

3. A-Fib in Chinese centenarians (Bama County): 4%

Clearly, even when there is no underreporting of A-Fib, the rates of A-Fib are still much higher in the U.S. than in Asian or Europe, consistent with the findings of Dr. Chugh’s study.  As the U.S. is a “melting pot” country where people come from around the world to live, why is it that their A-Fib risk goes up dramatically once they move here?

Based on these studies that I have presented thus far, this naturally begs the question, is 80-90% A-Fib preventable?  From my experience as a cardiologist treating thousands and thousands of A-Fib patients, the answer is a resounding “Yes!”  Even for people who have already been diagnosed with A-Fib, if A-Fib is diagnosed early enough and if aggressive lifestyle changes are made fast enough, it has been my experience that many cases of A-Fib will simply go into remission.

10 Ways to Cure A-Fib without Drugs or Procedures

As I have spent a lot of time researching the question of is 80-90% of A-Fib preventable, I would like to share with you 10 ways to cure A-Fib without drugs or procedures.  These approaches work as I have seen the results first hand in my cardiology practice.

Not only will these 10 strategies help your A-Fib but it will also help to prevent or reverse many other chronic medical conditions that afflict so many of us in the United States.  Even my 80 and 90 year old patients have taught me that it is never too late to change!

1. Change Your Genes

Genes certainly play a role in A-Fib, like most other medical conditions.  Studies do show that Caucasians have a slightly higher risk of A-Fib when compared to people of other ethnicities.

Despite what your “genes may say,” recent studies have shown that your lifestyle can determine which genes get turned on or off based on epigenetic markers.  Thus, even if you did inherit the “A-Fib gene,” this gene can be silenced through a molecular “tag” that comes from a healthy lifestyle which can attach to the outside of the gene.

As I have long had an interest in treating A-Fib, I wanted to know if I inherited any A-Fib genes.  Thus, for $99 I had my genome tested by 23 and Me at home by simply spitting into a test tube and mailing it back to the company.  Then, for an additional $5, I had my raw genetic data from 23 and Me interpreted by a different company called Promethease.  Interestingly, 23 and Me used to give you a detailed interpretation of your genetic results until the FDA became concerned that Americans would not be smart enough to know what to do with this genetic information.

Fortunately, I learned that I have the Gs273 gene which means I have the lowest risk of A-Fib among Caucasians.  Whew, at least my chances of A-Fib are reduced by 18% because I have this gene which protects me against A-Fib.

Even if I did test positive for the A-Fib genes, I know that I could turn these genes off by closely adhering to the next 9 lifestyle strategies that I discuss below.

2. Don’t Smoke

If you have ever smoked or are currently smoking then you are at a significantly increased risk of A-Fib.  Indeed, studies have shown that if you are currently smoking you are 2.1 times more likely to develop A-Fib.  If you are no longer smoking then your risk of developing A-Fib is 1.3 times higher.

Smoking likely causes A-Fib through a process known as oxidative stress, also known as “rusting of the body,” in which free radicals damage our heart cells and DNA.  The message though is very clear, if you can stop smoking now then you can decrease your risk of A-Fib by 36%!

3. Lower Your Blood Pressure

High blood pressure has long been known to raise the risk of A-Fib.  As the heart has to pump against a higher load it causes stretching and thickening of the heart, ultimately leading to scarring and enlargement of the left atrium.  As a result of heart scarring and enlargement, the electrical pathways are disrupted thereby causing A-Fib.

Studies have shown that having a history of high blood pressure can increase the risk of A-Fib by 56%!  Unfortunately, new treatment guidelines for high blood pressure have now become very lax, especially in older individuals.

Thus, even if you have high blood pressure, your doctor may now decide not to treat it.  The concern is that if blood pressure is not aggressively managed in A-Fib patients then their arrhythmias may become even more difficult to treat in the future.

Fortunately, if caught early, I have found that most cases of high blood pressure can be treated without medications.  I know this was the case with me.  To learn more about how to lower your blood pressure naturally, please read my article How to Lower Your Blood Pressure with These 8 Steps.

