Runners with Atrial Fibrillation – Considering the Watchman?

Are you considering the Watchman device?

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Ever since having a TIA/stroke, I certainly have thought a lot about it.

What is it? The Watchman, by Boston Scientific is a little device, sort of like a basket, that can be inserted into the left atrial appendage, theoretically blocking it off and preventing clot formation. As you probably know already, clot formation may lead to Stroke. The device was FDA approved in the US in March, 2015, and has been used in Europe since 2005.

It’s placed in the left atrial appendage via a catheter through an artery in the groin, and if all goes well the patient can discontinue their blood thinner (warfarin, etc.) within six months.

Sounds great, doesn’t it?

I know I’d love to be protected from having another TIA or stroke and not have to take a blood thinner – I’m currently on warfarin + aspirin which makes bicycling, especially mountain biking, quite hazardous. But truthfully, it’s not that I necessarily want to be off the warfarin: I just don’t want to ever have another TIA/stroke. Recall that I had my event while I was already taking Pradaxa (and I never missed a dose). I just want a treatment that is going to work.

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But there is some evidence to suggest the Watchman might not be as terrific as it sounds.

A recent study showed that the risk of a major bleed over the course of three years is the same with the Watchman compared to just staying on warfarin. Huh?

This is an excerpt from a Medscape article:

Patients with atrial fibrillation (AF) who received a left atrial appendage closure device (Watchman, Boston Scientific) or stayed on long-term warfarin therapy had similar rates of major bleeding during a mean follow-up of 3.1 years, in pooled analysis of two randomized clinical trials[1]. However, patients who received the device and were able to stop taking warfarin and clopidogrel at 6 months had lower rates of major bleeding from then onward, compared with patients receiving long-term warfarin.

Furthermore, in a very thoughtful, somewhat technical, article CMS Proposal on Watchman Is the Right Decision, Dr John Mandrola, a thought leader in Cardiology and Electrophysiology, agrees with the CMS proposal that “the evidence is sufficient to determine percutaneous left atrial appendage closure therapy using an implanted device is not reasonable and necessary.”

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There are two major studies in the US regarding the Watchman. According to Dr Mandrola in the PREVAIL study, “Due to an excess of ischemic strokes, Watchman did not reach noninferiority in this category in the updated analysis presented to the FDA.” In PROTECT-AF study, “ischemic strokes were numerically higher in the Watchman group.” Which, ultimately, “leads one to conclude that the device is not effective.”

As for me, personally, as much as I’d like to believe the Watchman is a solution for me, the evidence, so far, is not convincing. I’m going to wait.

By the way, if any readers have experience with the Watchman PLEASE leave a comment below. We would love to hear from you!

Adverse effects of the Watchman:

“The main adverse events related to this procedure are pericardial effusion, incomplete LAA closure, dislodgement of the device, blood clot formation on the device requiring prolonged oral anticoagulation, and the general risks of catheter-based techniques (such as air embolism). The left atrium anatomy can also preclude use of the device in some patients.”

By the way – I linked a couple of articles from Medscape. I’m not certain but I think you need to be registered for that sight. Sorry.

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Re A-Fib: 5 Things I’ve Learned in 10 years… A Guest Post by David Grayson Lees

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I’m a 64 year-old road/trail runner, marathoner and weight lifter diagnosed with atrial fibrillation more than a decade ago. I’ve had three ablations and as many cardioversions, plus I’ve swallowed the usual assortment of prescription meds. Now my a-fib has become paroxysmal atrial flutter—about one episode every two weeks or so, usually lasting a few hours—and while my running days seem to be over, I still regularly make it to the gym and I’m discovering the joys of walking and hiking.

Through trial and error—plenty of each, actually—as well as a fair amount of research, I’ve come to a handful of conclusions that may be useful. While I believe them to be true, keep in mind that my observations are true for me; your experience may well be different. Finally, since I’m not a physician, nothing here is intended as medical advice.

And now: 5 things I’ve learned in 10 years of dealing with the always-entertaining world of cardiac arrhythmia.

A-Fib won’t kill you…even though a diagnosis of a-fib—and its symptoms—can be very scary, barring underlying cardiac disease, a-fib is not inherently life-threatening. And so if you have just been diagnosed, relax as best you can.

…but a stroke could. Pay rigorous attention to your anti-coagulation regimen. Even if your CHAD score is zero, at least take a low-dose aspirin every day. Personally, I find Coumadin to be a true pain, what with blood monitoring, dietary restrictions and the like. I much prefer the newer meds, especially Xarelto. It acts quickly, and as an added bonus you don’t have to be continuously concerned with your INR numbers.

