Is Digoxin a Good Choice for Treatment of Atrial Fibrillation?

Is Digoxin a Good Choice for Treatment of Atrial Fibrillation? I want to make it clear, once again, that I am writing this blog as an endurance athlete dealing with atrial fibrillation (AF) – not as a clinician. I’m not a cardiologist or a primary care physician. I’m simply posing a question and not answering it. It is important for you to be in agreement with your cardiologist and primary care provider about your treatment plan Whatever you do – DON’T STOP TAKING ANY MEDICATION YOU HAVE BEEN PRESCRIBED BECAUSE YOU READ ABOUT SIDE EFFECTS ON SOME GUY’S BLOG!

Also – full disclosure – I take a low dose of digoxin.

Digoxin is the generic name for Lanoxin which has been actually been used for hundreds of years as an herbal preparation (Digitalis) from the foxglove plant, seen above, which is a lovely plant, don’t you think?

Digoxin is used to treat atrial fibrillation, atrial flutter, and heart failure. My cardiologist told me that many of the younger cardiologists don’t generally even prescribe it any longer.

Digoxin has a narrow therapeutic index, which means that at too low of a dose it isn’t very effective and at higher doses it is toxic. Because of this it has many side effects. It is unknown whether digoxin is safe during pregnancy. Digoxin works by improving heart function by strengthening the contractions and slowing the heart rate.

A 2018 paper published Journal of the American College of Cardiology concluded that digoxin increased mortality in patients with atrial fibrillation regardless of heart failure.

Conclusions In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations ≥1.2 ng/ml. Initiating digoxin was independently associated with higher mortality in patients with AF, regardless of heart failure.

Yikes!

Also consider that several of the authors of the study disclosed that they had financial ties to pharma and medical device companies, including pharmaceutical giants Bristol-Meyers Squibb and Pfizer who funded the study.

But look! Runners and other endurance athletes need to ask their cardiologists about digoxin toxicity because both dehydration and low magnesium increase the chance of toxicity. Who among us hasn’t been dehydrated?

I’m going to be asking my cardiologist more questions about digoxin next time I see her. As I mentioned I take a small dose and when we did lab work my digoxin level was low, below the therapeutic window, which she said was fine – she just wanted to make sire it wasn’t too high. Me too!

I’d love to see your comments!

Dehydrated Trail Runner – me!

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Coffee and Atrial Fibrillation – Update

A couple of years ago I posted an article on this block entitled Does Drinking Coffee Cause Atrial Fibrillation?   

It had been determined that drinking coffee, even in fairly large amounts, did not increase the risk of an individual going into atrial fibrillation.

 

In their analysis, the researchers found that coffee consumption was not associated with AF incidence, even in more extreme levels of coffee consumption.

 

The article went on to state that while drinking coffee does not cause atrial fibrillation individuals who have no history of atrial fibrillation, it was thought that coffee may be related to recurrence of atrial fibrillation and individuals who have the arrhythmia intermittently:

 

“These findings indicate that coffee consumption does not cause atrial fibrillation,” Larsson says. “However, high coffee consumption may still trigger arrhythmia in patients who already have atrial fibrillation.”

 

 

It was stated that more research was necessary. 

A recent, widely reported Australian study, a very large review of existing studies, determined that coffee is likely safe for people with atrial fibrillation.

 

“Although coffee increases your heart rate, it does not make it abnormal,” explained senior researcher Dr. Peter Kistler.  . . . “We found that there is no detrimental effects of coffee on heart rhythm and, in fact, coffee at up to three cups per day may be protective,” he said.

 

Protective?  That sounds like terrific news!  It is always nice to find out that something that is so enjoyable, but which you have assumed is possibly unhealthy, turns out to be not only safe but good for you also, reducing, to a small extent, episodes of atrial  fibrillation.

 

 Kistler’s group found that, among more than 228,000 patients, drinking coffee cut the frequency of episodes of atrial fibrillation by 6 percent. A further analysis of nearly 116,000 patients found a 13 percent risk reduction.

One cup of coffee contains about 95 milligrams of caffeine and acts as a stimulant to the central nervous system.

Caffeine also blocks adenosine, a chemical that can trigger atrial fibrillation, Kistler explained.

 

This study did, however, go on to recommend that people with heart arrhythmias avoid caffeinated energy drinks.  Furthermore, people who are sensitive to caffeine, should still avoid coffee.  Again there are certain people who identify caffeine is a trigger for atrial fibrillation and those individual should, by no means, return to drinking coffee.

