Atrial Fibrillation News Update

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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Run, Smile, Drink Water and Don’t Die – A Guest Post by JoAnna Brogdon

Once upon a time there was a girl that loved to run just for the fun of it. She woke up early one morning on a cold and rainy March morning, excited to run the Rock Creek River Gorge Trail Run at Prentice-Cooper State Forest, just outside Chattanooga, Tennessee. She had run this race before and was wowed by the gorgeous gorge views and challenging single track trails.

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She signed up for the 10.2 mile run but wasn’t feeling exactly right that morning. She couldn’t put her finger on it. She was just a little off but that wasn’t going to stop her! She bounced out of bed and decided to do the 6.5 mile option instead of the 10.2—a decision that turned out to be one of the best she ever made.

The start was a little fast. Everyone was ready to get moving on the chilly and very wet morning. Soon the 158 runners headed into the woods and formed a single line, slowing the pace which was a good thing. The trails were incredibly slippery with tons of thick mud after much rain that winter. One runner took a face plant when crossing the creek and came up with a big gash on his forehead and blood dripping down his face.

“Are you OK said the girl?”

“Yes, I am just happy to be out here,” he responded.

“Me, too!” she replied. There were smiles on everyone’s faces as they headed up steep hills and carefully focused on the each step.

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At the half way mark, she was feeling OK but a little more tired than usual. No problem she said to herself, just having an off day. It was time to focus on other things, talk to people, make some jokes and carry on. She found a guy wearing a shirt that said, “Idiot Runner’s Club – Run, Smile, Drink Water and Don’t Die.” This sounds like my kind of runner thought the girl! They chatted and laughed about how slow they were going but how happy they were to be there instead of sitting on a couch or still sleeping in bed. The mud was so thick that their shoes nearly got sucked off but happily they went up yet another hill.

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Even though she wasn’t moving very quickly, her heart was starting to race quite fast. She slowed down and was walking more than running. She put her hands in the air a few times feeling like it was getting a little hard to breathe. Just focus on the gorgeous trails and it will be over soon, she told herself.

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There is that Idiot Runner again. He caught up and they were passing each other back and forth. It was time for more chatting and laughter. Only a few more hills and it will be time to relax and enjoy the day. One final push, climbing up through the narrow Indian Rockhouse and the race is almost over.

It is only 6.5 miles, she thought why does this feel so hard? She had run 50Ks and didn’t feel this bad. There goes a female racer. She will have to see if she can catch her but just felt so tired and ready to stop. Then she heard the crowd and knew that the end was near. She pushed as hard as she could one final time to make it to the finish line—she did it! And then she decided to sit down for a minute, she really didn’t feel so good … and then there was darkness …

…what is that noise?

She was waking up and heard a loud noise – it was her heart pounding at an incredible rate and a bright light in the distance. Someone was saying something to her, if she could only get to the light. She woke and found herself inside the medic tent with two physicians by her side. Her legs were cramping with the worst pain she had ever felt. Where was she? What had just happened? What was her name? Which hospital did she want to go to? So many questions…

She was being placed in an ambulance and sent to the local hospital. She was in rapid rate Atrial Fibrillation and needed a Cardizem drip to get her rate down. They admitted her to the hospital and the nurse came by to explain what A Fib meant. She drew a nice picture for the girl.

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She learned that A fib occurs when one or both of the upper chambers of the heart – called the atria – don’t beat the way they should. This can cause blood to pool in the left atrium, where a blood clot can form. If that clot breaks away, it can travel to the brain, where it can cause a type of stroke called an ischemic stroke.

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Two and half days in the hospital she waited for the meds to convert her heart back to normal sinus rhythm. They placed a band on her wrist that said “fall risk” – they had no idea.

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The doctor decided the only way to get her heart back to normal rhythm was to cardioconvert using an electric shock. She was wheeled down to the operating area and what a surprise– she saw the two doctors that were at the race. One was a cardiologist and the other was an anesthesiologist for cardiology. They were chatting and laughing and encouraging her that it was all going to be OK. Her cardiologist was running late and it delayed the procedure. He was known for this as he always took time with his patients. Right as the doctor arrived; the nurse looked at the monitor and said wait—she converted on her own! We don’t need to shock her heart. The girl was happy and believed that it was actually going to be OK— maybe not happily ever after but OK. She smiled as she remembered the new friend she had just met on the trail…

“Run, Smile, Drink Water and Don’t Die.” Now those were words to live by.

