FEATURE
COMPLICATED
AFIB
and
STROKE
What You Need to Know
10
Spring 2014
Neal Gregory enjoys riding his bike for health and fun. He once
completed a ride from Washington, D.C., to Pittsburgh.
Millions of Americans live with a condition
known as atrial fibrillation, or AFib. When
other conditions affect AFib, it’s called
complicated AFib. Here’s what you need to
know about this condition and what you can
do to take care of it.
A
trial fibrillation, or AFib, affects an estimated 2.7 million Americans. AFib is the most common type
of cardiac arrhythmia, a condition in which the heart doesn’t beat the way it should. The upper
chambers (atria) of a heart with AFib beat chaotically and out of sync with the heart’s lower
chambers (ventricles). This often results in a rapid heartbeat, which affects how blood flows
throughout the body.
By itself, AFib is not life-threatening. But in some patients, it can increase the risk of heart failure or stroke. That’s
why it’s important to manage AFib effectively, even if there are no symptoms.
What Causes AFib?
When the heart is working normally, the atria send
electrical signals to the ventricles across a connection
called the atrioventricular, or AV, node. In a heart affected
by AFib, those tiny electrical signals move irregularly, or
chaotically. This causes the AV node to get overloaded
with all these electrical signals, causing irregular beats in
the ventricles—but not as rapidly as in the atria. That’s
why a heart with AFib will often beat from 100 to 175
beats per minute, as opposed to the 60 to 100 beats per
minute of a healthy heart.
So what causes this? Sometimes there is no clear cause.
But many factors can cause these electrical signals to go
haywire. A congenital heart condition can be the cause, as
can previous heart conditions. Sleep apnea or exposure to
stimulants (whether medications, caffeine, tobacco or
alcohol) can also be a cause. Or it can be:
77 High blood pressure
77
Recent heart surgery
77
Inflammation of the heart muscle (myocarditis) or the
lining of the heart (pericarditis)
AFib becomes more serious when it is affected by
another medical condition, such as cardiovascular disease.
This is considered complicated AFib, and it means that
AFib is itself a risk factor for a more serious condition,
such as stroke or heart failure.
Symptoms of AFib
For some people, AFib has no symptoms at all. When
AFib has symptoms, they can include:
77 Mild fatigue or weakness
77
Difficulty breathing or shortness of breath
77
Palpitations (a sense of racing or uncomfortable
“flopping” of the heart)
77
Lower blood pressure
77
Valvular heart disease
77
Lightheadedness
77
Overactive thyroid gland
77
Confusion
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Acute or chronic lung disease
77
Chest pain
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FEATURE
COMPLICATED AFIB AND STROKE:
Risk Factors for AFib
Who is most likely to get AFib? Risk factors include:
77 Age: The older you get, the more likely you’ll get
AFib. About 11 percent of Americans over the age
of 80 have it.
77
77
Heart disease: No matter what type of heart
disease, including valve conditions and previous
heart attacks or heart surgery, it raises your risk of
getting AFib.
High blood pressure: If not controlled,
hypertension (high blood pressure) increases the
risk of getting AFib. It’s all the more reason to
keep your blood pressure in a healthy range.
77
Other chronic conditions: Medical problems such
as thyroid issues, sleep apnea and other health
issues can raise the risk of getting AFib.
77
Alchohol: Drinking alcoholic beverages can trigger
an episode of AFib in some people, and binge
drinking (i.e., five drinks in two hours for men,
four in two hours for women) can put a person at
higher risk.
77
Family history: You’re more likely to get AFib if
members of your family have or had it.
Managing AFib
You’ve probably heard this before, but a healthy diet
and plenty of physical activity are essential parts of
managing almost any heart condition in a healthy way.
AFib is no exception. With AFib, it’s very important
that you take care of your heart.
A heart-healthy diet, in particular one that is low in
sodium intake, is often prescribed for AFib patients.
Such a diet can typically include:
77 Eating more fruits and vegetables. Eating four to
five servings of fruits and vegetables each day are
recommended—with one exception. People on
warfarin therapy (which we’ll talk about later)
must avoid certain vegetables, such as those that
have vitamin K. These include kale, spinach,
Brussels sprouts, parsley, collard greens, mustard
12
greens and chard. Green tea can also be a
problem, and people on warfarin need to go light
on cranberry juice and alcohol. If you’re on
warfarin therapy, talk with your doctor about what
fruits and vegetables are safe for you to eat.
For some people, AFib comes and goes, stopping
and starting on its own. In other people, AFib is a
chronic condition in which the heart rhythm is always
abnormal.
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77
Eating more whole-grain foods: Foods such as
whole-wheat bread, rye bread, brown rice and
whole-grain cereal are rich in fiber and low in
saturated fat and cholesterol.
77
Using more olive, canola or safflower oil as your
main kitchen fat: It’s a good idea to use fat
sparingly when you cook. When you do, reach for
these oils instead of butter or lard.
77
Choosing chicken, fish and beans: Skinless
poultry, fish and vegetable protein are preferred
alternatives to beef, lamb and pork because they
are lower in saturated fat.
