#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?


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-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.


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.


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.


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.


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.