 

Please comment with respect to your experiences with coffee, energy drinks, and atrial fibrillation.  Thanks!

The original study can be found here:

 Peter Kistler, MBBS, Ph.D., director, electrophysiology, Alfred Hospital and Baker Heart and Diabetes Institute, Melbourne, Australia; Byron Lee, M.D., professor, medicine, director, electrophysiology laboratories and clinics, University of California, San Francisco; April 16, 2018, JACC: Clinical Electrophysiology

Whatever Happened to AFIB Ultrarunner?

Sunrise at the start of an ultramarathon

So, whatever happened to “that one guy?” The one with the AFIB Ultrarunner blog?

When I decided to start this blog I had, of course, scanned the internet for similar blogs, and I found AFIB Ultrarunner. This was a somewhat short-lived but excellent 2010 blog by an unnamed man who was an ultrarunner, who like me, was dealing with atrial fibrillation (AF).

Afibultrarunner” was actually the name I originally chose for this blog, but it was taken so that’s okay, I’d be simply “afibrunner.”

I’m particularly interested in contacting him for two reasons.

First of all, at the time I was starting this blog I was personally just starting to train for ultras. In fact, I went into permanent AF right at the end of a twenty mile training run while trying to train for my first 50K.  I didn’t really know how to train so I was simply running a twenty mile trail run every weekend and I truly loved those long, slow training runs; but evidently that wasn’t a good idea given what happened!

Second of all the AFIB Ultrarunner guy had had an ablation, and has an excellent description of his experience. I have never had an ablation and likely never will (I’ve been told my chances at success are poor) and wanted to find out how he did on a long term basis. At this point I’d really like to find somebody to write about the experience for this blog – but I’ve never been able to find out who he is or how to contact him.

His blog is excellent and ends, I think, on a very sad note:

My cardiac procedure was painful or uncomfortable in constantly new ways for 20 hours.  I think I took it

pretty well, but at the time I thought that that day would be amongst the worst in my life, as in up

there with losing a spouse, child or dying yourself (although this just might be my inexperience with death speaking.)  Also I tried two drugs and nothing worked. Also my condition effects my day to day life more, such as it is now harder to carry dog food from the car without an attack, and my running has suffered.

Lets hope 2011 has more adventure running, and less heart problems.

 

And that was the end. I’m curious. How’s he doing now? Still running? Still dealing with AF? Maybe he doesn’t want to talk about it anymore – he is a little secretive about his identity, although there is a photo of him during a 50 mile race but there’s no contact info. A fifty mile race while dealing with AF – not too shabby!

Hey, man, if you’re out there let me know!

Famous Athletes with Atrial Fibrillation

Famous Athletes with Atrial Fibrillation

This quick article is presented here just so you don’t feel you are all alone with your athlete’s heart in atrial fibrillation (AF).

This article from Everyday Health, which you may have already seen, reveals nine well known athletes who had AF.

1.) Billie Jean King, the iconic tennis hero, went into AF in 2015 and had a successful ablation. “Today, King says she continues to eat well and exercise, and she’s teamed up with Janssen Pharmaceuticals to educate patients about their afib-related stroke risk.”

2.) Basketball legend Larry Bird evidently had AF symptoms while he was playing (tachycardia, lightheadedness, disorientation) but never reported it to his team physician. After he retired in 1992 he was formally diagnosed with AF, which the article states he now has “under control.” (Whatever that means)

3.) Canadian professional triathlete Karsten Madsen was diagnosed with AF in 2010 and was successfully cardioverted, and reportedly continues to compete.

4.) World Class tennis pro Mardy Fish dropped out of the 2013 French Open with a mystery illness later diagnosed as AF, and treated with ablation. I’m not sure if he continued to play, but he is currently retired from tennis.

2014, Tour de France, tappa 10 Mulhouse – La Planche des Belles Filles, Belkin 2014, Trek Factory 2014, Mollema Bauke, Zubeldia Agirre Haimar, La Planche des Belles Filles

5.) Spanish pro road cyclist Haimar Zubeldia was sidelined for three months with AF, but with rest and treatment he was able to return to competitive cycling and finished sixth overall in the Tour de France that same year. Wow!

6.) Olympic rower Nicola Coles (New Zealand) developed AF weeks before the Beijing Olympics, and was cardioverted.  Because many common AF treatment drugs are banned  for Olympic athletes her treatment options were limited and she ended up using magnesium and fish oil to control her symptoms. her symptoms did not recur and she competed in Beijing with her teammate and they finished fifth. She subsequently retired from competition.