77
Limiting sodium intake: It’s recommended that
you eat less than 1,500 mg per day.
77
Reading food labels carefully: There’s a lot of good
information on the sides of cans and food
packages. Keep an eye on the serving size listed
there—many cans and packages hold more than
one serving portion, so multiply the listed contents
in order to get the real picture of how much fat,
cholesterol and other ingredients are in that
particular item.
One word of caution about alcohol and caffeine:
Both can trigger AFib episodes, so people who have
AFib may have to eliminate one or both from their
diet. Be aware that some over-the-counter medications
and nutritional supplements contain stimulants, which
can also trigger AFib episodes or interfere with antiarrhythmic medications. Talk with your doctor about
this.
Smoking, of course, is a big problem for people with
AFib, as it is for everyone who doesn’t have it. It’s
terrible for your health. But it’s especially bad for
people with AFib. Nicotine, a known cardiac
stimulant, can make AFib significantly worse, and
smoking is a known risk factor for cardiovascular
disease. If you don’t smoke, of course, don’t start. If
you do, make plans to quit now. Your doctor can help
you do it by prescribing medications that can help and
pointing you to other resources that are available to
you. Don’t forget about the Quit Line, too, which is
there to support people who are trying to quit
smoking. You can reach the Quit Line at 1-800-QUIT-
WHAT YOU NEED TO KNOW
NOW (784-8669).
Just as eating healthier is very important to a
person with AFib, so is getting lots of physical
activity. It should be part of your routine. Generally
speaking, you want to get at least 30 minutes of
moderate- to high-intensity physical activity most
days of the week. Getting more is even better.
In addition to getting a workout in (which can be
something as simple as a brisk walk — remember,
you don’t have to be an athlete to enjoy the benefits
of exercise!), it’s a good idea to create opportunities
throughout your day to get a little more activity in.
Try parking a little farther away from your
destination so you can get a few more steps in.
Take the stairs instead of the elevator. Take the dog
for a walk. Or walk instead of driving when you
have the opportunity to do so.
Treating AFib
A heart-healthy diet and plenty of physical activity can
help manage AFib, but sometimes more is needed. Because
AFib can play a role in heart failure and stroke, treating it is
essential. When AFib is caused by an underlying event, your
doctor will typically treat the event to see if that controls
AFib.
There are three important goals in treating AFib:
77 Resetting the heart’s rhythm
77
Controlling the heart rate
77
Preventing blood clots
One approach prescribed to restore the heart’s rate and
rhythm is cardioversion. This procedure can be done in
either of two ways:
77 Medication: Anti-arrhythmic medication can be used to
help restore your heart’s natural rhythm. It can be
administered as an intravenous (IV) or oral drug,
depending on what your doctor thinks will work best.
77
Electrical cardioversion: This is a very brief procedure
in which paddles or patches are placed on your chest.
The healthcare provider then sends an electrical charge
to your heart through these contacts. This charge
actually stops your heart’s activity for a moment, which
allows your heart to “reset” to its normal rhythm. You
will be sedated throughout the procedure, so you will
feel no shock.
An anti-arrhythmic medication is often prescribed
following cardioversion to prevent further occurrences of
AFib. The most commonly prescribed include amiodarone,
dronedarone, propafenone, sotalol, dofetilide and flecainide,
all of which can help maintain a normal heart rhythm.
However, they have side effects, which can include nausea,
dizziness and fatigue. Often anticoagulation is prescribed
for a brief time after cardioversion, even if the heart rhythm
has been restored to normal.
Cardioversion doesn’t always create a normal heart
rhythm, however. When that’s the case, your doctor may try
to control your heart rate. There are two ways to do this:
77 Medication: Your doctor will usually set a goal heart
rate for you, then prescribe medication to help you
reach it. These can include calcium-channel blockers,
beta-blockers and digitalis. Sometimes an ACE inhibitor
is also prescribed to help control blood pressure and
help reduce the risk of complications.
77
Atrioventricular (AV) node ablation: Sometimes the
medications don’t work as well as hoped, or the side
effects become too difficult. When this happens, AV
node ablation may become an option. In this procedure,
radiofrequency energy is applied to the AV node
through a catheter to destroy this small area of tissue.
Then a pacemaker is implanted to regulate the rhythm
of the ventricles.
The third goal of treating AFib is preventing blood clots.
The reason for this is the tendency of blood to “sit” in the
“corners” of the atria because the blood does not move
through as well as it should in a heart with AFib. When it
stagnates like that, blood is more likely to form small clots.
These clots can be dangerous because they can escape the
atria and move into the pumping chamber of the heart,
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FEATURE
COMPLICATED AFIB AND STROKE:
where they might get pumped out into the rest of the
body and become lodged in an artery of the brain, or
elsewhere. That can cause a stroke.
Because the risk of clots is so high in people with
AFib, doctors often prescribe anticoagulant (bloodthinning) medications to treat this tendency.
Anticoagulants work on the chemical reactions in your
body to slow the formation of blood clots. They do
this very effectively, but they do not break up blood
clots that have already formed.
there may be a lower risk of bleeding and stroke with
these newer drugs.