The End.

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JoAnna Brogdon, forty-three years old, went into a fib several times since the race and was hospitalized twice. She has no underlying chronic conditions and the doctors are unable to tell her why she has had a fib. She believes the worst part of the condition was the emotional stress and not being able to exercise as she had in the past. She underwent a cardiac ablation recently and her heart has been beating normally since. She is hopeful that she has put a fib behind her at least for now and looks forward to running, traveling and feeling normal again. JoAnna wants to support those that struggle with a fib and may be contacted at joannabrogdon@hotmail.com.

On Being Slow – Running with Atrial Fibrillation

Being in persistent atrial fibrillation is sort of like being a pickup truck with a four speed manual transmission, but you can only use second and third gear.

If you’re going to continue distance running in persistent atrial fibrillation you’d better expect to be slower.

I was already slow to begin with – my quickest marathon was four hours and forty minutes and it took me an hour to run a 10K. I’ve always avoided 5Ks because people in 5Ks simply run too fast. Once I was a back of the middle of the pack runner, well, now I’m truly a back of the pack runner.

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Training Run

I’ve always been a larger runner, and that’s definitely a factor in being slow. I’ve done a dozen marathons at over 6′ 3” and about 235 pounds, and have often felt that people would “mark” me, use me sort of as a target. I’ve felt particularly self-conscious about those people, often found in the back of the pack in a marathon, who will run up and pass me and then start walking – over and over again. This can be really annoying. One guy did that for 14 miles! I finally told him, “please either keep running or keep walking.” I know that these people are simply followers of Jeff Galloway (there are a lot of them in the back of a marathon pack), but it’s still annoying and it happens every race.

But if I was moderately slow before, I’m silly slow now. In an effort to preserve my pace I have actually lost about 40 pounds – but I don’t think I’ve even broken even. I had previously ran ten minute miles in shorter training runs, but now twelve minute miles are more common. As stated previously I had a cardioversion and was in sinus rhythm for thirty-three days – and at my new weight I was delighted to be able to train, for shorter runs, at a nine minute mile if I wanted to – but alas after a quick five-mile run in the thirty-third day I went back into persistent atrial fibrillation. I could feel it immediately and knew what had happened.

I imagine that a lot of athletes who are reading this blog are people who have had episodes of atrial fibrillation, or who go in and out of atrial fibrillation. I think people with intermittent atrial fibrillation become much more symptomatic and have a lot more trouble with training. They might not be able to train at all. But with persistent atrial fibrillation, at least in my experience, I have found that I stabilized and am able to train (a slower pace). You just have to get used to it.

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Back of the Pack – Haulin Aspen Trail Marathon and 1/2 Marathon

There are a few major differences, however. Prior to atrial fibrillation, like most runners, I would start out a long run at a fairly quick pace and more or less degrade as far as my pace was concerned as the miles accumulated. But with atrial fibrillation I actually start out quite slow, and after a mile or two find that I have picked up the pace quite a bit. I generally don’t do much interval training, but I imagine that is out of the question at this point. I live and train in the mountains and I can still run hills, but not really very quickly. When bicycling I find I don’t stand up and charge up hills any longer, but remain seated and spin more.

Being in persistent atrial fibrillation is sort of like being a pickup truck with a four speed manual transmission, but you can only use second and third gear. You start out pathetically slow, and your top speed is greatly diminished – but she can still drive as far as you want.

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Big Slow Runner – Before A Fib

The most important thing, of course, is that I am still able to continue trail running and mountain biking, and I am still able to participate in marathons and even ultra marathons. I still get to experience the sheer joy of slogging through a long trail run through the forest. I was never going to win any prizes to begin with, so what’s the difference?

Actually, I was delighted to get a medal for second place in my age group at the 2012 Bizz Johnson 50K, which I ran while in persistent atrial fibrillation. That was the first year they had a 50K at that event and there weren’t very many participants. I’m pretty sure that there were only two people in my age group, but still!

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Second Place (age group) Hell Yeah!!!!

One good thing about ultra running and marathon running, especially compared to 5Ks, for example, is that nobody really cares if you are slow. I was surprised that there were many people who finished behind me when I ran my first 50K in atrial fibrillation. Although it is kind of embarrassing to be so slow, you just have to change your mindset, and when you get involved with ultra sports, especially with atrial fibrillation, you need to simply enjoy yourself, enjoy the run, enjoy the trail, enjoy the people, and not worry about time.