7.) US astronaut Deke Slayton, one of the original Mercury program astronauts was diagnosed with AF; but he continued with his astronaut training program. In 1970 he had his AF under control and was reinstated to full flight status and eventually was able to pilot the first Apollo Docking Module for the Apollo Soyuz Project. 

8.) Eight time Olympic champion canoe racer Brigit Fischer was diagnosed with AF and forced to drop her plans of qualifying for the 2012 London Olympics at the age of fifty:

Though she believed she was in better shape than in her last Olympic comeback, Fischer admitted that being told she had atrial fibrillation confirmed her suspicions that something was wrong. Already the most decorated Olympian in German history and only the third woman to win at least eight gold medals, Fischer decided her health was more important than another medal. 

9.) Fourteen time NBA All-Star Jerry West played with AF symptoms believing them to be panic attacks. He was eventually was diagnosed with AF, was cardioverted, but continued to have to deal with AF.

If that isn’t enough you can check out this site:

53 best Celebrities with A-Fib images on Pinterest  Although I haven’t really taken a long look at this site, and can’t attest to it’s accuracy it’s oddly comforting to think that we’re not only in the same boat as folks above, but also with people like Gene Simmons and Barry Manilow.

 

Alcohol, Athletes, and Atrial Fibrillation

Alcohol, Athletes, and Atrial Fibrillation

 

Beer drinking with my buddies at Marster Springs Campground

Does alcohol cause atrial fibrillation (AF)?

We’ve been reading for years that a glass of wine or two can reduce the risk of heart attack and stroke; and it’s pretty clear if you’ve been hanging around at the finish lines of marathons, ultras, and long distance bicycling events that endurance athletes like to drink alcohol. Also, some studies have shown that endurance athletes have up to a five-fold increase risk of AF

So . . . is alcohol consumption a risk factor for endurance athletes dealing with AF?

Uhh . . . yeah.

Drinking alcohol frequently raises the likelihood of developing AF,  and more alcohol means more risk. One to three drinks (considered to be “moderate drinking”) increases the chances of AF, and “heavy drinking” (four or more drinks per day) increases the odds even more. It’s been suggested that every extra daily drink increases the risk by 8%!

Even if you aren’t a daily drinker so-called binge drinking, defined as five or more drinks in a day, also increases the chances of AF. (Some call it “binge drinking,” I might call it any weekend during my college years!)

Typical weekend from my college days

So how much alcohol is safe? Once you’ve been diagnosed with AF one or two drinks per day is probably safe, but three or more may be likely to trigger an episode. Also – make sure you figure out how much alcohol is one drink – a standard glass of wine versus a large glass of wine. A bottle of American light beer is going to be less alcohol than a bottle of craft brew IPA or stout.

My personal advice is that once you are diagnosed with AF the best move would be to quit alcohol altogether. That’s what I did. But consider that this advice is coming from a guy who is in permanent AF.

A very helpful WebMD article advises that even with moderate drinking you should avoid drinking every day: 

Even if you drink moderately, experts suggest you take a few days off from drinking alcohol every week.

  • Limit yourself to one to two drinks a day.
  • Try to have 2 to 3 alcohol-free days every week.
  • Talk to your doctor if you have an episode of AFib within an hour of drinking alcohol.

 

Exactly how does alcohol increase the chances of AF?

It isn’t clear why, but it is thought that hit might be related to increasing vagal tone. The more alcohol you drink, the higher the vagal tone. Another idea is that dehydration caused by alcohol triggers AF. A lot of people with AF know that alcohol can trigger their AF. Let’s face it – alcohol is basically a toxin with some pleasant side effects.

If you already are being treated for AF alcohol can interfere with the treatment – increase blood pressure, interact with anticoagulants, etc.

What is “Holiday Heart”?

Basically it is a nickname for the way heavy drinking around the holidays, so called “binge drinking” can trigger AF. According to Medscape:

Holiday heart syndrome most commonly refers to the association between alcohol use and rhythm disturbances, particularly supraventricular tachyarrhythmias in apparently healthy people. Similar reports have indicated that recreational use of marijuana may have corresponding effects.