4. Don’t Drink Alcohol

I realize that you have probably heard that a little alcohol is good for the heart.  While newer studies challenge whether alcohol is healthy or not for the heart, certainly when it comes to A-Fib any alcohol can be dangerous.

In a large study of 79,019 people with no prior history of A-Fib, researchers found that over the following 10 years, even just 1 alcoholic drink a day increased their risk of A-Fib by 8%.  This risk then went up to 39% for those people having 3 or more alcoholic drinks each day.

This large study showed for the first time that there is no safe level of alcohol that you can drink when it comes to A-Fib.  The more you drink the higher your risk of A-Fib.

5. Minimize Stimulants

Any drug which stimulates the body also stimulates the heart and may increase the risk of A-Fib.  As a cardiologist treating patients with A-Fib, I am seeing more and more cases of A-Fib from energy drinks, like Red Bull, especially in young men.

It is not clear yet if this increased risk of A-Fib from energy drinks is from the caffeine, sugar, taurine, or other chemicals in these drinks.  Ongoing studies will hopefully answer these questions.

While there are no reliable studies yet on the subject, I am also seeing many cases of A-Fib from patients taking Attention Deficit Hyperactivity Disorder (ADHD) medications.  The amphetamine compounds in ADHD medications are causing a wide array of arrhythmias in my patients.

When it comes to caffeine and A-Fib, the data are not so clear.  Some studies suggest there is an increased risk of A-Fib with coffee while others do not.  At the end of the day, you need to find out for yourself whether or not caffeine is triggering your A-Fib. If you find that you go into A-Fib on the days you have caffeine then it just may be a trigger for you.

6. Get Restorative Sleep

Sleep is critical when it comes to preventing or reversing A-Fib.  Unfortunately, as a society we are sleeping less and less.  For example, we now sleep 2 hours less than in the 1960s.  Studies show that not getting enough sleep can increase your risk of A-Fib by 3.4 fold!

One of the biggest problems for A-Fib patients struggling with getting enough sleep is sleep apnea.  Unfortunately, many patients with A-Fib are also overweight which then leads to sleep apnea.

In sleep apnea, the extra fat in the neck and in the back of the tongue can obstruct your airway while sleeping.  Usually, the spouse or sleeping partner can make the diagnosis as these patients tend to snore and occasionally stop breathing while sleeping.

If you think you might be suffering from sleep apnea then get tested.  Depending on what study you look at, your risk of A-Fib is about 4 times higher with sleep apnea.  In my practice we offer sleep apnea screening for most patients with A-Fib.

As of the time I am writing this article, there are no studies yet showing that getting treated for sleep apnea with a CPAP machine will reduce or reverse A-Fib. However, in patients who have had an A-Fib ablation, one study has shown that CPAP therapy can double their chances of a successful ablation.

7. Reverse Your Diabetes

Diabetes is another epidemic striking the U.S.  Indeed, studies show that diabetes has increased by 75% over the last 20 years in the U.S.!

Diabetes is another important A-Fib risk factor.  As with high blood pressure, if aggressive lifestyle changes are made early enough, most cases of diabetes can be reversed.

In one of the most insightful studies on the role of diabetes in A-Fib, researchers reported that diabetes increases your risk of A-Fib by 40%.  Even more interesting was the finding that the higher your average blood sugar and the more years you are diabetic, the higher your risk of A-Fib.

Like with smoking, the reason why diabetes increases A-Fib is likely due to oxidative stress, or “rusting” of the body.  If you now suffer from diabetes, there are likely lifestyle changes that you can make to either put your diabetes in remission or significantly reduce the amount of medications you need for this condition.  Your heart will definitely thank you for these lifestyle changes!

8. Lower Your Stress Levels with Yoga

Probably one of the main questions patients ask me on their first clinic visit for A-Fib is “did stress cause my A-Fib?”  If you have asked this same question of your doctor they likely downplayed this link between stress and A-Fib.

The truth is that the heart and the brain are intimately connected.  Any stress you may be feeling will be felt by your heart as well.

