Ablation for asymtomatic patients?

I am really falling behind, my answer before the article below (I just saw this today while looking for something else) would have been WHY bother? My father in law is in this cohort, if current knowledge and technology was available 15 years ago, I would say go for it as he was a very active fellow until his recent incidents. Research below from St. David's on long term persistent AF patients that were asymptomatic. The big improvements in exercise capacity and impact on QOL. Downside is that one can become more symptomatic if the procedure is unsuccessful in restoring NSR. The bottom line is still to get it while it is still paroxysmal. I guess the other consideration is that if exercise makes you miserable and doesn't improve your QOL, then it may be best to continue living with AF.

[www.ncbi.nlm.nih.gov]

The big ongoing risk we are finding now with unaddressed AFIB whether symptomatic or aysmptomic is the now large wave of research in the last 3 to 5 years that has confirm Silent Cerebral Ischemia indeed is THE number one issue after anticoagulation issue is addresed.. but the ongoing presence of AFIB even complicates the OAC issue too long term as now long view evidence shows that a fair amount of the gradually accumulation of these individually asymptomatic or 'silent' brain infarcts or micro bleed based white matter lesion in the brain are collectively over time anything but asymptomatic and more definitely appear to contrubute to a significantly higher risk for early onset dementia and alzhemiers.

The problem is in past AFIB EP and Cardio patient follow up history, no one ever made the link between the patients long term AFIB and those increased numbers who dropped out of life early with early onset dementia ... because the right hand had no frickin' idea what the was even going on with the left hand of neurological consequences for these patients.

They would continue to see their AFINB patients maybe once a year for 15 minutes until they just stopped coming and most cardios and EPs had no way of knowing or connecting that they had dropped out of life due to an earlier than normal for regular onset dementia, onset of Alzheimers or dementia.

Now enough prospective and retrospective studies have been done to raise a very large red flag over this issue and its it among the most active research topic right now in new ongoing research projects being started or planned to help better define this relationship which now appears very solid and strong.

All this song and dance about how asymptomatic AFIB is no big deal at all, just OAC them and rate control them and they are fine ... is not at all turning out to be that way after all for a significant number of AFIB patients who did not find a way back to NSR soon enough.

The bottom line story on this is that to prevent the AFIB related silent cerebral ischemia build up, one most start early and work diligently, by what ever means they can to reclaim as much NSR as possible and reduce total cumulative AFIB burden as much as possible as well.

The risks for these silent white matter lesions accumulating during AFIB is complicated both by under anticoagulation leading to small micro emboli as well as overdoing anticoagulation just enough to cause micro bleeding increase and thus cause mini bleeds which can also turn embolic as well. Each event may not register in symptoms or imaging as a big problem, but as these accumulate there is a threshold beyond which the person starts to lose functional amount of brain tissue.

Shannon



Edited 1 time(s). Last edit at 07/17/2015 10:37PM by Shannon.

Having recovered from prior longstanding persistent/permanent AFIB, and an avid exerciser, my experience is that it did not impact ability to exercise very much. Rate control (70's at rest) without being sedated was the key. I achieved this with Bystolic at 30mg+ (Cardio-Selective Beta-Blocker). Not saying it was the same overall though.

Many other changes occur while being in AFIB all of the time, I don't think we can narrow it down to just several ones, although everyone is different. I am wondering if a study has been done on the impact on the Adrenal glands of being in AFIB all of the time. If anything at first my exercise capacity went up, due to what felt like was an increase in Adrenalin after onset of an episode. Also although I was basically asymptomatic, I did notice subtle effects like increased irritation and not being as calm as I was while in NSR. Also other subtle effects like increased persperation, and reduced capacity to tolerate heat was noticed. The pulse is not as strong while in AFIB, while being sufficient for basic bodily functions, reduced ability to cool the perimeter of the body is probably one of many of these subtle effects that are not noticed or studied much.

Shannon: Is there a way to test to see if I had any of this damage that you are describing? Like a CAT scan or MRI of the Brain? Also I posted in the General Health Forum about BHRT for my suspected Adrenal Burnout, can you briefly respond to that post?



Edited 3 time(s). Last edit at 07/14/2015 05:12PM by The Anti-Fib.

Shannon, I don't know if you have seen the 60 minutes segment on the Laguna Woods (also known as Leisure World before they converted to a city) that was put together by Leslie Stall. They talked about dementia, alzheimer's and show brain cross sections post mortem of the subjects that died with various stages of dementia and it was entirely consistent with your post. It was really eye opening. If you haven't seen it, look it up on the 60 minutes website. My father in law has excellent brain still, his heart though is not in very good shape at the moment.

