I have many patients who have only had one episode of atrial fibrillation. Typically this is a patient who had an unusual event that caused the atrial fibrillation.
I have one patient, for example, who had an episode of atrial fibrillation 15 years ago at a time when he had acute pericarditis. The pericarditis has not recurred and neither has the atrial fibrillation.
Some patients have their first episode of AFIB at the time of a severe pulmonary infection and have not had recurrent spells for decades. Others might have it at a time of profound hyperthyroidism that is corrected and not recur. About 1/3 of patients undergoing open heart surgery develop atrial fibrillation and recurrence rate is low.
I wish we had a good category name for the "one and done" fibber. And I wish we had good studies informing how best to manage anticoagulation in this group.
It has been a fascinating journey with afib since I started my cardiology training in 1984.
Once studies came out showing the superiority of warfarin over aspirin preventing stroke in afib I gave lots of talks (paid for by DuPont, the maker of Coumadin) on anticoagulation and how the new-fangled INR was superior to measuring PT alone. This was, of course, before I became the skeptical cardiologist and declined Pharma gifts/money/talks in order to maintain my unbiased status.
Mandrola recognizes the value of AFIB ablation for select patients, the limited efficacy and the complications but thankfully is not a gungho enthusiast. Most recently on TWIC he described how there are multiple white areas in the brain in patients who have undergone ablation, presumably micro embolic events, significance TBD.
I grew up in the era of rate control with digoxin (although a few attendings still used digitalis). Then came beta blockers. Around that time, I decided (without much clinical data) that rhythm control provided the best alternative to "simple" rate control. Part of the issue was blood pressure maintenance with the early beta blockers, which were prone to both hypotension and bradycardia. The landscape's also changed on anticoagulation. I'm old enough to have had to transition to INR from PT/PTT, while managing warfarin. Everyone diagnosed with AFib went straight to warfarin and we hoped we didn't bleed 'em out or fail to reach adequate status.
I'm interested in Mandrola's comments on ablation. Perhaps I've been more afraid of the potential complications than I should, but I was hoping ablation would be a panacea, freeing almost anyone from the risks associated with AFib including but not limited to stroke. Of course, I always expect some rogue pathway to allow a new arrhythmia to develop if AFib was the initial presentation. And I'm well aware of the duration of the procedure... I was involved with Paul Gillette and Tim Garson in early work on cryoablation (both open and catheter-based) for reentrant tachycardias. The animal model work could take all day, although we improved times in the cath lab with patients, somewhat out of necessity. We also looked at electro- and thermo-ablation for AV dysfunction and some rather ugly persistent reentrant ventricular pathways.
I'm not surprised that the finding that exercise has a strong favorable effect, nor that alcohol intake can precipitate or prolong AFib. These have been on my radar for a long time.
Chip,
I have many patients who have only had one episode of atrial fibrillation. Typically this is a patient who had an unusual event that caused the atrial fibrillation.
I have one patient, for example, who had an episode of atrial fibrillation 15 years ago at a time when he had acute pericarditis. The pericarditis has not recurred and neither has the atrial fibrillation.
Some patients have their first episode of AFIB at the time of a severe pulmonary infection and have not had recurrent spells for decades. Others might have it at a time of profound hyperthyroidism that is corrected and not recur. About 1/3 of patients undergoing open heart surgery develop atrial fibrillation and recurrence rate is low.
I wish we had a good category name for the "one and done" fibber. And I wish we had good studies informing how best to manage anticoagulation in this group.
Dr. P
Is there ever a "one and done" situation with Afib? In my case 2 years ago.
AC
Gerry,
It has been a fascinating journey with afib since I started my cardiology training in 1984.
Once studies came out showing the superiority of warfarin over aspirin preventing stroke in afib I gave lots of talks (paid for by DuPont, the maker of Coumadin) on anticoagulation and how the new-fangled INR was superior to measuring PT alone. This was, of course, before I became the skeptical cardiologist and declined Pharma gifts/money/talks in order to maintain my unbiased status.
Mandrola recognizes the value of AFIB ablation for select patients, the limited efficacy and the complications but thankfully is not a gungho enthusiast. Most recently on TWIC he described how there are multiple white areas in the brain in patients who have undergone ablation, presumably micro embolic events, significance TBD.
Dr. P
I grew up in the era of rate control with digoxin (although a few attendings still used digitalis). Then came beta blockers. Around that time, I decided (without much clinical data) that rhythm control provided the best alternative to "simple" rate control. Part of the issue was blood pressure maintenance with the early beta blockers, which were prone to both hypotension and bradycardia. The landscape's also changed on anticoagulation. I'm old enough to have had to transition to INR from PT/PTT, while managing warfarin. Everyone diagnosed with AFib went straight to warfarin and we hoped we didn't bleed 'em out or fail to reach adequate status.
I'm interested in Mandrola's comments on ablation. Perhaps I've been more afraid of the potential complications than I should, but I was hoping ablation would be a panacea, freeing almost anyone from the risks associated with AFib including but not limited to stroke. Of course, I always expect some rogue pathway to allow a new arrhythmia to develop if AFib was the initial presentation. And I'm well aware of the duration of the procedure... I was involved with Paul Gillette and Tim Garson in early work on cryoablation (both open and catheter-based) for reentrant tachycardias. The animal model work could take all day, although we improved times in the cath lab with patients, somewhat out of necessity. We also looked at electro- and thermo-ablation for AV dysfunction and some rather ugly persistent reentrant ventricular pathways.
I'm not surprised that the finding that exercise has a strong favorable effect, nor that alcohol intake can precipitate or prolong AFib. These have been on my radar for a long time.
Thanks for a very informative piece.