New Year - Are we getting there?

New Year – Are we getting there?

Dear Fellow Afibbers,

First of all I would like to wish everyone the very best for 2013, especially a bountiful harvest of normal sinus rhythm. I would also like to thank everyone for their many thoughtful contributions to the Bulletin Board over the past year. You probably have no idea how much comfort you have “dispensed” and how many lives you have helped make better.

In reviewing the year it seems to me that we have made significant progress in keeping “the beast” at bay.

Many afibbers have been able to reduce their afib burden very significantly by correcting magnesium and potassium deficiencies following The Strategy <[www.afibbers.org] as developed by Jackie and Erling>.

Other afibbers have found that adjusting their diet or lifestyle, in particular in regard to vigorous sports activities and alcohol consumption has provided relief.

Just recently GeorgeN and several other vagal afibbers have found that supplementation with ginger is very effective in preventing vagally-mediated afib episodes [www.afibbers.org].

Finally, many afibbers have found an effective antiarrhythmic drug or have undergone successful catheter ablations and are now living normal lives.

In my own case, I have had a few breakthroughs since my successful ablation in April 2007. However, I believe I may have discovered a way of preventing further episodes which I would like to share with you.

It has always puzzled me why cold drinks are a powerful trigger. I was first alerted to this in 2001 through an article in American Journal of Medical Science:

Am J Med Sci. 2001 May;321(5):355-7.

Atrial fibrillation in father and son after ingestion of cold substances.
Tan CW, Gerry JL, Glancy DL.Department of Medicine, Louisiana State University Health Sciences Center and University Hospital, New Orleans 70112, USA.
Abstract
A man and his father each developed atrial fibrillation after the ingestion of a frozen sweet. In the son, atrial fibrillation recurred with the subsequent ingestion of cold beverages. Neither patient had documented episodes of atrial fibrillation at any other time. The son also had multiple other episodes of palpitation, suggesting brief episodes of atrial fibrillation, and these occurred only with the ingestion of cold substances. Possible mechanisms include direct cooling of the left left atrium through the wall of the esophagus and autonomic stimulation by the cold substance.

A subsequent LAF survey found that about 10% of all afibbers, irrespective of whether their afib was adrenergic, mixed or vagal were sensitive to cold drinks to the point where they would initiate an afib episode.

This comment in the 2001 abstract really caught my attention:

Possible mechanisms include direct cooling of the left atrium through the wall of the esophagus and autonomic stimulation by the cold substance.

I also recalled these statements in my first book Lone Atrial Fibrillation: Towards a Cure:

Analyses of heart rate variability have confirmed that AF episodes are preceded by a change in the balance between the adrenergic and vagal branches of the autonomic nervous system [ANS]. Researchers in Taiwan found that some AF patients experience an increase in adrenergic activity immediately prior to the start of an episode while others experience an increase in vagal activity. [1].

Italian researchers have looked at the ANS connection specifically for patients with intermittent (paroxysmal) lone atrial fibrillation. They observed abrupt changes in the balance between the sympathetic and parasympathetic branches of the ANS in the 5 minutes prior to the onset of an AF episode. One group of patients experienced a sharp increase in adrenergic tone (adrenergic afibbers) while another group experienced an increase in vagal tone (vagal afibbers). In a third group (mixed afibbers) the researchers found that the two mechanisms operate during different hours of the day with an episode sometimes being preceded by an increase in sympathetic activity and sometimes by an increase in vagal activity. The Italian researchers conclude that the balance between vagal and sympathetic drive is probably more important than a high sympathetic or a high vagal tone as such[2].

Swiss researchers recently reported that vagal afibbers whose AF originates from foci in the pulmonary veins experience an increase in adrenergic tone about 15 minutes prior to the onset of an episode. However, with time, the adrenergic response diminishes and just before fibrillation begins, the vagal branch becomes dominant[3].

From this research it is clear that an afib episode is preceded by a period during which the ANS is unbalanced. Many afibbers, me included, experience this imbalance as a feeling of dread – Oh, No! Not again!