Are there any stats on people that have AF and subsequently getting Alzheimers, or is this something that can happen due to what you have posted when in AF.

Liz

The 60 minute video is no longer available after much digging. Below is the transcript of the episode. The discussion on dementia and alzheimer's starts in part 2 but the whole thing is worth reviewing.

[www.cbsnews.com]

Yes Liz, I have published a few study reviews over the last year and a half showing very strong correlation with early stage Alzheimers and AFIB patients from large registries of AFibbers, that fact that the younger groups of AFibbers under 70 had the most significant impact from dementia and Alzheimers strongly implied that these were not just two co-existing morbities that share similar etiologies but rather a more direct association between onset of AFIB, duration of AFIB and appearance of dementia and alzheimers earlier and in larger numbers that the controls without AFIB who tended to be older when their mental decline started and it was more severe overall in the AFIB group.

Im going to publish a new updated review .. I almost used it in t his issue but simply ran out of space other wise we were looking at a War and Peace sized tome here this issue :-).

But in two months we will have that for you and others which gives even more insight into this very compelling relationship between AFIB as well as Silent Cerebral Ischemia (SCI creation), as a highly likely contributor derived from AFIB towards this very clear increased risk of dementia and Alzheimers which now each new study seems to only reaffirm and strengthen the connection, Im sorry to say ...

The Intermountain Group who penned this now broad overview of what we know about this issue, said that the bottom line for both SCI creation via poorly treated AFIB and Dementia risk is that you MUST start very early in ones AFIB history and work hard with every measure we can bring toward restoring NSR as our best change to alter and possible reverse this course. It s not something you can just flip a switch and change once enough precious brain neurons are toast done the road from a gradually increase in micro embolic and micro bleeding or oxygen debt insults resulting from on going AFIB over time that all seem under the radar and rather benign during much of the slow progression toward dementia..
'
Until recently literally no one ever and the connection between a persistent Afibber who was well rate controlled and anti coagulated and those that developed early dementia until the numbers started to raise flags in this larger registerers of Afibbers. The smaller EP and Cardio groups would never recognize this in a million years as they just could not see it happening on the long scale and so continued to feel it was perfectly save to just stay in AFIB for ever if it really didnt seem to bother you too much.

Shannon

This study suggests to me a large downside to ablation: starting with only asymptomatic cases 36% had AFIB recur and became symptomatic, presumably worsening the risk of ischemia as well. The abstract doesn't detail the statistics of these 36% wrt exercise intolerance or QOL. I would hate to be in the 36%, too large a risk. Is this considered to be a positive for ablation in such a cohort?

Keep in mind Safib this study is NOT talking about a complete expert ablation PROCESS .. asymptomatic patients are nearly ALL persistent AFIB who by definition often require a second and occasionally a third true touch up only, for the last one or two max follow up procedures after a top tier full index ablation, in order to achieve the approx. 85 % freedom from AFIB levels long term that is very much happens for this most challenging class of long-standing persistent AFIB patients many of home have enlarged LA diameters etc.

And those 15 to 20% that might either need to stay on an AAR drug or go for a further ablation or perhaps a maze procedure if they are highly obese, But what ever the case for this far small percent who are not AFIB free entirely a single procedure. Most all of them will find a net major improvement in their AFIB burden even when not eliminated altogether

That is a humungous advantage, and this mistaken impressions happen when people get so mixed up with not reading these studies in the broader real world context.

And become symptomatic does not mean terrible high speed AFIB ,,, ir means everything from becoming away of added fatigue or mild shortness of breath all the way up to more significant symptoms but most people that convert from long standing 'asymptomatic' afib to being more aware of afibs impact on them after an initial ablation in a process that is not yet complete most often are minor increase in awareness of symptoms.. usually flutter ... that they didn't much feel before.

However, most so called asymptomatic people are really symptomatic and feel the fatigue, SOB, headaches from less brain perfusion etc etc, but they don't feel the irregular heart beat and in some cases they do feel a flutter as it has a different steady pace and is often a bit faster but often not about 130bpm and usually easily controlled with rate control drugs if not Flec, that later of which often works much better after even a not you fully successful initial ablation as the first step of a two to three step ablation process for stopping long term a long standing persistent AFIB!

That is a small price to pay having one or possible two procedure extra MAx with an elite level persistent ablationist when you know that up front!

This is why when people read this studies without really understanding the larger context one can so easily make a lot of misleading assumptions and thus flat our wrong conclusions about what the study is saying about real world benefit vs risk of such a procedure.

