Tag Archives: anticoagulant

Update: Atrial Fibrillation, Pradaxa Fail, Transient Ischemic Episode, Blood Clot in Left Atrial Appendage

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Ridgeview Trail - Moore Park

Ridgeview Trail – Moore Park

About two weeks ago I was out for my typical Saturday two hour trail run on Moore Mountain with my dogs. It was a fine day and I felt great, and with about ten minutes left in the run I ran into three of my friends who were out mountain biking. My friend Linda, a Physician Assistant, was trying out her fancy new mountain bike and we stopped to talk for a while. She showed me her new bike and I introduced her to my new dog. I noticed, and commented, that I was having a little trouble getting my mouth working properly. I didn’t have any trouble finding words, or even saying the words, but my tongue just felt sort of thick – especially with consonants like “R” that seem to be made in the back of the mouth. I immediately did my self inventory for asymmetry and muscle weakness and found none. I attributed it to having had one of those little, annoying white sores in my mouth, accompanied by some swollen glands and thought nothing of it.

Linda Cyclecross racing

Linda Cyclecross racing

I finished my run, which involved a fairly technical descent, ate my post-run Clif Bar, and went home where I noticed nothing amiss. I forgot about it until Linda texted me the following day asking how I was doing and saying she was worried about me. I assured her – I was fine!

The next Monday, at work, I thought I’d ask my friend and co-worker, Dr Zakir Ali, if he thought the incident was any reason for concern. Dr Ali is a neurologist who works a couple of days a week at the orthopedic clinic, where I work as a podiatrist.

He wasn’t as dismissive as I was about the incident and said that that was very suspicious for a TIE (transient ischemic episode). A TIE is basically a small, brief stroke, in this case likely caused by a small blood clot that resolves fairly quickly. Dr Ali said I should, at the very least, get an echocardiogram to see if there is a clot in my left atrium, and possibly a carotid artery scan as well.

I have been in permanent atrial fibrillation and on Pradaxa, a potent anticoagulant (blood thinner) for two years and had never missed a dose. I thought he may have been over reacting – and I had had an echocardiogram just two months ago.

But Dr Ali had told me, “You will never regret checking.”

And I agreed.

Okay.

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So I called the on call cardiologist, explained what had happened, and he told me a standard echocardiogram would be useless as it won’t show a clot, and recommended a trans-esophageal echocardiogram, and also a carotid scan (ultrasound).

I mentioned that I had had a trans-esophageal echocardiogram before (in 1994!) and it was like swallowing a telephone. He said he’d get anesthesia involved and we set up both procedures not expecting to find anything.

So the carotid scan came first and was normal, as expected.

Last Wednesday I went to the hospital and checked in to Day Surgery – which was a peculiar and strange experience for me. I’ve been working there, as a surgeon, for the past twenty-five years, but this was my first time being there as a patient. It’s a little disorienting, and oddly embarrassing, to be on “the other side of the door.”

Anyway – Dr Vince Herr, the anesthesiologist, gave me some propofol so I don’t remember a thing; but when I woke up I was told that I had a small clot in my left atrial appendage, and turbulence in my left atrium as well. This was a surprise for everybody involved. Judging from my lab work and the bruises on my arms the Pradaxa seemed to be working – but evidently not well enough! And that “small clot” looked pretty big to me – downright dangerous.

Trail Running on the PCT

Trail Running on the PCT

At that point I was immediately started on Lovenox injections twice daily (for six weeks!), the Pradaxa was discontinued, and I am beginning to take warfarin (Coumadin); and of course I stay on the beta blocker (carvedilol). My cardiologist gave me the first Lovenox injection right in the post-op area.

Also it looks like no running or bicycling for six weeks – which of course is devastating to me, emotionally, but – shit! – blood clot / stroke / potential death – yes, I am definitely sticking with the program!

The injections are easy to do, they burn a bit but don’t really hurt, and every injection leaves a bruise. Believe it or not I enjoy and look forward to each injection because I’m hopeful that they will be helpful.

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I’m disappointed that the Pradaxa failed – it is much easier to take that warfarin. Remember that I am a vegetarian and one of my passions is eating healthy food, especially kale. Also everyday, up until now, I eat a little square of nori (seaweed – like the wrapper on sushi) thinking that it would be a good source of iodine as I don’t eat any seafood or use table salt. Kale and nori are probably the two worst foods to eat if you’re taking warfarin!

Taking warfarin is going to be a real challenge – changes will be made, changes that actually seem sort of unhealthy. The one advantage is that warfarin is, unlike Pradaxa, reversible, which is a true benefit in the case of a bike or auto crash, a GI bleed, a head injury, and so on.

Moore Park Trails

Moore Park Trails

In six weeks the trans-esophageal echocardiogram will be repeated and hopefully the clot will be gone. If not some sort of procedure (by the electrophysiologist) is in store for me. Hopefully I will 1.) not die and 2.) get back to trail running. Until then my nerves are wracked worrying about having a major stroke!

I need to say that I feel incredibly blessed – if I hadn’t met my friends and stopped to chat I never would have known I was having a TIE. And if Linda hadn’t have texted me the next day I wouldn’t have ever pursued it, because I had, in my mind, completely dismissed it. And also – how many people actually have a neurologist right in their office who is willing to talk at any time?

Clearly I’m not through this yet – but in a way I feel I have already dodged a bullet. Really, if it weren’t for Linda that blood clot would have just kept getting bigger and who knows what would happen next? I might be dead by now. Even as it is now – who knows? But at least now I know I have a problem and the treatment plan has been changed.

So thanks, Linda!

Me and Linda in Costa Rica

Me and Linda in Costa Rica

I would appreciate any comments, especially shared experiences, you might have.

To be continued. Wish me luck.

Afibrunner: Patient Perspectives: Long-Distance Running and Mountain Biking in Permanent Atrial Fibrillation / EP Lab Digest

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Patient Perspectives: Long-Distance Running and Mountain Biking in Permanent Atrial Fibrillation / EP Lab Digest

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I am honored to have had an article published in the December 2014 issue of EP Lab Digest, a monthly journal for electrophysiologists and allied health professionals who work in electrophysiology labs.