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Your EP isn’t interested in prevention. Typically, EP’s are all about fixing stuff rather than prevention. Which is weird, because unless you’re on the younger side of 40 and/or your a-fib has been freshly discovered, one ablation usually won’t do the trick. Of course, I’m grateful to my two EP’s, one rated among the best in California and the other acknowledged as one of the best in the world. It’s just that neither one has ever expressed any interest in the contours of my life, including what my exercise habits happen to be, what sorts of supplements I take, or what my days are like. Now, I’m not looking for a new best friend, but it’s clear that for them I’m a unique problem to be solved rather than a unique human being. I’m not angry about it; after all, these docs chose a field in which their major interaction with patients occurs when the patient is unconscious.

Still, I believe the implication is clear: you are pretty much on your own when it comes to figuring out how to modify your life style, exploring vitamin/mineral supplementation, and gathering the latest non-nutsy information.

(BTW, in terms of info, two websites I recommend are Dr. John Madrola and The A-Fib Report. Dr. John is a younger EP who always has a thought provoking take on new developments in a-f treatment and research and The A-Fib Report is a readable compendium of international a-f research, written in lay language. It requires a nominal membership fee that’s well worth it.)

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Supplementation could work for you. I haven’t thrown out my beta blocker (Sotalol AF, not regular Sotalol) but along the way I have had excellent results in controlling the frequency and duration of my atrial flutter episodes by supplementing with 200 mg of magnesium citrate in a pill taken at lunch and ¼ teaspoon of potassium citrate dissolved in water taken in the morning and again at dinnertime (Please note: ingesting too much potassium involves some quite severe health risks, so be careful.)

Life is good. But first, the bad news: as near as I can tell, nobody knows what causes atrial flutter. The gang of suspects spans endurance sports (!) to mysterious biochemical mechanisms that somehow encourage the formation of tissue substrates that make the electrical system of the heart go haywire. Researchers—and your EP, too–are just guessing, leaning on statistical correlations rather than employing demonstrable causal connections. Maybe cutting out caffeine will help you; maybe it won’t. Maybe abstaining from demon rum will prove to be the answer; maybe not. Obviously, if you are over-drinking, over stressing (like many of us who are into enduro sports) under sleeping or happen to be engaged in other deleterious deeds, changing your behavior is simply a good idea, a-fib or no a-fib. Just don’t expect that any one thing will be the answer.

The good news is, you can have a great life even with a-fib and a-flutter. No, I don’t love my a-flutter episodes; they are annoying and sometimes, even after a decade, still frightening. I don’t run anymore, but a long walk or a moderate—I know, I know, not my favorite word, either—hike turns out to be a lot of fun. No, I can’t put the same hemodynamic load on my heart that I used to, but I can still work up a nice funky sweat underneath the weight machines at the gym.

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Besides, working out is only a part of life. My friendships, relationship with my son, work, and my love life (I’m getting married again, and I’m stoked!) are just as satisfying as ever.

Maybe more so.

Those of us with a-fib or a-flutter aren’t sick, not truly. Nor do we need to afraid.

So—live!

(Thanks to Linda for the inspiration. Thanks to you for reading.)

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

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.

Atrial Fibrillation – A Visit to the Electrophysiologist

While at my previous job, at Klamath Family Practice Center, I always had easy access to an EKG. Just for the record, remember that I am a podiatrist, not a family practice physician, but if I wanted to have an EKG done I would just have a tech do one on me. I have had a fairly long history of arrhythmias, including PACs, PVCs, and even runs of paroxysmal supraventricular tachycardia. But one day when I returned from a 20 mile trail run I was in a particularly persistent arrhythmia and I wondered if it was atrial fibrillation. I had the tech do an EKG and my suspicions were confirmed.

At that point I walked down the hall and went to see my primary care doctor, who is also one of my coworkers, and she recommended Pradaxa, gave me some samples, and made an appointment for me to see my local cardiologist, Dr. Dale McDowell.

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At Dr Martin’s Office

Dr. McDowell, with whom I have been a patient for the past twenty years, then examined me, did a stress EKG, told me to continue with the Pradaxa, and advised that I should see an electrophysiologist for consultation.

We have several cardiologists in Klamath Falls, all of whom are excellent, but we don’t have any electrophysiologists. An electrophysiologist is a subspecialty cardiologist who focuses on arrhythmias, and are the ones who performed the ablations, install pacemakers and defibrillators, and so on. I think their most common patient is probably people like me who have atrial fibrillation.

I had an appointment with David Martin, MD of Southern Oregon Cardiology and I will admit that I was extremely nervous about this appointment, because I was afraid that he would tell me I had to quit running and quit mountain biking. Or at the very least he would tell me to quit running marathons and start running 5Ks. I was also afraid that he was going to put me on a performance killing medication such as a beta blocker, or worse, recommend and ablation procedure which could be quite an ordeal.