The idea then occurred to me that we may have a window of a few minutes in which to effectively abort an episode if we could quickly rebalance the autonomic nervous system. But, how to do this?

Well, and I know that this sounds very simplistic, if cold unbalances the ANS to the point of initiating an afib episode maybe, just maybe, warmth could have the opposite effect irrespective of what caused the ANS to become unbalanced in the first place.

So, when I next felt that dreaded feeling I quickly prepared a large glass of hot water, just hot enough to be able to swallow it without discomfort, and added a teaspoon of potassium gluconate plus a pouch of Emergen-C and swallowed the content of the whole glass as quickly as possible together with a 200 mg capsule of magnesium glycinate (Bluebonnet).

The effect was pretty well instantaneous. A couple of seconds after the hot water hit my stomach all was quiet and no afib episode ensued. I have now tried this three times and each time it has worked as advertised.

In view of the fact that the effect is instantaneous I am even beginning to wonder if the potassium, magnesium, and Emergen-C are really necessary as it is not plausible that their effect would be instantaneous. However, I am not that keen on trying just hot water by itself, but I’ll certainly let you know if and when I muster up the courage to do so.

In the meantime I would certainly be most interested in hearing about your experience if you decide to try this method of aborting afib episodes.

Hans

References

1. Huang, J.L., et al. Changes of autonomic tone before the onset of paroxysmal atrial fibrillation. International Journal of Cardiology, Vol. 66, No. 3, October 30, 1998, pp. 275-83
2. Fioranelli, M., et al. Analysis of heart rate variability five minutes before the onset of paroxysmal atrial fibrillation. Pacing and Clinical Electrophysiology, Vol. 22, May 1999, pp. 743-49
3. Zimmermann, Marc and Kalusche, Dietrich. Fluctuation in autonomic tone is a major detriment of sustained atrial arrhythmias in patients with focal ectopy originating from the pulmonary veins. Journal of Cardiovascular Electrophysiology, Vol. 12, March 2001, pp. 285-91

Han:

I don't get warnings like you have described, I can go to bed feeling great then wake up a few hours later in AF Even when I am just resting at night watching T.V., when I get AF it just happens, no warnings. So, does the hot water help if one has gone into AF?

Liz

Liz,

I don't know if it would work once the afib episode is in full gear. My first thought would be that it probably will not. However, why don't you experiment a bit? Keep a thermos with hot water right next to your bed and as soon as you wake up with afib swallow a cupful or more as quickly as you can - just make sure that the water is not uncomfortably hot.

I would also suggest that you consider taking ginger before bedtime. GeorgeN has had really good luck with that and if your episodes occur in the middle of the night they are obviously vagally mediated.

Hans



Edited 1 time(s). Last edit at 01/01/2013 11:55PM by Hans Larsen.

Hans, thank you for this blog. When I come in after I walk I drink a large glass of cold or cool tea and I immedatly get
the flutters. I was wondering what was going on ! It happens everyday, I do not go into afib but flutters are not
nice to teel and of course I think that I am close to afib.

I will make sure I warm the tea up now. We do live in Fl in case you think I some kinda nut for drinking ice tea.

Thanks again for the input.

Thanks Hans,
And a very Happy New Year to you and Judi as well! And this is an interesting and certainly plausible explanation for the welcomed effect you have discovered!

I too was often triggered by cold liquids or too cold ice cream etc and a good while ago switched to mostly room temp water. In any event, should I ever have any flippies or that feeling again, I will know what to do and give it a whirl .. though I am hoping you dont hear from me on this account :-).

On the ginger before bed, I assume that timing is related to its effect on Vagal AFIB?? Though I no doubt started out as Vagal, I suspect a good while ago prior to my original ablation I switched to a more mixed bag of Vagal and Andrenergic triggering. Post ablation I had no more AFIB, prior to this second, and hopefully last, ablation last August to isolate my LAA, the only issue I had was atypical left flutter periodically and I noticed it rarely gave that kind of impending doom- like warning feeling you describe that I am familiar with from previous years.

