Does eliminating afib reduce risk of stroke, etc?

Hi All,

It seems to be common wisdom that having fib increases the risk of stroke and mortality. Yet I have seen studies and medical articles on the subject that say having an ablation or otherwise eliminating afib does not reduce the risk of stroke. Likewise life expectancy is not necessarily improved if you eliminate the afib. I heard one doctor say that getting off of anticoagulant medication should not be the rationale for having an ablation. This doesn't make sense to me. Hoew can having afib increase a risk if eliminating afib doesn't reduce the risk? Does anyone have insight on this seeming paradox?

In addition to getting rid of afib, you'd also like to lower your CHA2DS2-VASc score as much as possible <[en.wikipedia.org]

In my case, I keep my afib in remission (about 4 hours in 4 episodes in 5 years with high dose mag & deraining from endurance activities) and a CHA2DS2-VASc score of zero. I also focus on things like BP (105/65), HbA1c 4.6% & etc. I take no meds except for flec PIP when I do have an infrequent episode - this is any meds, not just for afib. At 62, I remain fit and have very low inflammatory markers on my 2x per year extensive labs with Dr. Gundry.

I think that overall Stroke Risk is decreased by eliminating AFIB. Maybe just not as much as we think. This reminds me of the Studies about a decade ago that showed that Rhythm Control had the same Stroke/Mortality rate of Rate Control.
You have to factor in the acute risk of the treatment. When they added in the Complication risk for treatment like Pro-Arrythmic events from Anti-Arrythmics, Complications from Ablation procedures, or Stroke Risk from Cardioversion, doing nothing but rate-control came out about to about the same risk as trying to get people back into NSR.. Many times Treatments have not been successful, or only partially successful, and the patient still had AFIB in the end anyways. This factors into the over-all Statistical analysis against treatment.

Regardless of the Studies, almost everyone I have heard of feels better in NSR. I myself am fairly Asymptomatic, and it doesn't really negatively effect me to have an AFIB episode for several days. I can control my rate in the 70's with Diltiazem and a little Bystolic. I still make it to the Gym like normal. Having said that, I still wouldn't want to be in AFIB all of the time though. No way ever!

Quote
The Anti-Fib
I think that overall Stroke Risk is decreased by eliminating AFIB. Maybe just not as much as we think. This reminds me of the Studies about a decade ago that showed that Rhythm Control had the same Stroke/Mortality rate of Rate Control.
You have to factor in the acute risk of the treatment. When they added in the Complication risk for treatment like Pro-Arrythmic events from Anti-Arrythmics, Complications from Ablation procedures, or Stroke Risk from Cardioversion, doing nothing but rate-control came out about to about the same risk as trying to get people back into NSR.. Many times Treatments have not been successful, or only partially successful, and the patient still had AFIB in the end anyways. This factors into the over-all Statistical analysis against treatmen!

One thing I recall from those studies is that the arms of the studies were based on intention to treat. The rhythm arm meds didn't actually do a very good job of keeping people in rhythm. This may have been a reason why outcomes weren't much different.

This lack of med effectiveness is a reason why there is a big emphasis on ablation now.

Gary - The risk of stroke from Afib is caused by pooling or collecting of blood in the heart which allows a clot to form and if the clot is expelled into the blood stream, then it can cause a stroke. So, normalizing rhythm is preventive.

However, as is emphasized in the posts on the connection of silent inflammation and clot risk, anyone who has elevated risk markers has the risk of clot formation which can end in stroke or MI. The CHADs scoring emphasizes that potential but doesn't test the 'markers' indicating the potential risk.

Everyone needs to be aware of the impact that excess oxidation and silent inflammation has on the potential for clot risk.

Here are the links:

Unfortunately, the one titled Silent Inflammation – Risk Marker for Stroke, Heart Attack & Much More
was moved to the General Forum side for some reason...so in a typical search, it wouldn't show up..
-- moved topic --
[www.afibbers.org]

Hope this helps.

Jackie

[www.afibbers.org]

Additionally, if you just do a search on 'clot risk' you'll find many useful discussions.

I think these studies if accurate are both interesting and revealing. In one case you are testing for difference in two distinct populations without treatment, while in the other you are testing for difference in the same population with treatment, which are very different problems. Assuming the methodology is sound, this suggests that the main benefit of treating afib is not stroke prevention or life expectancy but rather easing symptoms. However, one might expect easing symptoms would have long term consequences such as the ability to live a healthier and happier lifestyle, and hence decreased stroke risk and increased longevity. But evidently this was not the case. It would be interesting to know what the duration of the studies were, and whether these kinds of lifestyle changes were made, what their impact was, and so on.

Thanks everyone for your input. AntiFib, I think I see your point, but treating vs. not treating is not the comparison I have in mind. I'm asking if eliminating vs not eliminating a-fib reduces risks of stroke and mortality.

