How much vitamin K is too much?

My recent holter monitor showed some Afib and an episode of atrial flutter. I have had PACs for several years and I know what they feel like. During the time I wore my monitor, I felt a kind of fluttering feeling in my heart, but nothing like the full-blown attack I had just a few days ago, which was the first time I had ever experienced anything like that. After reviewing my holter results with me, my cardiologist recommended that I start taking aspirin 81 mg, which my EP backed up. I am 54 years old, very healthy, and used to drink wine moderately but am off alcohol for now. My most recent stress echo was in September 2015 and demonstrated a strong heart with no disease or abnormalities. I have three questions:

Should I be watching my intake of vitamin K, and how much is acceptable? Are leafy green vegetables out for me because I am now a stroke risk?

My EP wants to perform an ablation procedure for flutter in two weeks. Is this wise, considering that I also have A fib? Should I go ahead with that procedure and then tackle treating the A fib (I have an appointment to see Dr. Natale's assistant in Thousand Oaks on February 9)?

Finally, how do I actually know I am in A fib or flutter? Most of the time, when I move around, I can feel some kind of funny feeling in my heart, but not rapid beats like I experienced a few days ago. That has happened only once. It feels more like the PACs, but not quite. It's more of a floaty, fluttery feeling. By the way, when I lie down or sit up in bed or on the couch, my heart rate seems normal, with steady, even beats.

Thank you!



Edited 1 time(s). Last edit at 02/05/2018 11:01PM by RussellG.

Do I understand correctly that you're taking only aspirin? And your EP wants to do an ablation in two weeks with aspirin as your only medication?

"Finally, how do I actually know I am in A fib or flutter?"

Just feel your Pulse with your Finger. Flutter is spaced evenly and Rhythmic, and AFIB is Irregular. AFIB has 2-3 beats in close together, then maybe a pause, then more beats in rapid succession. Also when in AFIB the Pulse strength will vary. Some beats will feel stronger than others. This is in contrast to Flutter, where the Pulse strength is the same. I would check your Holter Monitor results to see what your Flutter HR was, and also what your AFIB HR was. Sounds like the more intense event was the AFIB. PAC's can also make the HR irregular, but your Rate will not increase much, and you will probably not have near the symptoms of full blown AFIB.

"My EP wants to perform an ablation procedure for flutter in two weeks."

No I would wait until your Feb 9th Appt to get a 2nd opinion. How much Flutter have you had? It sounds like only 1 documented episode, and was it that bad that would an Ablation emergent? Also, The Ablations either for the Flutter, or the AFIB, will not stop the PAC's.

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RussellG
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Should I be watching my intake of vitamin K, and how much is acceptable? Are leafy green vegetables out for me because I am now a stroke risk?

My understanding is that limiting leafy greens won't impact your stroke risk unless you are on coumadin/warfarin.

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RussellG
My EP wants to perform an ablation procedure for flutter in two weeks. Is this wise, considering that I also have A fib? Should I go ahead with that procedure and then tackle treating the A fib (I have an appointment to see Dr. Natale's assistant in Thousand Oaks on February 9)?

WAIT WAIT WAIT!!!

If you do get ablated, Natale will fix both afib and flutter at the same time.

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RussellG

Finally, how do I actually know I am in A fib or flutter? Most of the time, when I move around, I can feel some kind of funny feeling in my heart, but not rapid beats like I experienced a few days ago. That has happened only once. It feels more like the PACs, but not quite. It's more of a floaty, fluttery feeling. By the way, when I lie down or sit up in bed or on the couch, my heart rate seems normal, with steady, even beats.

Thank you!

A Kardia device can give you this feedback.

George

Yes, Carey, he wants to do an ablation for the flutter. I am also taking digoxin .125 but plan on tapering off. He mentioned that I would be placed on a blood thinner after the procedure.

Thank you, Anti-Fib. I'm not sure how much flutter I have had, other than the one episode. But I'm worried that I might be in flutter when it seems like my heart is beating normally (eg, when I am lying down).

Thank you, George. I've been avoiding food with anything close to high levels of vitamin K but it's put a serious crimp on my diet.

Leafy greens have no effect on aspirin. They also have no effect on the direct oral anticoagulants like Pradaxa, Eliquis, etc. They're only an issue with warfarin, which you won't be on or they would have already started you on it. And even people on warfarin are free to eat leafy greens. They just have to be careful about being consistent. A spinach salad every single day is perfectly fine for someone on warfarin. What's not okay is binging on spinach salad randomly.

So have all the leafy greens you want. There's no reason to limit your intake. You should be on an effective anticoagulant instead and your EP is doing you no favors prescribing aspirin.

Having said that, I agree with George when he said WAIT WAIT WAIT!!!

First, this whole plan sounds nuts. Either you're seriously misunderstanding your EP's intentions or I really question his abilities. Doing a flutter ablation alone on someone with mixed afib and flutter makes no sense whatsoever. None, zero, nada. No competent EP would do that. So I really hope you're misunderstanding him.

Second, aspirin is not an effective anticoagulant for afib and flutter, and no competent EP would prescribe it for that purpose in this day and age. And to do an ablation with nothing but aspirin and only starting an anticoagulant after the procedure is downright reckless.

My advice: Cancel this ablation and find another EP.