Actually too a 64% full success rate on one procedure and off all AAR drugs in outstanding success rate by itself .. considering this folks are in persistent AFIB with an ever present risk of stroke .. even while on OAC drugs too, it is just much reduced but certainly not zero and the stroke risk while in AFIB and on OAC increases at almost linear rates with each passing year! a 3% risk for 10 years is roughly a 30% risk of a stroke,... at 20 years around 60% ... and so on.

This study makes a very solid case for the wisdom of most asymptomatic people to consider getting this addressed. And it's rare indeed that even those formerly unaware of their heart beat when in AFIB people, that now do feel some heart beat when in AFIB or flutter after an index ablation and still have one of two touch ups to go, it is very rare indeed that their AFIB is not eliminated entirely by the end of the two to three total procedures ablation process.

Keep in mind we advise EVERYONE who is considering and ablation to remember alwasy it is a process and while the majority, particularly of paroxysmal patients are indeed one and done these days with a top EP, we urge everyone to consider and accept they will likely need two procedures to be done and jsut be happy as a clam if they turn out done in one!

Again, most people who claim to be asymptomatic truly are are not, and when you really question them there are typically at least two, three or more definitely signs and symptoms they notice of their arrhythmia but simply dont notice any heart beat at all, AFIB or NSR.

And we are not even talking about the Silent Cerebral Ischemia (SCI) accumulation while under constant persistent 'asymptomatic' AFIB ... asymptomatic indeed, until a bit down the road you start to forget your children's or wife's first name... and what you were just doing a moment ago, and just start having more of more of those 'senior moments' we all brush off until they can no longer be ignored and they start to equal real cognitive impairment .. etc with the early onset of dementia. Of course,m until recently no docs in a million years would think about that pesky silent AFIB your brother had for so long that everyone forgot about it until he seems to quickly go senile at a certain too early age.

Anyway, You get the picture I trust,

Closing the eyes now its late here.
Shannon

Shannon, I don't feel the paper or at least the abstract is well-written. For example, why make a big point about arrhythmia perception if it is misleading and/or the methodology to assess it is flawed? Also, why not show the statistics associated with failed procedures rather than make the trivial statement that there was no improvement associated with them? Or lacking these numbers either offer some brief explanation about their relevance or simply delete the non informative statement from the abstract. I plan on reading the full paper later, hopefully it is better written and addresses these issues. One other point: the recurrence-free-off-AAD is stated as 57% not 64%. Anyways, thanks for your comments, I do understand the context and implications of the study better now.

You are talking about Asymptomatic AF, what about Paroxysmal AF?

My mother had permanent AF for about 12 years, she died at 92 of heart failure, but her mind was intact. About 10 years ago when I was in Florida, I was staying at this Apt. Complex and met a man who said he was in his early 80s, we were talking about AF, he said he was in permanent AF since the age of 15, said it did not stop him from doing any sports, said he was in the army, seemed to be fine, I don't know of course if everything he said was true.

What about all of these people that have alzheimers, many did not have AF, I know a couple of people that have Alzheimers and did not have AF. I guess we all could have some tiny strokes that don't register and in time could lead to Alzheimers, AF or no AF.

Liz

I have seen the risk of stroke reported as 6% per year in AFIB patients with permanent AFIB. Based on that it means at 65+ years in AFIB, this old-timer was a also a lucky-timer as well.

safib - RE "This study suggests to me a large downside to ablation: starting with only asymptomatic cases 36% had AFIB recur and became symptomatic, presumably worsening the risk of ischemia as well."

Being symptomatic vs asymptomatic is strictly a QOL issue and doesn't impact the ischemia risk. You will still need to be on continuous anticoagulation therapy in either case.

SAFIB,

One thing I have learned from years of reading EP/Cardio research papers is to be very careful pinning too much opinion , either way on reading an abstract alone!

Always its wise to read the full paper before drawing any real conclusions at all, I typically read from 30 to 40 peer reviewed entire studies just to be able to come up with 4 to 6 worth summarizing every two months into relevant info for the lay afibber.

And if I had a dollar for overtime the actual study said something very different that what the abstract implied Id be a much richer man today I can tell you!

Abstracts are often poorly written summaries trying to convey an overall point. At least the study should back up the core message of the Abstract but even that is not true in more occasions than you would believe.

And some abstract and the studies that highlight, assume the reader has read prior studies that are reference in the main body and in the footnotes that are critical for understanding the study and especially the abbreviated abstract in the context the authors assume the reader already has and is aware of... This is often not the case so they can seem disjointed or incomplete very often at the abstract level.