So eliminating a-fib should give you a better CHADS2 score--yes. But are we able to answer the question -- Does eliminating a-fib lower your risk of mortality and stroke? I know it automatically lowers your CHADS score. Yes, I want to be free of a-fib, but not just to feel better, but also to hang around longer and not worry more than the average joe about stroke. I do try to lower things like CRP, etc. but just looking at a-fib itself as a risk factor, you would think that eliminating those pools of blood would put you back on par with non-a-fibbers (all other factors considered equal). Pooling blood increases risk. No more pooling blood? Sorry. you still need to take anticoagulants because you are marked for life?

If I don't die from stroke, heart failure or coronary artery disease, it seems I could just die from "a-fib," according to the statistics, even though it may have been eradicated by an ablation. It just seems odd to me that eliminating the problem does not change the long-term outcomes.

I suspect it is because afib is only a symptom of an underlying problem. Treating the symptom doesn’t cure the problem.

Let's look at 3 people all with the same chad score. All the same age, same fitness level, etc.


1. No afib, chances of dying from a stroke = ?

2. Afibber taking a blood thinner which continues for life, chances of dying from a stroke = ?

3. Successfully ablated afibber, not on blood thinners (me), chances of dying from a stroke = ?


Is there a difference in longevity (just considering a stroke ending your life)? My guess is no. Others may differ.

Quote
Ken
Let's look at 3 people all with the same chad score. All the same age, same fitness level, etc.


1. No afib, chances of dying from a stroke = ?

2. Afibber taking a blood thinner which continues for life, chances of dying from a stroke = ?

3. Successfully ablated afibber, not on blood thinners (me), chances of dying from a stroke = ?


Is there a difference in longevity (just considering a stroke ending your life)? My guess is no. Others may differ.

I would agree with your guess. The interesting thing is that it seems the studies did not control for fitness level. If you remove that control, then one might expect the population 2 to be skewed towards lower fitness, and consequently less longevity. Of course, the other populations might be skewed towards higher even overtrained fitness, which might also negatively impact longevity. More data and analysis is probably needed to resolve these kinds of questions.

Gary, AFIB ablation does indeed reduce all cause mortality as now confirmed in two very well done Randomized Controlled Trials (RCT's). The AATAC multicenter-Multinational RCT published in April 2016 by St Davids Med Center, Bordeaux France's Hopital Cardiologique du Haut Leveque, Kansas University AFIB Center, Milan Italy AFIB center of Claudio Tondo, Ospedale dell' Angelo in Mestre Venice Italy, CPMC in San Fran and Petr Neuzil's Praque AFIB center; All comparing 'AF Ablation vs. Amiodarone in Persistent AFIB patient with Congestive Heart Failure' .... Plus the recent impressive multinational CASTLE-AF RCT headed by Nasir Marrouche from University of Utah group also comparing AFIB ablation in Congestive Heart Failure (CHF) patients vs standard medical therapy in Afibbers with CHF.

Both of these landmark RCTs confirmed each others findings showing a significant reduction in all cause mortality as well as significantly fewer hospitalizations for CHF and significant improvement in bot exercise tolerance and Quality of Life in the successful Catheter ablation arm vs the medical therapy arm of combined CHF + AFIB patients.

Plus the long awaited CABANA RCT that has been in the works for over 10 years now is set to report final findings this May 2018 at HRS Conference in Boston and the latest preview of CABANA given last week at AF Symposium 2018 also implied reduction in all cause mortality would be one of the key findings of this large international AF Ablation RCT.

The studies you reference are all part of the earlier stage AF ablation reviews that either were not powered to detect the illusive mortality benefit from a procedure or simply were too early in the game to do so.

Read both the AATAC and CASTLE-AF and see the impact on mortality, plus improved HF cardiac output (significantly higher LVEF), significantly improved exercise capacity and significantly improved Quality of Life as well as significant reduction in All-Cause Mortality in both RCTs.

It often takes a very long time for a procedure or device therapy to demonstrate clear reduction in Cardiovascular and/or All-Cause Mortality, and thus while older studies have noted that we did not yet have clear confirmed evidence of reduction in mortality from AF ablation, most all practicing AFIB ablationists .. certainly those at high volume centers ... have long ago recognized that ablation of AFIB does indeed confer a mortality benefit, but that it would just take more time to prove it via multiple RCTs.

This time for clear recognition is now upon us and there really is no honest debate about the issue any longer outside of a few trogolodytes of the EP world that are likely contrarian by nature and who do not perform many ablations .. or any ablations ... themselves.

Hope that clears up your question ...

Cheers!
Shannon



Edited 1 time(s). Last edit at 01/21/2018 02:00PM by Shannon.

How do these studies address patients without CHF?