The managing editor, Jodie Elrod, had approached me about writing a “patient perspective” article as she was familiar with my afibrunner blog. The article is basically a synthesis of material already presented in this blog, particularly my article called Atrial Fibrillation – A Visit to the Electrophysiologist.

I am delighted to have this opportunity to communicate with the EP community and promote my plea for empathy with respect to the endurance athletes afflicted with atrial fibrillation.

Thanks EP Lab Digest!

Also interesting – my cousin Chuckie, (an electrophysiologist – I’m sure they don’t call him “Chuckie” at work), who I mention in my article, had an article published in the November 2014 issue of EP Lab Digest.

Bicycling the Rim Drive Crater Lake National Park and Atrial Fibrillation

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I haven’t blogged for a while because we’ve been on vacation in Croatia for two and a half weeks, and of course after being gone for that long I’ve been incredibly busy at work. I am working on along blog entry (actually it’ll be a separate blog) about Croatia, so stay tuned.

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Me During a Brief Rest Stop

In my opinion bicycling around Crater Lake is one of the finest bike rides in the entire United States, and Crater Lake National Park will, from time to time, close of twenty-four of the thirty-three miles of the Rim Drive to allow bicyclists, hikers, and runners to have a relatively car free day. This year they had vehicle free days on two Saturdays: September 20 and 27, and I made time to be there for both days.

Since I live near Crater Lake N. P. I’ve had the opportunity to ride the rim several times, but this year was my first time doing it in permanent atrial fibrillation (and while on a beta blocker). Always a challenging ride under any circumstances, adding a fib and a beta blocker to mix changes things a bit.

Most riders start at the Steel Visitors Center (Park Headquarters) and ride clockwise. The first thing on the agenda is a three mile climb with 650 feet of elevation gain up to the Rim Village. This is actually the steepest hill along the route, but not the most difficult, in my opinion, mostly because the legs are still fresh. It is quite odd to pedal up a climb like that and find a lake at the top. There are several climbs and descents along the thirty-three mile route, and rarely is there any flat road, and the two toughest climbs, in my experience, are in the second half of the ride – the long easy climb to Cloud Cap (where most people stop to sigh and eat their Clif Bar) and the last grind up to Dutton Ridge. I might even say that you only need two gears to ride the rim – whatever you use as your easiest climbing gear and a big gear for coasting downhill.

Elevation varies from 6700 to 7700 above sea level. Personally I don’t have an issue with the elevation at Crater Lake because I’m used to living at higher elevation, but people coming from sea level might feel it.

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Bicycling in Croatia with Margo

To be honest, none of the climbs (going clockwise) are particularly steep, and there is only a total of about 3500 feet of climbing, but the climbs are so long and persistent that it seems like more. The descents can be fast and one could easily go 50 mph down the descent from Cloud Cap, but don’t. The speed limit is 35 mph and there are often surprising potholes encountered once you get up above 40 mph. The vehicle free days are great because you don’t have to worry about cars behind you. One day I was descending at 45 mph, a speed at which the wind in my ears prevents hearing anything, riding right down the middle of the lane, and was passed by a van. I thought, “What’s your hurry, bro? I’m already going 10 mph over the speed limit!”

The scenery is world class and seeing it slowly, up close on a bike, complete with the sounds and the smells is unimaginably beautiful. Being there on a vehicle free day with hundreds of bicyclists from all over Oregon is even better – there is an amazing energy in the air on the vehicle free days.

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Snowshoeing with Libo April 2013

If you are going to ride the rim, especially on a vehicle free day, keep in mind that once you are past the Visitor Center and the Rim Village (basically once you are past the first three miles) there is no water. I’m a heavy sweater so I’ll take three liters on a hot day. Actually along the last big climb there are some little “waterfalls” right along the roadside and I have seen people filling their water bottles there and it is probably fine; but it is definitely not tested and designated as potable water. Also keep in mind that there will be no SAG wagon trailing you so make sure you have the proper gear and tools for changing flat tubes and minor repairs.

As far as riding the rim in a fib while on a beta blocker, well, it is much slower. I was able to ride it but it took me at least an extra hour. I had a triple chainring on my old road bike, and I used to be able to do the entire ride in the middle chainring (except for part of the first climb); but now I am using my easiest gear for most of the climbing (my new bike has compact double, but the gearing is similar). I think I need to be happy with being able to complete the ride without falling to pieces, and quit lamenting my slower speed.

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Photo by Margo

My personal preference, now that I am in a fib, is to keep going and minimize rest stops. It seems every time I stop it’s like starting over again. On the first Saturday I was riding with a group of friends, including my wife Margo (her first time doing the rim ride) and I told them I wouldn’t be stopping much and that they could catch up to me. The last I saw them was at the top of the first climb, and I actually completed the ride a half hour or so ahead of them – they had fun, stopped at the many overlooks, stopped for lunch. I was the tortoise to their hare; slogging up the hills and only stopping a few times.

Another difference is that now that I am on an anticoagulant I brake a lot on the descents. I’m usually the biggest rider in whatever group I’m riding in and consequently the slowest climber that makes up for that by being the fastest descender. No more. Now I think about how descending slowly will help me keep my blood inside my body and I was passed by dozens of riders on each hill. As a matter of fact I kept getting passed by the same groups over and over. They’d pass me on the climb, then I’d pass them at the top of each hill where they’d stop to look at the stunning view of the lake, then they’d pass me on the descent and I’d pass them again at the bottom of the hill where they’d evidently stop to chat. Over and over – sort of fun.

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Skiing with Jan (evidently I’m relying on old photos because I only took one photo for two days of riding around Crater Lake – like I said I don’t stop enough!)

I returned and rode the Rim Drive again the following weekend as well but my friends didn’t accompany me. It was a much cooler, windier day and looked like rain, and they had other plans. I ended up doing the first half and deciding to make it an out and back. I was thinking about the big descent down the other side of Cloud Cap in the heavy wind and thought that might not be the best idea on account of my being anti-coagulated. I learned that riding the rim counter-clockwise is not as safe as riding clockwise. When riding clockwise the lake is to your right; but when riding counterclockwise there was quite often a steep drop off and no shoulder and no guard rail. The drop offs weren’t a thousand feet or anything like that but they were certainly much further than I wanted to go over on my bike so I did the long descents towards the middle of the lane although I pissed off a few drivers I will live to ride again. There is no way I will ever ride the entire rim counterclockwise. Keep in mind that most drivers are looking toward the lake (why wouldn’t they) and if you are between the driver and the lake they are likely to see you. But when riding the other direction there is more risk of being unseen.