In any event, read the study first and reference the relevant footnotes the author emphasize too to get the bigger picture.

Shannon

Not sure what the new 2014 guidelines from the AHA/ACC/HRS say, but my reading of the 2011 guidelines was that they made the clear distinction that Ablation was not recommended for Asymptomatic LAF'ers

[circ.ahajournals.org]

TAF - In the 2014 guidelines, there were 10 references to asymptomatic patients, none of that explicitly state whether it was a good idea or a bad idea to ablate. What they do show is that asymptomatic patients are a huge concern because of stroke risk and EPs seek to ferret those patients out to put them on anticoagulants. In the patient management flow chart, whether someone is symptomatic or asymptomatic does not appear to impact the EP's consideration although I am sure it does impact how a patient decides with regards to ablating or not.

[circ.ahajournals.org]

The St David et al cohort are chronic Afibbers and it takes a lot more skill to ablate those patients successfully. If a person with AF progresses to that stage, the decision will depend on whether he has access to high level skills. I am sure the study results will be entirely different if the trial was done at your average center.



Edited 1 time(s). Last edit at 07/17/2015 01:41PM by researcher.

Researcher did you actually look at the full text, or just the executive summary?

______________________________________________________________________________________________

6.3. AF Catheter Ablation to Maintain Sinus Rhythm: Recommendations

Class I

1. AF catheter ablation is useful for SYMPTOMATIC paroxysmal AF...

Class IIa

1. AF catheter ablation is reasonable for some patients with SYMPTOMATIC persistent AF...

Class IIb

1. AF catheter ablation may be considered for SYMPTOMATIC long-standing persistent AF...

Class III: Harm

2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation.
______________________________________________________________________________________________

No they don't use the word Asymptomatic, but they do only advise Ablation for SYMPTOMATIC AF!

It never even says that CA is a cure for AF in these Guidelines. "Studies have demonstrated a reduction of AF-related symptoms" is as close as it gets. CA is a treatment for the Symptoms of AF, not a cure. That's why you won't see a set of guidelines recommending CA for Asymptomatic AF. Any CA performing EP who is honest would admit that the CA process burns off the nerve endings so that patients don't feel the Palpitations as much. And for the Asymptomic patient, CA can only make symptoms worse, if they were not noticable in the first place.



Edited 1 time(s). Last edit at 07/19/2015 05:08AM by The Anti-Fib.

Ive been on a mini vacation the last 5 or 6 days since finishing the latest issue of The AFIB Report but I ear-marked this thread to come back too today.

It's true Anti-AFIB that asymptomatic AFIB ablation is not yet indicated as an officially guidelines sanctioned process, and no where does ablation, nor drugs nor nutrients rank as a 'cure' for AFIB by the Cardios much stricter definition of a true 'cure' than some here seem happy to rather cavalierly toss out there.

Regarding the lack of guidelines acknowledgment at this time, that is strictly due to a few issues that are common during early stages of many new protocols moving toward more general guidelines approval.

1. Most accepted guidelines are looking to one degree or another in the rear view mirror and typically do not include more recent and cutting edge developments and the same is true here with ablation of asymptomatic patients which has been going on for some years in most all top centers where they specialize in persistent AFIB ablation.

The guidelines are voted on by a wide array of EPs trying to include recommendation for ALL of them to rely on and follow. With paroxysmal AFIB ablation there is a higher level of confidence noted in the guidelines level than with persistent ablation, reflecting primarily that a smaller number of ablationist and centers are appropriately experience to be including these more challenging cases, where the level 1a guidelines are intended for general across the board recommendation for adoption.

2. It often takes some years for a very important and sure to be approved process to gain that approval as the process spreads with consistent success among wider groups of center and EPs over time. That in no way implies that the pioneers of these procedures had it wrong or were out of line in recommending it tot their select group if patients, just as many drugs are used as 'off label' but perfectly defensible scenarios for the betterment of their patients as well.

These guidelines, by definition, tend to be conservative and cautiously adopted over time which is fine. But its those blazing the trial ahead that make the real changes for the better in this field.

3. There are many EPs that should not be doing persistent ablations, and that includes asymptomatic ablation which are not appreciably different in their process or degrees of success with top tier centers than are symptomatic persistent ones. However, when you discuss this with non-ablation EPs and certainly those who do not do persistent AFIB work and who are automatically biased against ablations and sometimes very sincerely so from their own exposure to results from less than highly skilled ablationist working on their patients,, they will almost always dismiss it and stick to the safe and simple (for them).