Shannon,

Thank you very much for the message, and the call. I'll look for those studies. Your explanation makes good sense, and I am glad to hear we have this data to counter the naysayers. It just didn't make logical sense that removing a risk factor would not reduce risk.
Best,

Gary

SAFB, keep a look out here for my report this coming May on the CABANA findings when this 2204 patient 10 year RCT comparing AFIB Catheter Ablation to AAR drug therapy and Rate control drug therapy for Afib patient who do not have CHF... the combination of benefits dovetails across the board from the latest update on the findings of CABANA after its December 2017 primary final end point of the study had been achieved. The full report with all details will be out this May so not much longer wait.

Doug Packer from Mayo gave an overview two weeks ago at AF Symposium of where CABANA is now that the trial is essentially finished and in the books, and the news, not surprisingly, is very good for CA. Including a significant mortality benefit for regular Afibbers having CA..... As well as for those with CHF+ AFIB who are well reported on already in the AATAC and CASTLE-AF RCTs.

Shannon



Edited 1 time(s). Last edit at 01/22/2018 08:02AM by Shannon.

Ok, thanks for information. Let me refine my question: how do these studies address patients without CHF (or other major comorbidites) AND where the test is between ablation and no treatment (i.e., no drug therapy of any kind), except for anticoagulation according to CHA2DS2-VASc? Does ablation reduce all cause mortality in this case? What about the subset who are mostly asymptomatic? I fall in the above category, hence my interest. I suspect that data from such a group would be less available. I hope CABANA addresses this, and look forward to the report.

SAFIB almost by definition CHF patients are not asymptomatic so you’ll likely have to wait for the full CABANA to see if they discriminate to that level of patients ... keeping in mind two factors to factor into that equation being: 1. Up until recent years most so-called ‘asymptomatic’ patients were not offered ablations by the average run of the mill PVI-only majority of ablation EPs and: 2: truly ‘asymptomatic’ patients tend to be quite rare.... 9 Times out of 10 when an EP carefully takes a history and questions those AFIB patients that do not report feeling AFIB as an irregular HR and don’t have any idea the typical handful or more of very real daily symptoms they do report that they simply have never connected with a cardiac origin, like Shortness of Breath, heavy fatigue, loss of concentration and cognitive slips, headaches etc etc, ... we find that very few Afibbers are truly asymptomatic and feel zero impact from their AFIB.

There are some that are truly asymptomatic, but such folks are a distinct minority and rarely even seek out ablation understandably. The more typical Afibbers who get labeled as ‘asymptomatuc’ are the subset of Afibbers who claim up front not to ‘feel’ AFIB but most such patients have just as many reported physical, mental and even emotional symptoms, with the exception of not sensing their hearts out of whack, as those who are fully symptomatic reporting Afibbers.

Plus, we do know that so called ‘asymptomatic’ afibbers have similar stroke risk as the more typical fully symptomatic patients and are thus put on blood thinners at similar rates. Alas, the asymptomatic-labeled patients which, for the most part, is an inappropriate label and misnomer in my view and that of many EPs, are typically even more poorly compliant with taking blood thinners long term without that ‘unfriendly’ daily reminder of a jumpy heart to inspire them to remember.

In fact, of all AFIB patients who qualify for a blood thinner, 80% who started on one will have stopped the OAC within 6 years of their initial prescription!!

A last point that comes to mind in this discussion is that we may have to wait for the results from a study that was recruiting ‘asymptomatic’ patients last May at HRS Conferencecin Chicago to do multiple MRIs over the time frame of the study to look for not only early onset dementia, Alzheimer’s snd congnitive function decline which we know happens in asymptomatic patients as well as in symptomatic Afibbers at an earlier age onset than with non-AFIB dementia, Alzheimer’s and cognitive disfunction patients,
This new study’s aim is to see if a similar level of Silent Cerebral Ischemia (SCI) is also detected in such asymptomatic patients as they find in symptomatic Afibbers? I was at HRS Scientific Session Conference last May in Chicago when I saw that recruitment had started on this study.

This increasingly obvious major problem arising from living with poorly managed AFIB I feel is one of the Prime motives outside of obvious symptom relief and to improve quality of life, for doing whatever one can to restore durable NSR by whatever means one must, to achieve that goal by starting with electrolyte repletion and all the check lists of life style risk reduction steps as needed individually, and most often requiring the inclusion of an expert ablation process at some point for the most robust and stable freedom from all Atrial arrhythmia for the vast majority of afibbers based on real world reporting here the last 19 years.

Shannon



Edited 1 time(s). Last edit at 01/22/2018 10:20AM by Shannon.

I am so glad you wrote this post. Its like you are taking words out of my mouth. I am too so confused by that. A-fib = higher stroke risk. so if ablation keeps you out of afib, shouldn't you have the same stroke risk as a non affiber?