Carter Lake Century 2011 (not my video)

Another good time to ride around Crater Lake in the Crater Lake Century. I have never ridden with the organized century (I’ve always been training for something at that time – it’s held in August) but I have been told it is a blast. As far as I know the Rim Drive isn’t closed during the century but there are about 300 riders up there that day. The number of applicants is limited so register early if you want to get in. The century, obviously, involves more than the thirty-three mile Rim Drive and in addition to more climbing from Fort Klamath up to the Park Headquarters, there is some routing around the local farmlands near Fort Klamath to make it an even one hundred miles.

I would love to hear from other bicyclists, especially cyclists dealing with atrial fibrillation. Please feel free to comment below.

SOB Trail Run 15K Race Report: Atrial Fibrillation, Running, Beta Blockers – My First Impression

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SOB Trail Run

I have been in permanent atrial fibrillation for a couple of years now, but only been taking an anticoagulant (Pradaxa). But things have changed and for the past month I have been on a beta blocker, carvedilol.

Prior to starting the carvedilol, while in permanent atrial fibrillation, I had been able to run two marathons and one ultramarathon (50K) without any more trouble than the normal marathon type suffering, but over the past six months I have noticed things have been changing. I’ve slowed down, even for me, and distances are getting harder. My last half marathon was a joke and I was at the end of the pack within the first two miles. After a run or mountain bike ride of an hour or more I would have problems afterwards – my blood pressure would drop and my pulse would stay high. After a long run, especially if it was a hot day (which they all are, recently) I would get so light-headed after standing up I sometimes had to grip onto something to remain standing.

A visit to the cardiologist, and a subsequent echocardiogram, revealed that my heart rate was increasing and my ejection fraction was decreasing, and for that reason the cardiologist wanted me to start on a beta blocker.

A beta blocker, in this case carvedilol, is a drug that reduces stress on the heart by slowing the heart rate, decreasing the force with which the heart beats, and reduces the tone of the arteries throughout the body. The end result is that blood pressure is reduced, as is heart rate. The heart needn’t work so hard.

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SOB 50 Mile Course – tough!

Some non-endurance athletes actually use beta blockers as performance enhancing drugs – it is said that it calms a person, reduces performance anxiety, and is commonly used in less endurance specific sports such as golf, target shooting, archery, and even in music performance.

Clearly these drugs are performance diminishing for endurance sports like distance running and mountain biking. We like to stress the heart, raise the heart rate, and we don’t have very much stress – we’re long distance runners after all – the mellowest people around.

I generally am in at least half marathon shape year round. Even if I’m not training for anything my weekend long run is going to be between nine and twelve trail miles. Prior to starting the beta blocker I had signed up for the 15K at the SOB Trail Run at Mount Ashland (Oregon) – one of my favorite races. This relatively high altitude run is basically all up and down trails and fire roads (zero flat sections) and I have done it at least six times in the past, including completing it twice in atrial fibrillation. I was curious to see how being on the beta blocker would affect my race.

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DNF

The answer was I DNFed (did not finish) and dropped out fairly early in the race. That was terrible – most of my friends were running the 50K or the 50 mile and I DNFed the little 15K???

The course at the SOB is brilliant, really. A lot of trail races start out right away on singletrack, but the SOB has about a mile(?) of fire road at the start so everybody has plenty of time to figure out whether they are going to be running with the fast people or the slow people before they hit narrow Pacific Crest Trail. I ended up at the very back of the group that was running, but I was still in front of the few people who were walking the 15K.

I found that as soon as the course headed up hill I was unable to run. My chest felt funny – not chest pain, just felt weak, not right, and my legs felt dead. I wasn’t short of breath, I was just unable to do it. I decided, in my typical OCD mode, to continue running for five more songs on my iPod shuffle, and then turn around and drop out, thinking that I should at least get a little bit of a work out in, and that I could justify keeping the T-shirt I had paid extra for. I knew I could have walked the course, but that is not what I went there to do.

I was delighted that the fifth song on my iPod turned out to be an oldie from my high school days: Yours is No Disgrace by Yes. Not actually I song I still like very much, but in this context it seemed like a cosmic pat on the back.

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A Cosmic Pat on the Back

On the way back I met a woman who was also DNFing (sprained ankle) and we walked the last section of the race together, commiserated, and removed our numbers so they wouldn’t mistake us for the top finishers. At the finish line we informed the race officials that we had dropped out so they didn’t need to send a search and rescue team to find us.

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DNFing and commiserating together as we remove our race numbers

So this article is, basically, my first impression of being on a beta blocker, in addition to the atrial fibrillation, and trying to remain an endurance athlete.

So far I feel that the beta blocker is more of a hindrance to my running and cycling than the atrial fibrillation alone had been – but then again, because of the atrial fibrillation my heart function is gradually diminishing.

I should say, on a positive note, that the beta blocker is working, and is doing what it is supposed to do. I check my heart rate and blood pressure at least once per day and since I started the carvedilol I am right where the cardiologist wants me to be. And I can understand why people who aren’t trying to be athletes might like the med – it seems to have a mild calming effect. Furthermore I no longer feel like my heart is a fish flopping around in my chest, and my post work out blood pressure and heart rate has stabilized.

I am optimistic that the carvedilol will be worthwhile and will help me preserve and regain my ejection fraction. But really, what choice do I have?

So here is how things have changed so far (compared to just permanent a fib without the beta blocker):

1.) As far as mountain and road biking is concerned I have been able to ride all the hills that I used to be able to ride, although I am much slower. My wife now has to wait for me at the top of a climb, and that’s fine. I am delighted I can still ride and don’t have to get off and walk my bike.