Hi Carey, the story is that my cardiologist noticed some A fib on my 3-day holter and told me to take aspirin 81 mg a day. He then referred me to an EP in his medical group, who went over the holter readout with me and pointed out a couple of episodes of A fib as well as one episode of flutter, and then immediately recommended the ablation procedure, without adjusting my medication. I was told only to stop taking the aspirin the day before the procedure. If one has both A fib and flutter documented, what then? I'm very nervous about taking just aspirin at this point. I see my cardiologist tomorrow for a stress echo and will ask him some questions for sure. My appointment with Kelly at Dr. Natale's Thousand Oaks office was put off until March 21. I also have pretty constant PACs when I move about, which makes it difficult to determine exactly which type of disordered rhythm I am experiencing at any particular point in time. I can't believe that I have not been placed on some kind of continuous monitor to determine, over the long term, whether it's my PACs that are predominant, or whether indeed this fluttery floaty feeling in my heart with almost any movement is indeed A fib, in which case I would certainly want to be on blood thinners. By the way, when I recline, everything seems to calm down, so I do that quite a bit.

Well, they put you on a 3-day holter so that's a decent amount of monitoring. Now that you describe the discussion again I don't think he's planning on doing a flutter-only ablation now and an afib ablation later. He's planning on doing just one ablation for both. (Whew!)

But the aspirin really, really concerns me. It's been shown to be significantly less effective at preventing strokes in afib than warfarin and the NOACs (Pradaxa, etc). He should know that. I'm no EP but not having you on an anticoagulant going into the procedure is contrary to everything I've ever known about ablations, and I've done more than a few myself.

Next issue is how many afib ablations has this EP done? If the number isn't at least in the hundreds, preferably in the thousands, then walk away.

I'm sticking with my previous advice. Cancel the ablation and schedule with Natale. It will take you months to get in to see him but it's worth it.

The plan is for an ablation just for the flutter, followed by 3-4 weeks of anti-coagulant therapy. I suppose treating the A fib would be considered afterward. How do I find out how many procedures he's done? He is Dr. Ali Sovari out of Oxnard, California.

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RussellG
The plan is for an ablation just for the flutter, followed by 3-4 weeks of anti-coagulant therapy. I suppose treating the A fib would be considered afterward. How do I find out how many procedures he's done? He is Dr. Ali Sovari out of Oxnard, California.

Ten years ago, my cousin got same advice from EP in FL. I implored him to get a second opinion from a nearby Natale protege', Sergio Pinski. He took my advice and Dr. Pinski fixed both problems at the same time. Cousin is still going strong in NSR.

Why would you want two procedures when one will suffice?

As to number of procedures, I'd want it to be in the many thousands.

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RussellG
The plan is for an ablation just for the flutter, followed by 3-4 weeks of anti-coagulant therapy. I suppose treating the A fib would be considered afterward. How do I find out how many procedures he's done? He is Dr. Ali Sovari out of Oxnard, California.

Walk away. Do not do this. He's proposing doing two procedures when you need only one. The only reason I can imagine why he would do that is financial.

Also, as best I can tell his experience doing ablations is very minimal. Total rookie.

Dr. Sovari seems to have a fairly impressive record in cardiac arrhythmia research, including peer-reviewed publications and some awards. His training and fellowships and affiliations seem quite good, as far as the general reputation of the institutions go. That doesn't put him in the league of Dr. Natale of course. He seems to have generally broader interests, but a more specialized background and skill set in treating afib.

His experience and protocol in treating afib can be found in eplabdigest. He treats mainly symptomatic paroxysmal afib via cryoballoon technique. He has done hundreds of ablations. The anticoagulant therapy is held to the day before the procedure.

He cites the FIRE and ICE trials as evidence for his approach. The article and the subsequent comments and discussion are in NEJM and NEJM Correspondence

The question I have is how cryoballoon compares with rf restricted to paroxysmal af, and not the persistent and/or more complex cases where an expertise like Dr. Natale's is essential? Also, what other evidence based results are there that refute the conclusions of the FIRE and ICE trial results, other than the Correspondence cited above?

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safib
Dr. Sovari seems to have a fairly impressive record in cardiac arrhythmia research, including peer-reviewed publications and some awards. His training and fellowships and affiliations seem quite good, as far as the general reputation of the institutions go. That doesn't put him in the league of Dr. Natale of course. He seems to have generally broader interests, but a more specialized background and skill set in treating afib.

His experience and protocol in treating afib can be found in eplabdigest. He treats mainly symptomatic paroxysmal afib via cryoballoon technique. He has done hundreds of ablations. The anticoagulant therapy is held to the day before the procedure.

He cites the FIRE and ICE trials as evidence for his approach. The article and the subsequent comments and discussion are in NEJM and NEJM Correspondence

The question I have is how cryoballoon compares with rf restricted to paroxysmal af, and not the persistent and/or more complex cases where an expertise like Dr. Natale's is essential? Also, what other evidence based results are there that refute the conclusions of the FIRE and ICE trial results, other than the Correspondence cited above?

Thank you very much for providing me with this information. Dr. Sovari is scheduled to perform an ablation for flutter, not A fib this time, which I am sure will have to be addressed afterward. Good to clear up the concerns I had about preoperative protocols concerning checking for thrombus etc.

Please wait for Dr. Natale consult. Don't knowingly sign up for two procedures when you only need one. Learn from our mistakes and experience!

I agree with waiting for Dr Natale. He did both at the same time for me a few years ago and not a beat out of place since.