Those flutters would usually start with a bang out of the blue .. one second all is right as rain and the next second my heart was going at 180bpm!

Not sure if in that case the hot water treatment would have helped, as the only way to convert those flutters was by ECV?

Nevertheless, its a very interesting finding and hopefully many others will find it very useful.

Cheers!
Shannon

Cold drinks and cole air both get to me. As well as chocolate. My worst case scenario is a chocolate milk shake... I will give this a shot. Thanks for posting.

Hans,

I have experienced the ice cold drinks bringing on ectopics and afib. I've also experienced drinking hot water immediately to settle it down. When I tried it, I just drank hot water from the tap, not wanting to wait to heat anything else. My very slow heart rate (38-40 BPM) immediately went to normal and the ectopics ceased.

On previous occasions, I successfully tried various vagolytics including ginger powder (before I started using it all the time) and a licorice tincture.

I generally gave up the worst offender - frozen blueberries in almond milk, so I don't have repeat experiences.

I can say that: 1) this has only been an issue this year when my whole system has seemed much more sensitive to vagal disturbances and 2) my success with ginger [www.afibbers.org] appears to have made me unsensitive to this trigger.

Thanks for all you do!

Happy New Year!

George



Edited 1 time(s). Last edit at 01/02/2013 10:27PM by GeorgeN.

Since my ablation I have been heating all my drinks, as the effect of cold drinks on my esophagus/heart after the procedure was clearly detrimental to my recovery.
Tom

One correction to my statement above that I didn't notice any precipitating triggers or feeling of my atypical left flutter about to start at any time in between my AFIB ablation and before my LAA isolation . On one occasion about a year and a half ago, I had a Jamba Juice that had an extra amount of crushed ice in it and as soon as I took the first sip ... BAM! I was in high speed flutter and on my way to the ER for another ECV.

Alas, even in that case I'm not sure the hot water would have converted the flutter once it got going?

Shannon

Cautiously saying this but a teaspoon of ginger powder washed down with a gulp of room temperature water fixed it for me between Xmas and New Year...will keep you posted if I get a postiive repeat.

Hi Hans

If you delve into the field of neurogastroenterology you will find a possible connection and just maybe an answer to the cold and hot drink afib mystery.

“During the interdigestive state the dominant frequency of the gastric myoelectrical rhythm amounted to 2.81. Ingestion of the cold drink resulted in an immediate decrease in the dominant frequency of the gastric slow wave activity to 1.95. This effect was statistically significant for 15min following the start of the meal ingestion. During that time the percentage time of normogastria was significantly reduced in favour of bradygastria, which dominated in the frequency spectrum of the electrogastrogram. Ingestion of the acaloric hot drink brought about a transient increase in the dominant frequency of the gastric myoelectrical rhythm[/b] observed from 6 to 10 min postprandially.”

[books.google.com.au]


I did a bit of research into tachygastria and bradygastria several years ago for my own gastric induced afib and posted a bit about it. I and many other afibbers believe our afib starts in the stomach (a funny feeling in the stomach just prior to an attack).

Personally, I think the electrical activity in the stomach is a BIG player in the afib puzzle:
• Why do so many afibbers have gastric problems?
• Is our stomach electrical activity faulty just like our hearts?
• Do the two play off each other?
• Does bradygastria in the stomach stimulate immediate bradycardia in the heart then afib?

Many questions and no answers and there won’t be until research neurogastroenterologists and research EP’s start working together with simultaneous ECG’s, EEG’s etc.

Keep up the good work, Hans.
Dean

Hello Dean,

Very, very interesting observations, but as you say, more questions than answers. Perhaps irritable bowel syndrome, which affects some afibbers ties in as well.

Hans

I have noticed that once afib strikes, if I bundle up in a warm blanket and just relax a bit, it will get me back to NSR most of the time. Not too long ago, I drank some ice cold water that was in my car overnight and it immediately triggered afib.

Dean there is absolutely no doubt in my case that gastric upset triggers afib. What I put in the old tummy can either have a fairly immediate effect, or it can be delayed, but I am convinced it is where the cascade begins.