In an interesting study, Swedish researchers randomly selected 7,494 men and asked them if they had a “stressful job.”  They defined a “stressful job” as a job in which there were high demands and low autonomy.  To me, this sounds like most jobs including my own job.

Researchers then followed these 7,494 Swedish men for the next 7 years.  At the end of the 7 years they found that those who reported having a stressful job were 32% more likely to develop A-Fib.

It is not just a stressful job that can cause A-Fib but any negative emotions as well.  In a fascinating study by my friend, Dr. Rachel Lampert at Yale University, she found that feeling sad, angry, stressed, impatient, or anxious increased your risk of going into A-Fib on that day by 3 to nearly 6 fold!  Even more interesting was that at least when it comes to feeling angry or stressed, this increased risk of A-Fib is carried over to the next day.

Perhaps this explains why my good friend, Dr. Dhanunjaya Lakkireddy, showed in a well designed clinical study that yoga can reduce your A-Fib burden by 24%.  It is for this reason that I now recommend yoga for my A-Fib patients.

9. Exercise Moderately for Life

It has long been known that exercise is good for the heart.  The same, when done in moderation, is also true when it comes to A-Fib treatment.

In an interesting study, Australian researchers were able to show that when they could get men to go from “couch potatoes” to at least some limited form of exercise that they could reduce their A-Fib burden by 50%.  When it comes to exercise, even just a little bit can have a huge benefit when it comes to the heart.

However, those people who carry exercise to the extremes like in the case with competitive long distance cross country ski racers, marathon runners, or Ironman triathletes, the risk of A-Fib can increase significantly in these people.  Indeed, studies show that the faster your times in these endurance events and the more you of them you do, the higher your risk of A-Fib.

The cause of A-Fib is endurance athletes is likely due to fibrosis (scarring of the heart) due to pushing their hearts beyond what they were designed to do.  For many of these endurance athletes, if they would simply back off on their training or stop competing competitively, their A-Fib would go away.  However, this is something most of these patients cannot do as they have become “addicted” to extreme levels exercise.

These endurance athletes also cannot take medications for A-Fib as they are unable to compete effectively on cardiac drugs.  Thus, I have found that for most of my competitive endurance athletes with A-Fib, we have had to move toward an A-Fib ablation procedure so that they can continue to compete.

10. Lose the Extra Weight

Since the landmark Framingham A-Fib study in 2004, it is well known that obesity is a powerful risk factor for A-Fib.  In this study, people who were overweight had up to a 52% increased risk of A-Fib.  Researchers identified that the increased risk of A-Fib in overweight people is likely due to enlargement of the left atrium.  Today, from the same ongoing Framingham Heart Study, we also know that extra fat accumulation around the heart and scarring of the heart from obesity are also to blame for the increased risk of A-Fib.

Recent studies have shown that if people can get off the extra weight they can reverse their A-Fib.  For example, my friend Dr. Yong-Mei Cha at the Mayo Clinic, showed that gastric bypass surgery can prevent A-Fib.  Another friend, Dr. Prashanthan Sanders from the University of Adelaide, showed that by simply losing 32 pounds in an overweight person they could dramatically reduce their A-Fib burden.

This is something I have also seen in my own A-Fib practice.  Weight loss seems to be the most effective way to reverse A-Fib without drugs or procedures in my overweight patients with A-Fib.  It doesn’t take much weight loss to see a clinical benefit.  Even just losing 5 to 10 pounds can have a significant benefit.

I recently gave a presentation to an A-Fib audience on this exact blog article. Here is a link to this presentation.

Disclaimer

If you have A-Fib and want to drive it into remission without drugs or procedures, please work under the close supervision of your physician to achieve this goal.  This goal is certainly possible as I have seen it for many of my patients.

With this article I am not providing any medical advice.  All information shared is general information based on published medical studies and information that has been shared at medical conferences.  In addition, do not self diagnose or treat based on anything that you have read in this article.

#AF-002 Do I Have to Take a Blood Thinner for A-Fib?

January 2nd, 2014 by

Do I Have to Take a Blood Thinner for A-Fib?