 

The most common rhythm disorder is atrial fibrillation, which usually converts to normal sinus rhythm within 24 hours. Holiday heart syndrome should be particularly considered as a diagnosis in patients without structural heart disease and with new-onset atrial fibrillation.  Although the syndrome can recur, its clinical course is benign, and specific antiarrhythmic therapy is usually not indicated. Interestingly, even modest alcohol intake can be identified as a trigger in some patients with paroxysmal atrial fibrillation. 

Finally – what is meant by “Drinker’s Heart” (a.k.a “beer drinker’s heart”)?

That’s cardiomyopathy, a serious disease of the heart muscle, related to chronic heavy drinking. Don’t let it happen to you. It’s bad.

 

beerMPG

I would love to have any readers with comments post them below. I’d love to hear from  athlete’s with atrial fibrillation who have had experience with alcohol as a trigger. Thanks for reading.

 

Jim and Alison’s Story – a Guest Post by Alison

Note: I had originally intended to post the article about atrial fibrillation and alcohol today, but I’m going to hold off and post, instead, this excellent guest post from Jim and Alison. Wow – I can’t relay relate to their story! Please comment below.

Jim Competing in a Triathlon

My husband Jim started running 35 yrs ago.

He and a neighbor were doing races for fun. At 6’2 with a swimmer’s build he had always been active with distance hiking as a teenager and as an adult he added martial arts, weight lifting and biking.

Once the kids were on their own we had more time to devote to our love of running and hiking, soon discovering the incredible joy of trail running and hikes rated ‘Very Strenuous’. We traveled across the US to hike and even started to explore trail running and hiking in the Alps. Jim added triathlons and spent most of his free time working hard to maintain that level of fitness. Then he began “hitting a wall” during runs and hikes. We would laughed it off, he would eat an energy gel, and then pushed on through it. We had all kinds of reasons for “The Wall”. We even changed the term to a “Flat Tire”. Some excuses were: Didn’t sleep well the night before, needed more carbs, exercised too much the day before, and the list goes on.

What raised a warning flag was when we ran a simple 5K fund raiser where he worked. It was an out and back and as always he quickly disappeared ahead of me. Soon the fast runners began appearing on the return side, but no Jim. As I approached the turn around point there he was walking and looking awful. We both didn’t laugh this time but he seemed fine later that day. Something was wasn’t right, but he was fine…right? The “Flat Tire” problem continued on and off. Then one day while lifting weights in the basement he came to the top of the steps looking ash grey, swaying unsteadily and saying “Something is wrong with me! My heart is beating weird.”

Pumping Iron

 

At the General Practitioners office the Nurse Practitioner brushed it off that he must have stood up too fast. She never took his pulse or blood pressure. After all he obviously looked in excellent shape!

I called a cardiologist group from a University in our area for their take on this and when I briefly explained what had happened they said Jim needed to be seen the next day. Wow! I felt a twinge of anxiety. At the cardiologist office there were no smiles from the doctor seeing Jim. Jim was given an EKG and asked many questions about his medical history and life style. Then oddly the doctor asked him how long had he been an athlete. We both looked at each other and chuckled ! Jim quickly corrected him, “Oh no! I’m not an athlete! I’m just having fun running, doing triathlons and hiking. It’s a good stress release too.” I was nodding with a big smile in agreement.

The doctor unsmiling replied “Triathlons too? So your an endurance athlete then with many years of distance running.”

We both stared at the doctor confused. Then the doctor grabbed the EKG paper and waved it at us sternly stating, “You have serious heart disease!! Your heart rate is very high, blood pressure high and your heart is in arrhythmia!”

“That’s impossible!” I protested, “Jim is in really good shape! He doesn’t even have a gut and he’s only 56!”

The doctor glanced up from his paperwork at my shirtless husband sitting on the examination table and said, “Yes he is in good shape, but his heart isn’t!”

I found myself starting to argue with the doctor and stopped. He was obviously used to the denial routine and was ignoring me.

So we sat there slack jawed for about 15 minutes as the doctor explained how Jim had gone way passed the point of moderate exercise benefits. He told us about the scarring, inflammation and the damage caused by not resting during long runs and pushing through tough workouts. And how many other people had, and were, doing the same thing to their hearts. Oh, and that shot of fine bourbon he so enjoyed every night? No more. We learned that alcohol is poison to the heart muscle. 

We’d never heard of any of this before, nor did we even consider ourselves athletes. The years of Jim enjoying his passions weren’t adding years to his life but were shortening it! I wondered if I’d damaged my heart as well. I get “Flat Tires” all the time, jeez…. Hiking was our joy in life together! We couldn’t just stop running and hiking. It was part of who we are!