Like other endurance athletes I often have to deal with people that really don’t understand what it is that we do, and why we do it. That’s one thing if it’s a relative, friend, or an acquaintance – but when it is somebody who is going to formulate a treatment plan that is going to affect the rest of your life, it can be a scary proposition.

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High Lakes Trail

So when I did a Google search on Dr. Martin I honestly wasn’t very interested in where he graduated from, or what he did during his fellowship – I just wanted to try to figure out if he was a runner, bicyclists, or a triathlete. The little blurb about him and the Southern Oregon Cardiology website didn’t mention anything one way or the other, but in his photograph he appeared to be a thin man, and I found that to be encouraging.

I think I even searched local race results looking for his name to no avail.

When I called to make an appointment I asked the receptionist, “Is this guy a runner, or anything like that?” She said that she had no idea.

It took a while before I can get an appointment and in the meantime I had a question. I had spent four or five months training to run an ultramarathon, the Bighorn Mountain Wild and Scenic Trail Run 50K in Wyoming. Even after I was diagnosed with atrial fibrillation I continue to train for this race, which was to be my first 50K. I was getting mixed messages from people as to whether or not I should run it. My primary care physician, who is an ultra runner and has completed a couple of hundred mile races, and who happened to be signed up to run the 50 mile event at the same race, told me to run it. She said it would just take me a little longer – no problem. A friend of mine, with whom I was going to run the race and was also running his first ever 50K, and is a family practice physician in Wyoming, told me to quit complaining and get on the plane to Wyoming for the race. My cardiologist in Klamath Falls, Dr. McDowell, advised me to quit running marathons and not to consider running an ultramarathon. I have a cousin in Chicago who is an electrophysiologist/caridologist and I spoke with him on the phone – he runs marathons and his wife runs ultramarathons. He said I should run it. Another acquaintance, who is a cardiac surgeon, but have never actually examined me, said he thought it might be safe for me to run the 50K, but advised me that it is important that I agreed with my cardiologist (good advice).

If you’re keeping track, so far that is four doctors that said go ahead and run it, and one doctor, who happens to be my cardiologist, and has the biggest vote, that said not to run it. I decided to call Dr. Martin (the electrophysiologist), who would be the tiebreaker, even though I hadn’t been seen by him yet, and ask him about running that 50K.

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High Lakes Trail

I was able to get a message to him through his nurse, and then she called me back and said I shouldn’t run it. So I didn’t run it.

This is unfortunate because I had already paid for it, but when I contacted the race director she told me I would be unable to get a refund, or even a credit for next year’s event. Also, I had already bought an airline ticket Wyoming which is more expensive than you might imagine. I was able to get a partial credit for this.

I didn’t want to waste all that training so I decided to run a marathon that weekend. I found a nearby marathon in Vancouver Washington and ran that while in persistent atrial fibrillation. It was slow, but I survived, and that’s another blog article altogether.

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Vancouver USA Marathon

When I finally got in to see Dr. Martin he examined me, looked over all the EKG’s, the stress test, the chart notes from Dr. McDowell, and the lab work and spent quite a bit of time talking with me.

I’m glad that my wife came along because she wouldn’t believe me if I came home and told her that he told me, “Keep exercising like you don’t have atrial fibrillation.” He then went on to tell me, “in the future you may want to consider some moderation as far as your exercises concerned.”

That seems reasonable enough. In fact I was delighted.

The next thing he said was kind of funny. He said, “People like you are a type – ultra marathoners, triathletes, Ironman competitors . . . and you can be pretty hard on your bodies.”

“People like you are a type . . .” Well . . . that certainly is true.

In addition to clearing me to continue with my running, he advised that I did not need to take an antiarrhythmic, which probably would not be very helpful in my specific case, and didn’t recommend a rate control drug at this point in time. Furthermore, he advised me that he thought I had a low likelihood of having a successful ablation procedure given the severe hypertrophy of my left atrium and the fact that the atrial fibrillation was persistent.

He did recommend that I try cardioversion with a “one strike and you’re out” policy – that is to say it probably would not be any type of permanent solution, but it is certainly worth trying at least once. That seems perfectly reasonable to me and I went back to Dr. McDowell for the cardioversion, and was in sinus rhythm for a total of thirty-three days.

I was so pleased with my visit to see the electrophysiologist, Dr. Martin, that I wrote him a letter afterward thanking him. I hadn’t really expected that kind of empathy.

I would be interested in hearing from other endurance athletes with respect to their medical care, and how they perceived the way they were treated by their cardiologists and electrophysiologists. Please feel free to leave a comment.