2.) Running is more negatively influenced. My previous slow pace is even worse, and hills are quite difficult. Not surprisingly I do not like this one bit. A slow jog feels like a 5K effort. But I am still able to run – Yay!

3.) Long runs in heat are not possible. I am just not able to do a long run in heat, and lately every day has been warm. Understand that I am a big red-faced Irish-American who considers anything over sixty degrees to be hot running weather; plus I live in a very sunny place, a high desert climate without a lot of shade. It is not surprising that this is happening. A normal person running in heat will have a higher heart rate for a given pace, and will need to slow down. If you are on a beta blocker that reduces the maximum heart rate by a significant amount, well: “game over.”

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My goal is to continue running and mountain biking on trails like this: Brown Mountain Trail

4.) I suspect that the beta blocker might be making me lazy. I don’t know if that is the right word, but I had a full day off in the middle of the week a while ago and I had planned on, among other things, writing this article and going for a trail run, and next thing I knew it was late afternoon and I hadn’t done a thing. What? By that time there was a thunderstorm so I was not going out for a run – but the article still hadn’t been started. I hope this is not going to be the case from now on. Being lazy and depressed is far from my idea of fun.

I am going to wait until I have had more experience with the beta blocker and write a better informed article. I’m going to sign up for a relatively flat (downhill, actually) trail half marathon and try to redeem myself.

In the meantime I would love hear about other people’s experiences with the dreaded beta blockers. Please post a comment below.

Joe’s Story: A Middle-aged Runner Deals with Atrial Fibrillation and Heart Failure – A Guest Post by Joe

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This is Joe’s Story – a guest blog article based on Joe’s comment on this blog describing his fascinating experience with atrial fibrillation and subsequent heart failure. Joe has really demonstrated persistence and a positive attitude that, I think, a lot of athlete’s with atrial fibrillation possess. Joe is making a comeback from serious, life-threatening heart failure, and he has done a good job of accepting the new reality of his post a fib performance.

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Joe Triumphant

Hi Everyone – I’ve had A-Fib for about three years now.

I live in the tropics and cycle, run, do weights. I train five days a week but not hard or too easy. I believe I got into this mess when I cycled up our small mountain here on the island I live on three times a week back then. I would only drink reverse osmosis cleaned water consuming about four liters just going up the mountain. I’d do weights in the morning and cycle in the afternoon and believe me it gets hot and humid. It’d take me about two hours to cycle up to the top of this very very steep course. (approximately 5K to the top)

In hindsight now I guess I’d been over-training terribly and not putting back potassium and minerals into my body at all. I happened by luck (or fate) to be given a heart monitor and thought it was cool to use it on my cycle ride up the mountain. I set the max at 185 and started off – as soon as I started up the steep hill after a five kilometer preamble the damn thing started beeping – it was at 205 and I just started up the hill! Like an idiot (ha ha) I kept going and it would not shut up. Did it the whole way up and for the next month it was like that. Can’t believe it now I did that but as I’m in constant A-Fib now the reality speaks for itself.

Been put on beta blockers and have to take warfarin. I suffered a sever influenza sickness last year and it really took a toll on my ticker. My left ventricular ejection fraction (LVEF) was only 17% when I finally went to see the Cardiologist here as the echo showed.

Fast forward now to a month and a half and I’m back up to 35%. The goal is to get back to 55%! I love running and exercise and like some of you wrote would rather plonk on the trail then sit on the couch, so be it. I used to run with the goal of just finishing the run and was happy about it.

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This is Joe’s heart on heart failure

Then I got into times, was happy about that too. Before my illness last winter my times were at my all time best. Slow for a lot of runners but for me great. After all I run to please me so I accept what ever pace I come home at. Not a biggie. The doc was amazed at how fast my heart recovered and I even saw the difference on the screen of my heart’s movement. The echo I had before it looked like Jabba the Hutt sleeping. I think I attribute this to doing a LOT of research on the internet getting informed of what I was dealing with and trying it slowly with my Doctor always in the know. He was very skeptical of the supplements I was taking but has done an about face now. I also believe the coconut water I drink everyday now has helped in a big way. I noticed I don’t have an ammonia smell anymore when I sweat. I always had that smell when I drank the Osmosis water. I drink a mineral water now along with the Coconut water.

Anyways – I do prattle on. The thing is not to Panic and get informed!

I wear a Polar T-80 watch with GPS and follow the Zone rules. Yeah, I’m running about four minutes slower than normal but I feel great after a run now and do not dread the next one. Hoping my pace will kick up a notch as the info says it will as the body adapts.

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This forum is great may I add and it sure is reassuring to read of Peep’s in their 80′s who’s lived with A-Fib for 20 or so years and keep running. Hopefully one day soon someone will find a cure for this curiously annoying ailment.

When I had 17% ejection rate it happened really fast. The time line is like this: on a Friday I ran a very fast 5K run for me. One of my best times. Later that day flew to spend three days with a friend, and after returning home I got ill and by Wednesday was full blown into whatever ailment I had (Influenza?). I tried running a week later but could not even go further than 50 yards! Then I stopped and decided to rest a week, do nothing and fight this illness. Well, it got worse and worse – my lungs started filling up with fluid and at night I could hear bubbling in my lungs. Fast forward a week of no sleep, etc, etc, and went to a doctor was put on antibiotics. I didn’t get better, still the same symptoms. (Turns out the heart, because of it not beating properly causes the fluid to back up and then it seeps into the lungs so any of you with these symptoms see a doc. You can do a thumb press on your shin and if the indentation stays and is deep you’ve got fluid retention and need a diuretic).

After a couple more weeks of this I decided because of previous symptoms I felt there was something wrong with my heart again. Seemed to be doing the same old symptoms of A-Fib. I thought I was free of it for almost two years or else it was Silent A-Fib and I did not know it!

My cardiologist gave me an echo and all he said was “What did you do?” Man, you don’t want to hear that from your doctor!

Like I said before I even could see my heart wasn’t doing anything. Just sort of sitting there: legs up – arms crossed!

He put me on meds again and the dreaded warfarin. They worked almost right away! I was on Codarone (amiodarone) for only a month and everyone should know that this is a dangerous drug! Long half life and it’s like shaking hands with the devil. Used a lot as a last resort. But! – for short periods it works miracles. Using it over six months or more can have repercussions.