We left the doctors office silently with scripts for blood work, several different cardiac tests, and prescriptions for a blood thinner, as well as a medication to reduce his heart rate. All of this to lessen his chance of stroke. Appointments were made with other doctors in the cardiology group as well. (Our care was excellent, by the way.) Jim was told he could still workout but not to push. With any luck he could stay this way for the next three maybe five years before needing an ablation. That sounded very scary! Your going to burn what?!!Where?!!

Jim was handed a wallet sized laminated card with a copy of his EKG on one side and the doctor’s business card on the other.

“Please call us immediately if you have any problems. One of our team will meet you at the hospital. Give this card to the ER personnel.”

Really?!!! Wow!!! WTH?? Well, at least he might have three to five years, so everything’s ok….I guess… right?

One of the tests revealed a slightly enlarged heart. We were told again the ablation would help the AF, a temporary fix, but there was no cure. The ablation surgery could also make it stay the same, or it could make it worse. We both figured he had a few years before it got worse so we decided to wait. Unfortunately we didn’t have the five years or even three – Jim’s problems increased rapidly. He started having trouble going up the stairs at work. He was getting more and more tired. There were days where his face looked grey and haggard. His heart beat wildly in his chest. He began spending more and more time having “lazy days” where he would spend all day laying on the sofa watching tv, too dizzy and exhausted to do much else. Sleep was difficult as his hearts crazy beats kept him awake.

Interestingly family insisted he was fine! Not Jim! He’s in great shape! Wish I looked like him! He’s just stressed and needs to take yoga classes! So we had no much needed support. His episodes of AF were soon lasting for days. He was in AF more then out. I stopped tracking it on the calendar. Jim’s mood tanked. During the autumn of 2016 he decided he wasn’t going to let this best him so we went away to hike in the Blue Ridge mountains. The ascent that should have taken us three hours took almost six. I watched my husband frustrated and angry as he struggled to get up that mountain. I don’t know how many times I had to stop and wait for the man who always used to have to wait for me. The next day he was too weak to leave the car for an easy three mile hike to an overlook. I realized our time in the outdoors was now over and so were all our plans for good times.

Jim decided he wanted the ablation surgery.

He retired from his job before the surgery. Having already buried our son, Jimmy, several years ago from the war, mortality wasn’t the stranger it is to most people. We even had an intense discussion with the surgical team right outside the operation room over the forms Jim had signed. Apparently they don’t tell you everything that they are going to do during the ablation! Jim had a DNR order.

“I don’t want to be resuscitated if my heart stops,” stated my husband. But as it turns out, if the heart doesn’t reset itself after the ablation then the doctor will shock it back into rhythm, which in fact stops the heart, albeit but a moment. It was finally agreed that as long as Jim didn’t come out of the operating room worse then before he went in the team could do whatever they felt necessary.

 

He’s Primarily a Hiker Now

It’s been almost a year since the surgery and Jim only has that flipping feeling several times a week and his energy is back. He prognosis is: If he goes one full year post surgery without going into AF then he has a 70% chance of staying AF free for another three years. So we are back enjoying our hikes! But now we have put a limit on them. Six hours or ten miles whichever comes first, pace: 2.5 mph, not 4 mph. Plus the doctor recommended break every hour. We both gave up running. The doctors said he could still run but we already know he has damaged his heart enough and don’t need to hurry the AF back any faster then need be. As it will return! One of our doctors said, “Once in constant AF the heart wants to stay in constant AF.”

Cycling and AF Blog

John’s Bike

I’d like to recommend that readers of this blog take some time to check out the Cycling and AF Blog , if you haven’t already done so.

In this easy to read blog, with generally short entries, you’ll read of the personal journey of a middle aged road cyclist /club rider from England.

His atrial fibrillation (AF) began with some vague  symptoms in 2015, eventually diagnosed as AF. Follow his personal journey dealing with alcohol, coffee, diminished cycling performance, beta blockers (and other AF drugs), two ablations (!) and an Atricip procedure.

I think readers of this blog will find his journey interesting. Based in England the healthcare system is different, as are some names – a TEE (trans-esophageal echocardiogram), for example, is a TOE (trans-oesophageal echocardiogram).

I would certainly like to learn about the Atriclip procedure – I’ll research that and post about it in the future.

Speaking of alcohol – I’m planning my next blog post to be about alcohol and AF.

I hope you enjoy the Cycling and AF Blog as much as I did.

This is me, in AF, riding around Crater Lake