If there is one thing I have learned as a cardiologist specializing in atrial fibrillation (A-Fib) it is that patients do not want to take a blood thinner.  While strokes are a feared complication of A-Fib, many of my patients would rather take their chances than gulp down a blood thinner each day for the rest of their lives.  Are there any other options?

The A-Fib Guidelines Have Changed

Until the most recent A-Fib guidelines came out in 2014, a large percentage of my patients could be safely treated with just a baby aspirin each day to prevent a stroke.  Unfortunately,”expert opinion” has swung too far in the other direction and now almost everyone is indicated to take a blood thinner for the rest of their lives.  This has huge implications, especially for women, as I will describe in this article.

Lisa’s Dilema

Lisa is a very healthy and active 65 year old woman.  She skis vigorously in the winter and competes in mountain bike races in the spring, summer, and fall.  Her passion for life are her skis and her mountain bike.  Lisa also has a history of A-Fib.

Lisa’s A-Fib interfered with her ability to compete in sports.  She had tried flecainide to control her rhythm but that only made things worse.  Frustrated, and with no other good options, she opted for a catheter ablation procedure to rid her of her A-Fib.

Fortunately, her ablation procedure went very well and she has had no further episodes of A-Fib.  She is now back to skiing and and mountain biking.  She is loving life again but she is still on a blood thinner despite her high risk of trauma from skiing or mountain biking.

As dangerous as skiing is, my orthopedic colleagues tell me that they see far more fractures and other serious injuries from mountain biking.  As a mountain biker myself I can readily attest to this.  For example, last summer I went over my front handle bars three times while mountain biking the legendary trails of the Wasatch Mountains in Utah.  Fortunately, I do not take blood thinners.

According to the latest A-Fib guidelines, because Lisa is a woman and she is 65 years old, the guidelines would call for her to be on a blood thinner for the rest of her life.  These guidelines stipulate that a blood thinner is recommended regardless of the fact that she has had a successful ablation procedure with no further recurrences of her A-Fib.

What should she do?  Can the guidelines really be right in her case?

Who should be on a blood thinner for life?

Before we get back to Lisa’s case, we need to back up and review the latest A-Fib guidelines.  Whether or not you should be on a blood thinner for life is determined by your CHADS-VASc score.  It does not matter if your A-Fib comes and goes (paroxysmal), present all of the time (persistent), or whether you have had an ablation.

In the CHADS-VASc scoring system, people can have a score of 0-9.  Lower is better with this scoring system.  Based on your score, here are the recommendations:

CHADS-VASc of 0: No blood thinners of any kind are needed

CHADS-VASc of 1: Blood thinners, aspirin, or nothing could be prescribed

CHADS-VASc of 2-9: Blood thinners for life

How do I know what my CHADS-VASc score is?

If you want to know your CHADS-VASc score there is a simple way to calculate your score.  Here is the scoring system:

C: Congestive heart failure, 1 point

H: High blood pressure, 1 point

A: Age 65, 1 point

D: Diabetes, 1 point

S: Stroke or Mini-Stroke, 2 points

V: Vascular disease (prior heart attack or blockages elsewhere in the body), 1 point

A: Age 75, 1 point (you can have up to 2 points based on age)

S: Sex or female gender, 1 point

As you can see from this scoring system, if you are a woman then a blood thinner for life could be indicated.  Is this really a fair scoring system?

What are my odds of a stroke based on my CHADS-VASc score?

In order to make an educated decision regarding whether or not you should take a blood thinner for the rest of your life, you need to know what the odds of a stroke are.  According to the A-Fib guidelines, here is your annual risk of a stroke based on your CHADS-VASc score.

CHADS-VASc of 0: 0% annual stroke risk

CHADS-VASc of 1: 1% annual stroke risk

CHADS-VASc of 2: 2% annual stroke risk

CHADS-VASc of 3: 3% annual stroke risk

CHADS-VASc of 4: 4% annual stroke risk

CHADS-VASc of 5-9: 7-15% annual stroke risk

What are my odds of a life-threatening bleed on blood thinners?