Well, that day I came home from the doc’s I tuned up my mountain bike and went for a very short ride. I was out of breath the whole time. Did this for a couple of weeks and got stronger. Started weights again, and just started using the bars with no weights. Did this very very slowly and now after two months I’m almost back to benching 200. (ha ha – good for me anyways) The last check up the doc said my heart (Left ventricular ejection fraction) was up to 35% and I saw the difference in the video as well! Made me feel very very happy.

So now I’m trying something I never thought I’d do. I bought a Polar T-80 Heart monitor with GPS and run and cycle in the Zone. I exercise according to my heart rate. I’m finding I’m no longer exhausted during the rest of the day and overall feel better, stronger. It’s taking time to lose that competitive spirit though – ha ha ha – I’ve got friends who are in their 70′s running faster than me. My slowest times in years but I’ll stick to it and see if my times automatically come back up as the research suggests. This has to be done. I love being active but I hate being dead more so I have to accept and live accordingly. Don’t Panic!

A heart pumping at 33% efficiency feels a lot better than 17% I can tell you. I do more things than most of my friends. It still amazed me though how I can do weights for a hour, run for an hour then eat, chill and later in the day walking up a flight of stairs takes my breath away. It’s like a reminder – oh yeah I’ve got heart problems. A friend wisely told me that it could be like losing weight: fast in the beginning; then slower. I hope my ejection fraction % will keep increasing till 55%. Considered normal. Then I’ve got to deal with the A-Fib.

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Joe still the life of the party – but no more beer for this guy!

A very important footnote: I used to drink beer everyday for years! Love the amber fluid. After my first A-Fib about five years ago I stopped for about three months. Then about two years ago I only drank on Friday and Saturday. For two years I did this. No exceptions. I’m 51 now and even this was taking it’s toll I believe. Now I’ve cut it out completely and will go the distance – sort of sucks but I’m close to the three month period now and will keep going. My next visit to the docs is in August so I’ll hopefully remember to post what transpires.

If anyone is interested in what I’ve been taking for supplements, eating, drinking, and exercising please leave a message on this blog and I’ll be most happy to share. One thing I’ve always found frustrating with most blogs is when I’ve read what someone has done and it worked there was no follow up. I’ll try and keep posting on this one. Great site! Peace out…………… don’t Panic : )

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Update (from Joe)

Hi everyone. Went for my one month checkup at the cardiologist today and the results were better and improving. The Doctor said my heart has shrunk by a noticeable margin which is a good sign. (had an echo) It’s getting stronger. The ejection fraction went up a bit as well to around 37%. Getting nearer to 40% then in a few months hopefully 50 or 55%!! I was also able to wean off one med by half. I felt it in my run today – a really great run. Will continue on meds and supplements plus exercise and diet as is for another month. See ya then!

Emergency Pack for Trail Running or Mountain Biking While on Anticoagulants (Coumadin, Xarelto, Pradaxa, Plavix)

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This article is a work in progress and is only a description of my strategy for the time being. I hope to learn from readers of this blog about how to better plan for a trail debacle.

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Heading out for a trail run on the Pacific Crest Trail

What kinds of things should a person like me, who is dealing with atrial fibrillation and is taking an anticoagulant (I take Pradaxa), carry on a long run in the wilderness? Or during a long mountain bike ride in remote areas?

When the high country in our local wildernesses is not covered with snow, I will generally do runs, nearly every weekend, of anywhere between six to twenty miles. I almost always run alone (except for my trail buddy – Ringo).

Dangerous and a bad idea? Possibly. But this is what I enjoy in life so I don’t plan on stopping any time soon.

The most important piece of equipment is a phone. People complain that everybody is always on their smartphone, and they should NOT be talking on their phones on mountain summits when everybody else is trying to get all Zen-like and self-actualized, and whatever – that’s a different discussion. You certainly don’t even need to have your phone on; but you absolutely should take it with you, and it should be fully charged. The days of getting hopelessly lost and spelling out SOS with rocks hoping a search plane will find you are fading into the past. A smartphone is a GPS and a direct link to help.

I always carry my iPhone in a baggie with my ID and a sheet of paper towel (which I use for unrelated toilet purposes).

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Fully charged and protected from water

Even if there is poor cell phone coverage in your local high mountain or deep canyon wilderness, and a phone call isn’t always possible, I find that a text message can often still be sent. It might take a while but it eventually will be sent, especially if I am moving along a trail.

There is the standard emergency gear that most people take, often called the “ten essentials” which most people carry while in the wilderness. Of course there is truly no such thing as a standard ten essentials and the list of things you carry will vary depending on the season, your skill set, your location, and your past experience.

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My generic survival gear

I got out my little survival kit that I typically carry in the wilderness, and of course not everything is pictured here, and I might not even have all of this stuff with me on any given trip. Naturally I will also have other things like food, gels, electrolytes, a jacket, and plenty of water.

What I found in my default wilderness pack is:

Two knives – a mini-leatherman tool and a standard knife. I will only actually carry one of these.

Two lights – a headlamp and a tiny LED flashlight (one is plenty).

Fire starter – a cigarette lighter, birthday candles, a tampon, and hand sanitizer (which I discovered has completely evaporated).

A space blanket, a compass.

Repair gear (Shoe laces, tenacious tape, dental floss)

Pain pills: Vicoprofen samples – okay they expired in 2000 but I’m guessing they are still good (at least for a placebo effect). Missing: Benadryl for allergies or yellow jacket stings, and I probably should have some of my Pradaxa in case I end up unexpectedly staying out overnight. Also missing: small roll of duct tape, safety pins, and my whistle!

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Saint Christopher Medal

Oh, and there is a Saint Christopher medal. This one belonged to my grandfather. Well it probably won’t change anything, but it certainly couldn’t hurt. Feel free to substitute your own personal good luck charm.

But what about specific items for the runner on an anticoagulant? Is there anything else beyond the “ten essentials”?

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Other stuff: Map with reading glasses (if needed) and some rope

Obviously having a major bleed while running alone in the wilderness would be a disaster. Death is certainly a possibility. How can a trail runner prepare to increase the odds of a good outcome?