If there are any other athletes reading this who are in persistent a fib, or intermittent a fib, I would love to hear about your experiences, and I encourage you to leave comments.

Running Alone

Even before I was in persistent atrial fibrillation I generally would like to run alone, although occasionally I run with my wife, Margo. Bike riding was different – I would often go for mountain bike or road rides with friends. At this point, however, I generally go alone so I can just keep my own slow pace.

Ninety-five percent of the running that I do is trail running, and almost all that is done with my dogs – so technically I don’t run alone. They don’t care how slow we go – they are simply glad to be out there.

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Ringo on Mount McLoughlin

Ringo is a blue healer, border collie cross and is a great trail dog. He behaves well off leash, never chases anything, and always stays with me. There are a couple of races around here that allow dogs and he always gets to go along for these events.

Our other dog, Sophie, is a husky/shepherd cross and pretty much needs to be on leash 100% of the time (otherwise she runs off after God knows what), which can be challenging for trail running. It pretty much completely eliminates Sophie as a mountain biking partner.

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Running at Lake of the Woods with Margo, Ringo, and Sophie

I often run in wilderness areas, or even remote trails near town, and sometimes worry about having a fall and getting hurt on the trail. I guess that just has to be an acceptable risk. I like to say I’d rather die in Sky Lakes Wilderness (our local wilderness) than at Sky Lakes Medical Center (our local hospital – where I am on the surgical staff) – but I feel sorry for they people who find me – imagine finding somebody on the trail . . . that big and that dead! As a precaution I always like to tell my wife where I’m going, and of course, I always have my cell phone with me. I usually take a bandanna along so I have something I can use for a tourniquet if necessary – don’t forget I am on a potent anticoagulant (Pradaxa).

I’d be interested in hearing from other runners and mountain bikers who are training while on anticoagulants and find out what type of precautions you take. Please feel free to leave a comment.

Heat and Salt and A Fib

As stated previously I get pretty lightheaded when I get up from a sitting position after a hard workout, particularly in hot weather. Orthostatic hypotension. I don’t know why I get dehydrated so easily now, but I have learned that I need to eat something salty and drink a lot of water  after a workout, particularly a run or a bike ride which is longer than an hour or two, otherwise I get pretty dizzy when I first standup, and I’ve had a friend who is an nephrologist and another friend who is an internist both tell me to make sure I drink plenty of water after a workout and get some salt. Just one more fun aspect of being in persistent atrial fibrillation.

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Pre-Race Motel

This is the first time in my life I’ve ever actually been trying to get more salt. Most people spend their lives trying to avoid salt. I have started bringing potato chips for a post run snack to the trailhead for my long runs. Another great post run snack is some blue corn chips with some hummus with some Hoisin sauce.

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Pre-Race

Although it is neither here nor there, I’d like to state that I am a vegetarian (nearly vegan – if not for the occasional veggie pizza) as far as diet is concerned.

I also find that I am more sensitive to heat, which is obviously related. Last summer I would often start to feel pretty tired 17 miles into a 20 mile training run. In cool weather a 20 mile trail run is no problem. When I’m training for a 50K I basically try to do a 20 mile run every weekend.

Fortunately I live in Klamath Falls, on the East side of the Cascades of Oregon, where we have relatively cold Winters and generally cool Spring and Autumn. Summer, obviously, can be pretty hot – but nothing like Southern California, Arizona, Mexico, the South, etc.

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Resting During a Trail Run

I have also noticed over the past several years that I did quite poorly during marathons if the weather got hot. The concept of hot weather is a relative term – for me anything over 70°F (21°C) would be considered hot. My ideal running weather would be 35 to 55°F. Ten years ago I could do a 20 mile run when it was 90°F (32°C) without much problem. Those days are over.

I’d be interested in hearing from other people with atrial fibrillation with respect to this. Please comment.

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Ringo – Pooped Out After a Long Trail Run

Persistent and Intermittent Atrial Fibrillation

There are different types of atrial fibrillation. They’re all the same arrhythmia, the main difference is duration. Some people have intermittent (or paroxysmal) atrial fibrillation. This means that the individual goes into atrial fibrillation for a short period of time – maybe a couple minutes, maybe twenty-four hours, but less than one week. Most of the descriptions of atrial fibrillation I have found on the web describe paroxysmal atrial fibrillation.