To weigh the risks versus benefits you need to now know the risk of a life-threatening bleed based on taking a blood thinner.  To simplify this process, the blood thinner with the highest risk of bleeding is warfarin (Coumadin) and the blood thinner with the lowest risk of bleeding is apixaban (Eliquis).

The other FDA approved blood thinners in the U.S., dabigatran (Pradaxa), rivaroxaban (Xarelto), and endoxaban (Lixiana) all have an annual bleeding risk somewhere between warfarin (Coumadin) and apixaban (Eliquis).

In the best study to evaluate the real risk of bleeding with these medications, the ARISTOTLE Trial, the annual risk of life-threatening bleeding in 18,140 patients was 2.13% with apixaban (Eliquis) and 3.09% with warfarin (Coumadin).  To put these numbers in perspective, this means that each year 2 in every 100 patients taking apixaban (Eliquis) and 3 in every 100 patients taking warfarin (Coumadin) may die or be seriously harmed by a bleeding complication.

Can’t I just take aspirin instead of a blood thinner?

With the unavoidable risk of life-threatening bleeding with blood thinners I am frequently asked this question.  Unfortunately, aspirin has not shown any consistent benefit in stroke prevention in medical studies.  Some studies showed it was beneficial while others have not shown any benefit.

While a baby aspirin may seem like a very safe medication, there is still about a 1 in 200 risk each year of a life-threatening bleed from aspirin.  It is for this reason that the role of aspirin was significantly downgraded in the most recent A-Fib guidelines.

Will an ablation decrease my risk of a stroke?

Intuitively it just makes sense that if you can eliminate A-Fib then the risk of a stroke should go way down.  Indeed, this is what we have seen based on our experience at Intermountain Medical Center.

In our landmark study of 37,908 patients, we showed that an A-Fib ablation procedure can dramatically reduce the long-term risk of a stroke!  Regardless of how we analyzed the data, as seen in this subsequent medical study, ablation decreased the long-term risk of a stroke.

While other experienced centers have shown similar findings, as these results have not yet been verified in a multi-center randomized study, they are not yet accepted as fact within the medical community.  It is for this reason that the 2014 A-Fib Guidelines still do not recognize that in the right hands at experienced hospitals, an A-Fib ablation can decrease the long-term risk of stroke.  Thus, with the guidelines as they are currently written, we can’t offer ablation as an alternative to life-long blood thinners.

Are there any other options to avoid life-long blood thinners?

Yes, other options are available.  As 90% of the strokes from A-Fib arise from a pouch in the left atrium (left atrial appendage), this left atrial appendage can be removed or plugged to decrease the risk of a stroke.

Watchman Device

The best studied way to close off the left atrial appendage is the Watchman device.  We have implanted this device in hundreds of patients as part of medical studies at our hospital with excellent results.

It is an overnight procedure and patients go home the next day with no cutting and no stitches.  Also, the Watchman device has been available for years in Europe.  However, at the time of this writing it is still not FDA approved in the U.S.

Lariat Procedure

Another option is the Lariat Procedure.  Once again, this is another overnight procedure with no stitches that closes off the left atrial appendage.  We have also had excellent results with this device at our hospital.

While the FDA mysteriously approved this device, there are no convincing data from multi center trials yet that it actually works as promised.  As data are still lacking, many insurance companies are refusing to pay for this procedure.

The ironic thing is that the Watchman device has been extensively studied in thousands of patients and still is not FDA approved whereas the Lariat procedure was FDA approved with no significant data that it even worked.  Go figure.

Surgical Left Atrial Appendage Excision

For patients who require cardiac surgery for other reasons, surgical left atrial appendage excision can be another viable option.  Interestingly, while surgeons have been cutting off the left atrial appendage in A-Fib patients for decades, this surgical procedure has never been studied in a rigorous manner to see if it even works.

The tricky part with the surgical approach is that, even in the best of hands, surgeons will leave a “stump” of the left atrial appendage in about 1 in 3 patients.  Often this “stump” can be a cause of stroke in A-Fib patients.

Thus, in my patients who have undergone surgical removal of their left atrial appendage, I like to perform a transesophageal echocardiogram to confirm there is no remnant “stump” before stopping their blood thinners.

