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AFib burden

Posted by Pompon 
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Pompon
AFib burden
February 20, 2020 01:22PM
What's the % of AFib considered "dangerous" ?


I've had 8.5 months at 3.32%. Symptoms were awful and meds nearly useless. It was unbearable, so I had my first ablation (PVI). Was that percentage really dangerous, knowing my episodes were not long (less than 24h) ?

After my PVI, I had 5 months at 1.75% (still unbearable, even with meds), then a failed touch-up procedure followed by 13 months at 1.83%. Episodes were shorter, but still numerous. BB and Flecainide were killing me, and I still had afib.

I had another touch-up, spent 8.5 months at 1.54%, trying some meds, diets and supplements before having my last touch-up to date.

My burden for 2019 was at 0.79%. Short episodes. No more meds.

I believe this last percentage is harmless. Even better: since the beginning of the present year, I'm at 0.19% afib. No meds, exercising, I'm back to life.

I'd say less than 1% seems tolerable (when you're symptomatic), and likely harmless if episodes are short.
Am I wrong ?
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Carey
Re: AFib burden
February 20, 2020 04:26PM
There is no percentage that's dangerous as long as rate is controlled and anticoagulants are taken. After all, people in longstanding persistent afib have 100% burdens and they live just as long and just as healthy as anyone else.
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safib
Re: AFib burden
February 20, 2020 10:40PM
According to a recent study it may be close to 11% burden, and interestingly not related to longest episode length . This is independent of CHADS and not taking OACs. AFburden The JAMA paper has more details. For one thing, it seems the conclusion is less reliable for CHADS of 0 or 1.
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Carey
Re: AFib burden
February 21, 2020 12:30AM
From your study:

Quote

Findings In a cohort study of 1965 adults with paroxysmal atrial fibrillation, a greater burden of atrial fibrillation (≥11%) on 14-day noninvasive, continuous electrocardiographic monitoring was associated with a significantly higher rate of thromboembolism while not taking anticoagulation vs a lower burden.

These are completely expected results.
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Pompon
Re: AFib burden
February 21, 2020 12:35AM
Would this mean that:
1) Low afib burden (like I have now) without taking meds may be considered benign, considering I've no associated co-morbidities and my episodes are short and self-ending?
2) Having, say, 3*1h afib/month or 1*36h afib/year makes no difference?
3) I'm right neither taking meds nor having any ablation as long as my afib burden is as low as it is now?
4) I've always some Pradaxa with me, in case I've a longer episode (it's the stressfull thing: I'm never sure if and when afib will stop). Should I start taking it if I'm in afib for more than a couple of hours ?

Thanks for your help.
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GeorgeN
Re: AFib burden
February 21, 2020 07:57AM
Full Paper

Quote

Limitations

Our analysis had several limitations. Information on the exact reasons for undergoing arrhythmia monitoring and for not receiving anticoagulation was unavailable. Given the number of events, we had limited power to determine thromboembolic risk at more granular cutoffs of atrial fibrillation burden, but our data suggested a threshold of approximately 11% as meaningful in the overall cohort and across age, sex, and subgroups without diabetes, chronic kidney disease, and hypertension. We were underpowered to evaluate the association of atrial fibrillation burden with thromboembolism in this subset of patients with a CHA2DS2-VASc score of 0 or 1. Patients in the highest tertile of atrial fibrillation burden were more likely to receive anticoagulation, which led to modestly fewer person-years while not taking anticoagulation in this subgroup (586) than those in the first (690) or second (639) tertiles, but this would bias the association between atrial fibrillation burden and thromboembolism toward the null. While a greater burden of atrial fibrillation could theoretically lead to longer periods of blood stasis, the promotion of thrombus generation, and the development of worsening of certain stroke risk factors (eg, heart failure or impaired kidney function), we were unable to determine if the burden of atrial fibrillation is a marker of risk or causative. Although we studied primarily insured adults in California, our results are likely to be generalizable to other populations and practice settings. Our analysis that examined any intermittent periods of time not taking anticoagulation during follow-up as a continuous period for an individual patient was based on the assumption of a constant hazard of the outcome, which may not be true; however, we did not find any evidence of violation of the proportionality assumption. Our continuous electrocardiographic monitoring strategy was only up to 14 days, so we were unable to evaluate the potential value of longer (or shorter) periods to characterize the burden of atrial fibrillation. Finally, as stroke risk factors can accumulate over time in patients, risk stratification is a dynamic process and further study is needed to evaluate the incremental utility of repeated episodes of characterizing atrial fibrillation burden.
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safib
Re: AFib burden
February 21, 2020 08:52AM
Quote
Carey
From your study:

Findings In a cohort study of 1965 adults with paroxysmal atrial fibrillation, a greater burden of atrial fibrillation (≥11%) on 14-day noninvasive, continuous electrocardiographic monitoring was associated with a significantly higher rate of thromboembolism while not taking anticoagulation vs a lower burden.