Atrial fibrillation that lasts for longer than seven days is called persistent atrial fibrillation, and atrial fibrillation that lasts for over one year is referred to as long-standing persistent atrial fibrillation or permanent atrial fibrillation.

Regrettably that is the type of atrial fibrillation that I have. I have just “celebrated” my one year anniversary of persistent atrial fibrillation. I miss sinus rhythm.

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The Best Mile Marker

People who are in sinus rhythm most of the time and go into atrial fibrillation only occasionally are fortunate because they get to be in sinus rhythm most of the time, which is basically the hot set up for any type of endurance sports. The disadvantage is that when these individuals to go into atrial fibrillation the effects are pretty devastating, and more often than not they find themselves on their hands and knees wondering what happened. The other bad news for people with intermittent atrial fibrillation is that it may very well progress into a persistent type atrial fibrillation, and of course there is a risk of having a stroke. So it is important to discuss this and formulate an appropriate treatment plan with your healthcare provider.

The disadvantage of being in persistent, but relatively asymptomatic, atrial fibrillation is that you have a performance penalty all the time; but the advantage is that you stabilize, at least I have, and are able to participate in your sport, albeit at a slower pace. It never gets much worse or much better.

Maybe there are some athletes out there who are in persistent atrial fibrillation who are unable to continue to participate in running, mountain biking, etc. if so I would encourage you to share your stories in the comments section.

All unable to discuss at this point in time is my own personal experience.

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Bizz Johnson Marathon – I think I’ve done this one five times

Intro – Atrial Fibrillation and Endurance Sports

It turns out atrial fibrillation is pretty common in middle-aged endurance athletes. About a year ago, when I first went into persistent atrial fibrillation I was surprised to find out how common it was in athletes, but also surprised to find out there weren’t a lot of resources on the web. I am writing this blog in order to provide information about atrial fibrillation in athletes from an athlete’s point of view only.

My purpose is not to give medical advice. I am a podiatrist employed at Klamath Orthopedics and Sports Medicine and my practice is limited to the treatment of the foot and ankle – not the heart. Cardiology is not in my scope of practice.

Also – before you ask – I don’t plan to give podiatry advice in this blog, either.

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I’m a 53-year-old distance runner and mountain biker who is in persistent atrial fibrillation. Persistent atrial fibrillation means that I do not go in and out of atrial fibrillation, like some athletes, I am always in atrial fibrillation and I am not expected to ever be out of atrial fibrillation. I am more or less asymptomatic, except for palpitations and, of course,  a slower pace, and do not take any specific treatment except for a blood thinner (Pradaxa).

I continue to enjoy marathoning, trail running, mountain biking, hiking, and any other outdoor activity for that matter. I am not sure how many marathons I have completed, but probably around fifteen. I have trained for two 50K runs, but was only able to run one of them. I was discouraged to participate in my first 50K by my electrophysiologist (more on that later). That was before he actually saw me as a patient.

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Peterson Ridge Rumble 20 and 40 Mile Trail Run – a great race that allows dogs. Here is my dog, Ringo, at the starting line.

My most recent event was the Peterson Ridge Rumble, a 20 mile trail run in Sisters, Oregon. Upcoming events include Lake of the Woods 15K, Siskiyou Outback 15K, and then the Bizz Johnson 50K in October.

I have done at least one marathon and one 50K while in atrial fibrillation, but I suspect that I have been in atrial fibrillation for at least one other previous marathon. It’s likely that I’ve been going in and out of atrial fibrillation for the past several years, and that explains a lot.

In 1994 I had open heart surgery to repair my mitral valve. At that time I was mountain biking six days per week and had severe mitral valve regurgitation and severe left atrial hypertrophy and I had a repair – no artificial valve or a pig valve – I have all the original equipment. Unfortunately the left atrial hypertrophy never resolved and as a result I eventually ended up developing arrhythmias, including a lot of PVCs and PACs, and have ultimately go on into persistent atrial fibrillation. PVCs and PACs, otherwise known as premature ventricular contractions and premature atrial contractions, are generally benign, but quite annoying arrhythmias that everybody experiences from time to time.

I am not happy (or proud) to be in atrial fibrillation, but this is what I have to deal with. I was told that in my specific case an ablation procedure would likely have less than 30% chance of being successful, and even if it were successful it would probably not be successful for more than five years.

I was never a fast runner, even in my youth and I’ve always been a big, slow runner (6′ 3”, just under 200 pounds), but now I’m ridiculously slow. But running still brings me the same joy that it always has and I plan to continue.