Do natural blood thinners work?

While many of my patients swear by natural blood thinners, such as nattokinase, fish oil, garlic, or vitamin E, to date there are no data that show that any of these natural products can decrease the risk of A-Fib strokes.  Thus, given the lack of data, I cannot recommend these natural products as a substitute for traditional blood thinners.

However, where patients can get into trouble is when they combine these natural blood thinners with pharmaceutical grade blood thinners such as warfarin (Coumadin), apixaban (Eliquis), etc.  If you take any supplements please make sure your doctors are aware of what you are taking.

Should Lisa take a blood thinner for the rest of her life?

Getting back to Lisa, should she take a blood thinner for the rest of her life?  Her CHADS-VASc score is 2 for female gender and because she is 65 years old.

With a CHADS-VASc score of 2 her annual stroke risk is 2%.  However, her annual life-threatening bleeding risk on apixaban (Eliquis) is also 2% per year.  Seems like a wash, right?

To further complicate the analysis, she did have her A-Fib ablation procedure done at our hospital and we know from our study of nearly 40,000 patients that her long-term stroke risk is now low but definitely not zero.  Is she more at risk from bleeding out while skiing or mountain biking or from an A-Fib stroke?

As she is also concerned about her bleeding risk, on her own she decreased her apixaban (Eliquis) from twice a day to just once daily.  Once again I cannot recommend this approach as it has never been studied and it is an off label use of this medication.

At the end of the day, Lisa is a very intelligent patient who fully understands the blood thinner dilemma that she is in.  I cannot say whether what she has decided to do is right or not because it has never been studied.  Also, patients like Lisa who engage in high risk sporting activities have not been adequately studied in these big clinical trials.

What should I do?

By this point in the article you are probably confused as to whether you should take a blood thinner for your A-Fib or not.  This is why you need to have a very candid discussion with your physician to see if a blood thinner is right for you or not.

The new A-Fib Guidelines recommend that nearly everyone take a blood thinner, especially women.  The key is to clearly know your annual stroke risk, based on your CHADS-VASc score, as well as your annual bleeding risk depending on which blood thinner you are on.  Like almost everything else in medicine, it is a decision you and your physician need to make together in weighing the risks versus benefits.

Disclaimer

The decision whether or not to take a blood thinner for life is a huge decision with significant consequences either way.  This is something that you must discuss openly and honestly with your physician.

Please remember that everything I shared in this article is general information.  I never share medical advice.  Moreover, reading  this article does not create a doctor patient relationship.  Also, do not self diagnose or treat based on anything that you have read in this article.

#AF-001 The Most Important Factor to Cure A-Fib

January 1st, 2014 by

The Most Important Factor to Cure A-Fib

Do you or a loved one suffer from A-Fib?  A-Fib, which is also known as atrial fibrillation or “AF,” is the most common heart arrhythmia and affects 1 in 4 adults.  In A-Fib the heart typically beats very fast and irregularly leading to strokes, heart failure, dementia, and even premature death.

Just what exactly is the most important factor to cure A-Fib?  In this article we will explore the most important factor to cure A-Fib.

A-Fib 20 Years Ago

I can hardly believe it but 20 years have now passed since I graduated from Johns Hopkins Medical School.  I remember seeing my first case of A-Fib as a fresh young intern at Stanford University Medical Center in 1995.

John was an overweight 52 year old man who suddenly developed severe chest pain and palpitations while staying late at work one night to meet a stressful deadline.  Panicked he dialed 911 and was brought to the Stanford Hospital emergency room.  As I was the intern on call for the ER that night my pager went off and I was called to see John.

Seeing how severe his condition was we quickly shocked his heart back into normal rhythm.  It was just like what you might see on TV except his body did not jump off the table when we shocked his heart.

While this temporarily corrected his arrhythmia it was just a matter of time before I would see him again for more episodes of A-Fib.  In those days we really did not understand what caused A-Fib and all we had available to treat A-Fib were medications.

A-Fib Treatment in the Last 10 Years

Fast forward to the last 10 years.  Now, if you or a loved one has suffered from A-Fib then you have undoubtably heard about the very popular catheter ablation procedure.