These are completely expected results.

That is incorrect. The results are startling in that they suggest (i) there is a quantified risk associated with afib independent of comorbidities; and (ii) the risk is associated with the total burden and not with the longest duration.

As for the remainder of yours and George's comments, I already mentioned that the study applies only to those not taking OACs and was not reliable for CHADs of 0 or 1. This research is part of the ongoing effort of risk stratification, so that quantitative measures in addition to CHADs can be used to decide on anticoagulants. I must say that this is good but preliminary news for those like George who can effectively minimize their cumulative burden, even if they occasionally have a longer episode.
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safib
Re: AFib burden
February 21, 2020 08:58AM
Pompon:

The study is certainly preliminary and I am afraid you will have to draw your own conclusions. Perhaps ask your EP?.

Peter
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GeorgeN
Re: AFib burden
February 21, 2020 09:35AM
As
Quote

the mean (SD) age was 69 (11.8) years
, the applicability to younger people may also be limited.
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Carey
Re: AFib burden
February 21, 2020 10:21AM
I don't think there are solid answers to your questions except maybe #4. There's conflicting evidence on how long it takes for clots to begin to form during an afib episode, with one study showing it's only minutes. That study may be an outlier because the study population was older and sicker, but still, nobody has a firm answer to the question. So if I were you I would take the Pradaxa when an episode begins. That was my EP's answer when I was using Pradaxa as a PIP.
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Carey
Re: AFib burden
February 21, 2020 10:29AM
Quote
safib
That is incorrect. The results are startling in that they suggest (i) there is a quantified risk associated with afib independent of comorbidities; and (ii) the risk is associated with the total burden and not with the longest duration.

I don't think (i) is startling at all. As for (ii)... eh, maybe. One study doesn't warrant conclusions. Mainly, I think slicing and dicing numbers so finely just to avoid taking an anticoagulant is a waste of time and an unnecessary risk.
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safib
Re: AFib burden
February 21, 2020 11:28AM
Quote
Carey

Mainly, I think slicing and dicing numbers so finely just to avoid taking an anticoagulant is a waste of time and an unnecessary risk.

Again, this is not correct. If the results hold up, this means that a potentially large population of those with paroxysmal afib may not have to be anticoagulated for life, including those with CHADs of 2 or larger. There are many issues with anticoagulation including, cost, compliance, bleed risk, and surgical complications. Although the study is far from definitive, it is wrong to assert this type of research is a "waste of time", and your view is not held by the research community where further risk quantification is a high priority.
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Elizabeth
Re: AFib burden
February 21, 2020 02:31PM
You have someone right here---me. I had perioxyamal Af for 20 years, my episodes were anywhere from 12 to 24 hours, they usually started around 5:00 a.m., sometimes late at night before going to bed. During those 20 years I did not take any anticoagulants, except when first getting AF my doc. put me on Coumadin which I couldn't take, so it was dropped. I was in good health, no diabetes etc., I did have a thyroid problem which I took meds. for and occasionally I got an aura migraine (which I only took an aspirin for) that was it. I worked out a lot in my garden, yard, lifted heavy things, did a lot of work.

This has ended for me as I had too much thyroid hormone this past October and I have gone into persistent AF, so now I am on Xeralto, a Cardioversion has failed.

But the point of this discussion has to do with anticoagulants and I am here to say that for 20 years I did not take any and I had episodes of AF during that time. I did not have any adverse effects, nothing, I was fine all those years.

Liz



Edited 1 time(s). Last edit at 02/21/2020 03:08PM by Elizabeth.
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Pompon
Re: AFib burden
February 21, 2020 03:56PM
Quote
Carey
I don't think there are solid answers to your questions except maybe #4. There's conflicting evidence on how long it takes for clots to begin to form during an afib episode, with one study showing it's only minutes. That study may be an outlier because the study population was older and sicker, but still, nobody has a firm answer to the question. So if I were you I would take the Pradaxa when an episode begins. That was my EP's answer when I was using Pradaxa as a PIP.

Before having my first ablation, my symptoms were heavy. As soon as afib came, my BP - usually around 110/70 - used to fall as low as 85/50. I was just able to walk carefully. I guess my EF was strongly affected. I had to urinate every 15-20 min during the first couple of hours. Then the symptoms slowly subside and the episode self ended some 15-20h later. I always took Pradaxa at once.