I always make sure to let somebody know (usually my wife) where I’m going and I also send her a text (I text “OOTW” short for “out of the woods”) when I get back to my vehicle.

I also wear a Road ID. This way if somebody finds me they will know I am on an anticoagulant. Maybe this won’t help, but it certainly is worth wearing. At least they will be able to figure out why I bled out so quickly (I know – not funny).

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My Road ID

Another item I always carry is a bandanna. This can be used for a number of purposes, such as making a field dressing; but I want to have it in case I need a tourniquet. Plus – I have an extra one because my trail dog always has one draped around his neck.

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Bandanna

My bandanna came in handy a week ago when my wife Margo (not on an anticoagulant) crashed her mountain bike and punctured her left thigh with her brake lever. I used it to make a compressive dressing before we road our bikes back to where we could get a ride to the hospital.

One item I do not currently have but definitely need to obtain is a Quickclot field dressing. Evidently these things really work and are routinely used in combat situations. It is a topical coagulant (an anti-anti-coagulant?) which helps clot blood and also serves as a physical barrier to bleeding. I’ve been meaning to obtain one of these for a long time. They are available online via amazon.com, and I just ordered one.

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Quickclot

Question: Will the Quickclot sponge even work on bleeding in an individual who is on a direct thrombin inhibitor like Pradaxa? Answer: I have no idea. I’ll let you know if I ever get a chance to find out.

In case of bleeding the most important first step is to apply direct pressure. As a surgeon I have a lot of experience with this. Usually sixty seconds of direct thumb pressure will stop or slow most bleeding, but of course if you take an anticoagulant it will take longer. Apply direct pressure as long as necessary. Elevate the wound if possible. Don’t try to clean out major wounds as this will restart bleeding – that can be done later at the hospital.

A tourniquet is a last resort, but the bandanna can be used as a compressive dressing if needed.

Please understand that an anticoagulant doesn’t completely stop clotting of blood, it just makes it take longer. Eventually bleeding will stop. Hopefully before all the blood leaves your body!

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Ringo always has a spare bandanna for me

Bonus – How to stop a nosebleed:

I have been plagued by frequent nosebleeds since I was a child but, oddly enough, I haven’t had a single nosebleed since I started Pradaxa a couple of years ago. The best method I have found is to pinch the nose, fairly tightly, just above the nostrils, and lean forward. Don’t lie with your head back – that doesn’t work. Hold for a full sixty seconds. Repeat as necessary.

If you are, like me, a trail runner or mountain biker on an anticoagulant, I would love to hear from you. Please leave comments and suggestions in the comments area below.

Thanks.

Atrial Fibrillation News Update

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Here are a few internet news stories related to atrial fibrillation. In the future I’ll try to update more frequently so I don’t end up with four topics in one blog entry.

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Overall, the increase in risk of heart attack was about 70% in AF patients, even after accounting for other cardiovascular disease risk factors, such as hypertension, high cholesterol, body mass index, and history of stroke and vascular disease. However, when the researchers looked at subgroups, they found that increased risk of heart attack was more than doubled in women and African Americans with AF—but less than 50% for men and whites with AF.

I’m not sure what to say about this – hopefully runners with atrial fibrillation (who hopefully also have other heart healthy lifestyle choices – like a healthy diet, not smoking, reasonable body weight) will do better than the general population. One bit of good news – the blood thinners a fib patients take to prevent stroke also seem to help prevent heart attacks.

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“Novel” anticoagulants refers to the newer prescription anticoagulants that are used as an alternative to Coumadin (warfarin). Specifically: Pradaxa (which is the one I currently take), Xarelto, and Eliquis.

I can tell you that as a clinician there are not many things more frustrating than prescribing medications for people who are on Coumadin – it seems like it interacts with everything! One of the great things about the newer anticoagulants is that they have less drug interactions – but they still do have potential drug interactions.

Please click on the link to see tables for drug interactions involving Pradaxa (Dabigatran), Xarelto (Rivaroxaban), and Eliquis (Apixaban).

Obviously all of the novel anticoagulants can interact with any other drug that is *ALSO* an anticoagulant – like Plavix or aspirin. Keep in mind that this includes NSAIDs like Alleve (naproxen), Motrin (ibuprofen), etc.

Personally, I completely avoid taking ibuprofen and naproxen – but every once in a while (like after a brutal long run) I will take a Celebrex. Tylenol (Acetaminophen) is fine – no interactions with the anticoagulants (although it has its own issues).

By the way – if you read the article and see a possible drug interaction please don’t stop taking any of your meds – but contact your own doctor immediately for advice.

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A recent study has shown that Coumadin (warfarin) actually increases the risk of stroke for people in atrial fibrillation during the FIRST THIRTY DAYS of warfarin therapy. That’s just the first thirty days – the idea is to prevent having a stroke, and that’s what taking Coumadin does.

This finding does not suggest that anything will change – doctors are still going to put people on warfarin to prevent stroke. They just have to get through the first thirty days!

If you are on warfarin and you read this article – please do not stop taking your medication.

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Finally – the FDA has not yet approved the Watchman left atrial appendage closure device by Boston Scientific – but it has given a “vote of confidence.” It appears that this gadget, which is implanted in the left atrium to prevent the formation of the clots that cause strokes, may be approved by the FDA for the US market late this year. The majority of the panel agreed that the Watchman was equivalent to standard treatment with warfarin, but it hasn’t been compared to the new novel anticoagulants (see above).

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Pacific Crest Trail on Atrial Fibrillation?

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I live near the Pacific Crest Trail. The famous, fabled, fabulous PCT. Just about twenty-five miles away. You can look out our back window and stare lovingly at the mountains where it courses through the Sky Lakes Wilderness.

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Heading out to run on the PCT

Although I come off in this blog as a marathoner, or an ultrarunner, what I really enjoy more than anything is trail running (and mountain biking – but mountain biking is forbidden on the PCT so forget about that). I simply love trail running and hiking, especially in the local Sky Lakes Wilderness and Mountain Lakes Wilderness; and the best part of being at my level of fitness and health is being able spend a weekend day doing a ten, fifteen, or even a twenty mile trail run. Although it is a slog now because of the atrial fibrillation I still love it – I love the movement through the wilderness and I love the trail itself.