As a cardiologist specializing in the treatment of heart rhythm disorders I personally have done more than 4,000 of these catheter ablation procedures for patients suffering from atrial fibrillation.  A catheter ablation procedure is where we go into the heart with catheters through a vein in the leg.

This procedure is so minimally invasive that all it requires is an IV.  No cutting or stitches are needed.  Once catheters are in the heart we can 3-dimensionally map out the source of A-Fib and then either cauterize or freeze those areas of the heart.

While this treatment approach has been very successful in treating A-Fib, unfortunately the arrhythmia often comes back a few years later.  When A-Fib recurs the ablation procedure is done again.  Some patients may even have three or more of these catheter ablation procedures performed.

Is there a better way to treat A-Fib?

As I have been involved in helping to develop the catheter ablation procedure for A-Fib since it was first developed in 1998, it has always troubled me that so many of these “successfully” treated patients have had their A-Fib come back.  Why is this the case?

Fortunately, we now have a much better understanding of the various causes of A-Fib.  For example, the obesity epidemic in the U.S. has made the U.S. the A-Fib capital of the world!  In fact, A-Fib is nearly 10 times more common in the U.S. than in Asian countries.

It is not just the obesity epidemic but also high blood pressure, a poor diet, stress, lack of exercise, and sleep apnea, among other conditions, which is driving the A-Fib epidemic.  Based on our new understanding of the causes of A-Fib we now know that while a catheter ablation procedure can be very effective in treating today’s A-Fib, if aggressive lifestyle changes are not made then it is just a matter of time before new A-Fib areas develop.

This new understanding of A-Fib led my good friends and fellow colleagues in Australia to perform a landmark study in the cardiology world to see if aggressive lifestyle modification changes can improve the long-term success of catheter ablation.

The ARREST-AF Study

In the ARREST-AF Study, my good friends in Australia recruited 149 overweight A-Fib patients who had recently undergone an A-Fib ablation procedure.  Of these 149 patients, 61 volunteered to participate in an aggressive lifestyle modification program.  The 88 patients that were unwilling to “change their ways” after this heart procedure served as the control group.

This aggressive lifestyle modification program consisted of the following:

1. Weight loss

2. Aggressive control of blood pressure, lipids, and diabetes

3. Treatment of sleep apnea

4. Smoking cessation

5. Decreasing alcohol intake

The group of patients who signed up for lifestyle modification did very well in “changing their ways.”  They were able to lose 29 pounds (13.2 kg), stop smoking, limit alcohol intake, and get their blood pressure, lipid, diabetes, and sleep apnea under control.  Many of these conditions were even reversed.

With these changes, the group that participated in lifestyle changes were 3 times more likely to have their procedure work long-term.  Unfortunately, for the group unwilling to make changes, most had their A-Fib come back within two years of their heart procedure.

Take Home Message of this Study

The big picture or take home message of this study is that modern medicine is not a “fix” for poor lifestyle choices.  We simply cannot undo years of damage with a pill or a procedure.

If you want to beat A-Fib, or for that matter any heart condition, the most important factor is to adopt a healthy lifestyle.  Indeed, studies show that 80% of all heart conditions are completely preventable or reversible with a healthy lifestyle.

It is not just heart disease either.  A healthy lifestyle can prevent cancer, Alzheimer’s Disease, diabetes, and most other medical conditions.

We are not victims of the genes we inherited from our parents.  Whether or not we will suffer from long-term medical conditions in this life, to a large extent, is based on the daily decisions we make.

Even if you have abused your body in the past it is never too late to change.  The body has a remarkable ability to heal itself if we will just give it a chance.  Make the commitment today to make healthy decisions!

Do you want to learn more about how to prevent atrial fibrillation naturally?  Here is a recent presentation I delivered at the most recent Stop Afib symposium in Dallas, Texas.

What positive changes have you made in your life?  Please share with me your comments below.

Disclaimer

Please do not self diagnose or treat based on anything you have read in this article.  Please work with your individual physician in deciding what treatment strategy is best for you.