Now, it's different, but I'm still feeling my afib as soon as it comes. There are always runs of PACs to begin. No more other symptoms like low BP and low EF. On EKG, there are nearly always some P-waves here and there. That's why I don't take my OAC at once. I'm just planning taking it if I'm still in afib two or three hours later. It's pretty rare. The last time it happened, I went back in NSR as soon as I had swallowed my tab with a glass of water.

I don't feel I'm taking risks doing this, but I may be wrong. My CHADS score is 0, I'm active, working, hiking and riding my bicycle. Risks of bleeding have to be considered too.
I see my cardiologist next month. If needed, I can speak with my EP. Asking them what they think about that is a good idea.
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SteveCarr
Re: AFib burden
February 21, 2020 09:07PM
Findings that "there is a quantified risk (of thromboembolism) associated with afib independent of comorbidities; and the risk is associated with the total burden and not with the longest duration", would tend to support or imply that there is a specific (as yet officially unrecognised) metabolic/pathologic problem/process which is specifically the cause of "Lone" afib, and that that same problem is (silently) also causing other very serious damage and risks in sufferers, of unknown total cumulative magnitude in each individual.

And that is the answer to anyone who (sometimes somewhat critically even) asks why anyone would bother going through major efforts to find underlying dietary and/or lifestyle solutions to their afib rather than take an "easier" way out : getting rid of the underlying cause is also extremely likely to be yielding other major benefits beyond "mere" afib remission.

As people probably know by now, that is what I believe GeorgeN and I (and two of my family members) are achieving, and I think it is extremely striking that in those cases the metabolism of one chemical element is central. But I'm not here to labour that latter point in this thread (I've done that elsewhere); I'm merely pointing out the likely huge personal gains to be achieved by individuals finding and fixing the underlying cause.



Edited 2 time(s). Last edit at 02/21/2020 10:16PM by SteveCarr.
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Carey
Re: AFib burden
February 21, 2020 09:09PM
Quote
safib
Again, this is not correct. If the results hold up, this means that a potentially large population of those with paroxysmal afib may not have to be anticoagulated for life, including those with CHADs of 2 or larger. There are many issues with anticoagulation including, cost, compliance, bleed risk, and surgical complications. Although the study is far from definitive, it is wrong to assert this type of research is a "waste of time", and your view is not held by the research community where further risk quantification is a high priority.

"Not correct" in your opinion. I don't think you can summarily declare my statement incorrect.

My point is exactly what you said: "If the results hold up". The thing is, I don't think they will. But we'll see.
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Pompon
Re: AFib burden
February 22, 2020 02:39AM
Quote
SteveCarr

And that is the answer to anyone who (sometimes somewhat critically even) asks why anyone would bother going through major efforts to find underlying dietary and/or lifestyle solutions to their afib rather than take an "easier" way out : getting rid of the underlying cause is also extremely likely to be yielding other major benefits beyond "mere" afib remission.

I agree with that. I'd add that for most vagal afibbers, the first underlying cause is an irritable vagus nerve, maybe a genetic predisposition.
Ways to disturb vagal tone are numerous, and likely very individual. That's why I think you're right about dietary or lifestyle changes. For my own case, ablations - mostly the PVI - cut the highway for the worst ectopics. Other remaining roads have been cut too, with touch-up ablation. The remaining little paths are my business now.
It seems they stay mostly inactive as long as I can take my stomach reflux under control.
Dietary/lifestyle changes, as you said.
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safib
Re: AFib burden
February 25, 2020 04:40PM
Quote
Carey

Again, this is not correct. If the results hold up, this means that a potentially large population of those with paroxysmal afib may not have to be anticoagulated for life, including those with CHADs of 2 or larger. There are many issues with anticoagulation including, cost, compliance, bleed risk, and surgical complications. Although the study is far from definitive, it is wrong to assert this type of research is a "waste of time", and your view is not held by the research community where further risk quantification is a high priority.

"Not correct" in your opinion. I don't think you can summarily declare my statement incorrect.

My point is exactly what you said: "If the results hold up". The thing is, I don't think they will. But we'll see.

Well, my point is not whether the results hold up or not as no one can know that right now, but rather that the research should not be labelled as a waste of time (and I would assert the same for detailed studies of triggers). As for the results, we shall know a lot more about afib patterns and embolic stroke in a few years, precisely because risk quantification is both a high priority and the technology is now at the point to enable it Apple and JandJ Study
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