Usually the only one who goes with me is my little trail dog – Ringo.

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Ringo on the PCT at Brown Mountain

At this time of year – late Summer – all the thru-hikers, or I should say the small percentage that have made it this far, are coming through Southern Oregon. Most thru-hikers are traveling from South to North; they start at the Mexican border and hike through California, Oregon, and Washington with the goal of reaching the Canadian border. There are a lot of hazards along the way that can cause hikers to drop out and fail to finish – including blisters, running out of money, running out of time, deep snow, diarrhea, boredom, and forest fires.

I try to spend time on the PCT this time of year and will often photograph thru-hikers and post the photos on my flickr page.

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PCT Thru-hikers

In addition to trail running on the PCT I am also an “armchair traveler,” meaning I’ve read a bunch of books about thru-hiking the PCT, including:

Cactus Eaters by Dan White – probably the best written PCT book and my most recent read.
Cascade Summer by Bob Welch – a middle aged Oregon newspaper writer hiked just the Oregon section. This might be more my speed.
Wild by Cheryl Strayed – the most well known and popular PCT book that will undoubtedly get more people on the trail. Also a well written and engaging read.
A Blistered Kind of Love by Angela Ballard – fascinating dual journal by a couple thru-hiking the PCT. It was interesting how the different genders report their trail experience. The male writes about where they went and what they did, and the woman writes about how she feels.
Skywalker – Highs and Lows on the Pacific Crest Trail by Bill Walker – the most endearing and charming PCT book ever.
Pacific Crest Trail Hiker’s Handbook by Ray Jardine – groundbreaking and controversial – Ray clearly changed the way people approach long distance hiking.
A Long Walk by Hap Vectorline – a whimsical journal of a partial through hike that started at the Canadian border and made it as far as Oregon.
In addition to the books I read various PCT blogs, and many of the youtube videos as well.

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Hikers

My dream is to someday thru-hike the PCT – but I don’t think it will ever happen for a number of reasons. I’m certainly in good enough shape, and strong enough, but at 53 am I too old? I don’t think so – I’ve met plenty of thru-hikers that were middle-aged. They tell me they are slower and have to leave earlier and hike longer to keep up – but that would be no problem. I think hiking for that long on anticoagulants might be an issue. On Pradaxa falling just isn’t what it used to be! The main problem is, of course, finding the time. I work full time and just don’t have the resources to take six months off from work.

Maybe some day I could just thru-hike the Oregon section. Or maybe just the Sky Lakes Wilderness (fifty-one miles) – that could be done in a weekend. Why not?

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Ringo Dingo

But I still love running in the Sky Lakes Wilderness. As far as falling out on the trail and bleeding out, or having a stroke out there, or being eaten by a bear, or whatever, I like to say that I’d rather die in the Sky Lakes Wilderness than in the Sky Lakes Medical Center.*

*Our local hospital, where I am on the surgical staff, is the Sky Lakes Medical Center. I like our hospital – I’m just saying that I’d prefer to die with my sneakers on, so to speak.

Running and Mountain Biking with Atrial Fibrillation? Get a Road I.D.

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I used the see the Road I.D. commercials while watching the Tour de France and think, “Why would anybody buy a thing like that?” That was before I went into persistent atrial fibrillation and started taking a potent anticoagulant (Pradaxa).

Now something as ordinary and routine as falling down on a trail run or crashing on a mountain bike can become a big deal – maybe even a life and death situation.

roadID

My Road I.D. has my name, year of birth, hometown, my wife’s number and my sister’s number. Also it indicates that I am in Atrial Fibrillation, have no drug allergies, and am taking Pradaxa – an anticoagulant.

This way if I am found dead they know who I am and who to call to come pick up the bike and the body. If I’m still alive they will know about the atrial fibrillation and the anticoagulant. Pradaxa doesn’t have a reversal agent but any medical personnel will know to watch for bleeding and start an IV to push fluids. It certainly couldn’t hurt.

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Wearing my Road I.D. at a pizza parlor

I wear mine whenever I ride or run, and also whenever I drive. I take it off at work.

I was half joking when I said “if I’m found dead” but somebody (I can’t recall who) recently noticed my Road I.D. and said he wished his friend (brother-in-law?) had had one. Evidently he had gone out for a run and died out there (for whatever reason) and had no identification. Nobody knew who he was so they put the body in the morgue for the weekend. I seem to recall that the wife was out of town and they had a hard time figuring out who he was. Eventually when they started to figure out who he was and one of his children had to come from out of town to identify the body. I wish I could remember the details more clearly – but at any rate a Road I.D. wristband would simplify a situation like that.

There’s nothing special or unique about a Road I.D. – any medical alert bracelet would be fine; but a Road I.D. just seems cooler. It’s durable, comes in cool colors, and is highly customizable, it cleans up well when worn in the post work out shower, and goes on and off easily.

Mountain Biking and Atrial Fibrillation

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waldoburn

Mountain Biking in Oregon – Waldo Lake Trail

I’ve just returned from a nearly three-hour long mountain bike ride, so I thought it would be a good time to write about mountain biking while in persistent atrial fibrillation (this discussion is pertaining specifically to persistent A fib meaning I am always in atrial fibrillation and don’t ever expect to NOT be in a fib; I think people who have episodes of paroxysmal atrial fibrillation are going to have a different result).

One of my main concerns when I was first verified to have persistent atrial fibrillation was whether or not would be able to continue mountain biking. I started road riding in the early 80s, back when I still lived in the Midwest. When I moved to Klamath Falls, Oregon in 1987 I began mountain biking. This is a great place to ride, and we have a terrific trail system at Moore Park, as well as a couple of local high mountain singletrack trails that are legal for mountain biking (Brown Mountain Trail, Rye Spur Trail). I feel real connection to these trails and have been riding some of them for over twenty-five years.