4. Not all asymptomatic cases are good candidates for ablation just like not all paroxysmal or persistent cases are either. Dr Natale is at the vanguard of this rapidly growing area of persistent AFIB ablation and in reality it has been going on for a good while with the top tier centers. His main criteria is the younger the patient the more actively he encourages those with asymptomatic AFIB to go for ablation with ONLY a top level persistent ablationist and in his patients that of course is him. It is literally no different ablating a symptomatic or asymptomatic case for him.

The guidelines are only looking at the lower odds for one single initial ablation success for persistent AFIB for giving it a IIa or IIb indication, but the reality as we all know that persistent cases, and even long standing paroxysmal cases, more often require two or three max procedures to reach the top levels of success that experienced operators can achieve with a single basic paroxysmal case.

Also, Dr Natale evaluates each so-called 'asymptomatic' case looking for AFIB- related symptoms that are often unrecognized but very much there, they just don't feel the heart beat ... and only ablates those who have one or more defined AFIB related symptoms that will likely contribute to worsening disease or other co-morbidities going forward.

5. Also, the aim is to prevent those who are still relatively young (65 to 70 and under and especially from low 60s on down) from being stuck on OAC and rate controls drugs for 20 to 40 years, if at all possible to prevent that and to prevent the ongoing structural remodeling that often occurs with years of unabated AFIB, even if one is mostly unaware they have it and even when their rates are not too high such as to cause earlier cardiomyopathy. That risk for stroke even on OAC drugs continues to add up at from 2.5% to 3% annually on anticoagulation .. in 20 years that is approaching 60% odds. It is not a precisely linear increase with time but its close to linear. Looking out to 30 years and we are talking a statistical high likelihood of a CVA or significant bleed of some kind.

6. Plus, as the growing field of AFIB related Silent Cerebral Ischemia and the increasingly strong evidence of its direct association to a significantly increased risk for early onset dementia continues its rapid rise in prominence as a major long term concern of under treated on-going AFIB, the indication and focus on addressing so called asymptomatic .. or better said those who are not aware of their heart beating in AFIB ...will only increase to the point where within a couple years we are bound to see it accepted in the guidelines as a recognized approach for the properly screened patient going forward within highly trained persistent AFIB centers.

Anyway, your point is well taken AA, but please don't take the current rear mirror view of the guidelines to imply this is not a currently accepted method for the right patient within top centers. These case have been talked about and results discussed at each of the conferences I have attended the last few years.

That being said, many EPs who are mostly followers and not leaders in this field will gladly continue to defer and dismiss recommending any of their asymptomatic patients for ablation, until the guidelines finally catch up to prevailing leading edge practice and provide them the cover to change their tunes on this issue. With a few more randomized trial on this approach now under way being published the tide will turn as well, as is often how progress is made a step at a time in this field.

Shannon

P.S. Anti-AFIB. Im sorry I just noticed that I missed your references to your adrenal question and where you posted that. Please PM me and if you'd like with your cell number and a good time to ring you as it might be easier for me to discuss this with you over the coming days when we can chat about the options you might have for sorting out this issue for you over the phone.. its often easier to cover this kind of subject by phone and not dominate too much of the discussion here with these endocrinology issues even though related to AFIB as well.

Cheers!



Edited 1 time(s). Last edit at 07/19/2015 10:00PM by Shannon.

TAA- Yes. I read all ten references on asymptomatic patients. None of those exclude ablation as an option.

Researcher:

OK, I think I see how are you coming up with 10 references to Asymptomatic patients? I searched for "Asymptomatic" in the PDF format, and did see Asymptomatic about 10 times. The other way I did it, came up with only 4-5.

The guidelines in section 6.3. only recommend CA for "Symptomatic" Patients, thereby excluding Asymptomatic Patients from the recommendation.

There were 16 references to "asymptomatic" in total. Ten of that were in the discussion sections that are relevent to treatment and management. The remaining 6 were in the footnotes referencing literature that contained "asymptomatic" in the papers' subject-title. I downloaded the PDF and did the search in Adobe.

There is also no black and white definition of asymptomatic if you look at the HRS patient video on AF. There was a runner that was "asymptomatic" but then stated in the video that he couldn't figure out why he couldn't even start a run sometimes after feeling great the time before, then he got diagnosed while being checked for some other things. He was in permanent AF already. To me, I would consider not being able to do a normal activity that I enjoy a symptom. It is more of not knowing what he had, not that he was asymptomatic. The video is on the HRS website.

[vimeo.com]



Edited 1 time(s). Last edit at 07/20/2015 12:03PM by researcher.