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Rye Spur Trail, Klamath County, Oregon

I didn’t use to run is much as I do now, and back in the late 80s and early 90s I would pretty much mountain bike five or six days per week. I have developed some good bike handling skills, especially since in the early days there was no front or rear suspension, and nobody really knew what they were doing anyway. We pretty much plunged our quick release seat posts down into the frame, switched to granny gear as soon as we hit dirt, and would (inappropriately) lock up our back wheels and skid down steep hills – very much discouraged in this modern era. But that’s the way it was – skills develop over time.

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One of my old mountain bikes

At any rate I have developed good skills – skills specific to these particular trails, seeing that I generally know every rock and anticipate every little drop off.

There are two issues with mountain biking and atrial fibrillation. The first, obviously, is that my cardiac output is reduced by about 15 or 20%, so naturally I am a little bit slower. People get slower when they get older, too, so there’s that to deal with as well. But the real issue, I think, is the fact that I am on a potent anticoagulant – Pradaxa. One of the disadvantages of Pradaxa is that it works really well (but the real disadvantages that it does not have a reversal agent). Clearly – there is a risk of bleeding associated with crashing your mountain bike on the trail.

I sort of doubt whether Coumadin is that much safer than Pradaxa as far as this is concerned – while it is true that there is a reversal agent for Coumadin, what is the likelihood that, if I had a major crash, I would be able to get to the emergency department in time for them to give me the reversal agent? I generally ride alone, and our trails are pretty remote. It would take a while for me to get out of there, especially if I was bleeding all over the place, or even worse, if I were bleeding into the space previously occupied by important parts of my brain.

Over the years my skills have improved and my style has changed quite a bit. At age 53 I’m no longer much of a daredevil (I never really was). Back when I was thirty and was riding about five days per week, I estimated that I had one minor crash per week, and usually one major crash per season. In all that time I think I’ve only actually hit my head once (I definitely recall a bleeding ear after crashing on a technical descent on a trail called Garbage – never liked that trail).

I have always felt that all of your instincts and reflexes are directed toward protecting the head. It’s automatic.

Of course I have worn a helmet when bicycling since 1983. I even bought a new helmet when I went into atrial fibrillation and started anticoagulation. It fits better than my old one and it’s florescent green, so hopefully I have less chance of being run over by a pickup truck.

The only time I have ever had a significant bleeding problem while mountain biking was back in 1990. I came off the trail ride and was heading around the paved road at Moore Park to the picnic area to get some water when some young guys in a pickup shouted at me, “Wrong way, dude!” I didn’t yell back at them, but I turned around and glared at them as I zipped down a little hill to the picnic area, giving them a look that said, “You talkin’ to me?” I was going pretty fast at that point and hit a speed bump that sent me skidding across the pavement for a while.

I bet those guys were impressed.

Anyway, I had a lot of road rash, was just goes with bicycling to a certain extent, but the worst thing was I had a “degloving injury” on the side of my abdomen. What that means is that part of my skin more or less stuck to the pavement while the rest of me kept moving and the skin was pulled away from the underlying tissue. It didn’t break all the way through the skin, but I developed a hematoma the size of a baseball right where the “love handle” would normally be. Twenty-three years later it’s actually still there to a certain extent, not the blood, but a big lump of scar tissue beneath the skin, and the skin over that area is still kind of numb.

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Klamath Ridgeview Trail – Moore Park

That happened with no anticoagulation – I never even took an aspirin back then. If I had a similar injury now that would’ve been a major hematoma – I might even need a transfusion.

That’s the risk. Falls are part of riding a mountain bike. I’ve been on Pradaxa for a year now and I think I’ve only had two crashes. I am so much more cautious than I used to be that I rarely ever crash, and when I do crash it usually something stupid like having mud or ice in my pedals and not been able to click out when stopping, falling over like Artie Johnson used to do on that tricycle on Rowan and Martin’s Laugh In. I honestly can’t say that I’ve noticed more bruising or bleeding than I would expect prior to Pradaxa. So far, so good.

I feel it is important, however, that when you’re cardiologist tells you that you probably shouldn’t be mountain biking that you do what he says. Don’t be like me. Don’t disregard your cardiologist advice. Do as I say, not as I do.

All joking aside – there is a certain risk and if you can accept that level of risk, then continue mountain biking. If not, stay off the trails.

As far as how much persistent atrial fibrillation affects my climbing, well, when I first get started it is quite difficult. After I warm up it really doesn’t seem like it’s any different than not be in atrial fibrillation. Recall that I do not take anything like a beta blocker or an antiarrhythmic – if you take medications like that your experience may definitely be different. All I take is the anticoagulant.

I’m slow, definitely slower than I was twenty-five years ago, but it almost seems like it’s within the realm of what you’d expect from being that much older. Like I said in the article about running in atrial fibrillation, it’s almost like you’re a pickup truck with a four speed manual transmission, but you can only use second and third gear. But you can still have a lot of fun in those two gears! It just takes a while to warm up.

Personally I think road biking is more dangerous than mountain biking, as far as bleeding risks are concerned. All my best crashes have been on pavement, including my best mountain bike crashes (see above). And pavement is usually where cars, driven by people who are talking or texting on smart-phones, hit you.

As far as endurance and energy output are concerned road biking, by its very nature, is easier to do in persistent atrial fibrillation that mountain biking. On a road bike you get into a groove, and have a certain steady energy output. That’s perfect for atrial fibrillation. Anybody who trail rides, especially on technical, steep trails, can tell you that mountain biking consists of a little burst of energy here, then a little short, brief period of rest and recovery here (by slow pedaling for a couple of seconds), and then hammering the pedals again to get over the next little obstacle, or whatever. That’s what’s fun about it – it’s almost like doing a puzzle. Trail riding involves a lot of little, short, anaerobic bursts of energy – and of course atrial fibrillation has diminished this ability, as far as I’m concerned.

Although, speaking strictly of endurance, I don’t think that is changed too much since I went into persistent atrial fibrillation. I can still ride for just as long as I used to be able to ride. I have found that while I have lost speed with age I have gained endurance in spite of atrial fibrillation.

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Moore Park Mountain Bike Trails

I am very interested in other mountain bikers’ experiences with atrial fibrillation, especially athletes who take rate control or anti-arrhythmic medications. Please feel free to leave comments – Thanks!