See the box below for more information about these
newer drugs.
Anticoagulants are very effective drugs. They can
stop clots from growing. They can prevent clots, or
pieces of clots, from travelling to your brain. They
can stop other clots from forming. And they can
limit the risk of complications from blood clots,
including stroke.
The Newer Anticoagulants: Dabigatran,
Apixaban and Rivaroxaban
In recent years, this newer generation of anticoagulants has hit the market, and
research is showing that they can be more effective than warfarin in lowering stroke and
bleeding risk.
Unlike warfarin, these drugs do not require blood testing. They also cannot be
reversed, as warfarin can. However, this is not an issue so long as you take these
medications as they’re prescribed because they do not interact with certain foods or
other medications, as warfarin can, so they don’t require ongoing INR tests or individual
dosing adjustments.
There are some people who should not take dabigatran, apixaban or rivaroxaban,
however. These include people with kidney disease or an elevated risk of internal
bleeding. As always, it’s important to talk with your doctor about which anticoagulant
medication may be right for you.
The best-known anticoagulants are heparin and
warfarin, both of which have been used for many
years. Heparin must be given intravenously in a
hospital for several days, and requires frequent blood
tests to make sure it is working properly. Before
heparin therapy ends, warfarin is often then given
orally as part of the treatment. As with heparin
therapy, warfarin therapy requires regular blood tests
to see how the blood is clotting. If blood is thinning
too much or it is causing bleeding, your doctor may
need to “reverse” the warfarin. As mentioned earlier,
warfarin requires a special diet.
There are now newer medications for
anticoagulation available to people with AFib when it’s
not caused by a problem with the heart valve. These
include dabigatran, apixaban and rivaroxaban. Unlike
warfarin, these drugs do not require regular blood
testing, and the preliminary research indicates that
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Spring 2014
All anticoagulant drugs — heparin, warfarin and the
newer drugs — carry risks. Because they slow the
process of blood clotting, they can cause severe
bleeding in cases of injury or during pregnancy or
surgery. If you are taking an anticoagulant and
experience an injury involving bleeding, seek medical
care at once — and go to the emergency room if
bleeding is severe. Call your doctor if you notice any
bruising or bleeding.
Also, some medications, including over-thecounter (OTC) medicines, vitamins and herbal
supplements, can cause interactions with
anticoagulants. That’s why it’s critical to talk with
your doctor about all the medicines you take if
you’re prescribed an anticoagulant. Be sure to share
with your doctor if you’re having issues with side
effects, as well.
But keep in mind that it’s very important to take
WHAT YOU NEED TO KNOW
your medications as prescribed. Don’t stop taking an
anticoagulant unless your doctor instructs you to do so,
even if you’re involved in potentially risky behavior.
Another type of medication therapy used to treat AFib
is antiplatelet medication therapy. Antiplatelets include
aspirin, other non-steroidal pain relievers (such as
ibuprofen and naproxen sodium) and clopidogrel,
among others.
These all work by preventing platelets, a type of blood
cell, from sticking to each other at the site of a potential
blood clot. By doing this, antiplatelet medications stop
the clot from forming and help lower the risk of heart
attack or stroke, especially among patients who have
had one or the other, and in those who have certain
cardiovascular conditions.
Like many medicines, antiplatelet medications carry the
risk of excessive bleeding and have side effects similar to
those of anticoagulants. So it’s important to talk with your
doctor and weigh the risks and benefits of taking
antiplatelet medicine.
AFib and Complications
Left untreated, people with AFib are 5 to 7 times more
likely to have a stroke than are those who don’t have AFib.
That’s why the emphasis on getting AFib treated is so
strong. For people who have already had a stroke and
have AFib, the risks run even higher.
If you have AFib, being aware of the warning signs of
stroke is vitally important. If you have any of the following
warning signs, call 9-1-1 immediately. The warning signs
are:
77 Sudden numbness or weakness of the face, arm or leg,
especially on one side of the body
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Sudden confusion, or trouble speaking or
understanding
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Sudden trouble seeing in one or both eyes
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Sudden trouble walking, dizziness or loss of balance or
coordination
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Sudden, severe headaches with no known cause
Time is of the essence when a stroke occurs. It’s
important to take note of the time when stroke symptoms
first appeared, and to tell the doctor. A clot-busting drug is
typically administered to reduce the risk of long-term
disability for the most common type of stroke, but it must
be given within three hours of the start of symptoms.
Stroke risk encompasses age, the presence of other
complications (such as high blood pressure or diabetes)
and a history of heart failure or previous stroke. The
medications your doctor prescribes for you, which may
include anticoagulants and antiplatelets, can greatly reduce
the risk of stroke.
AFib can also lead to heart failure. This is a condition
in which the heart can’t pump enough blood for all the
body’s needs. That’s just one more reason to manage
AFib effectively.
Stroke and heart failure are the main complications that
AFib can cause. But there are other conditions that can
make AFib more difficult to treat. These can include:
77 AFib and uncontrolled high blood pressure: High
blood pressure (hypertension) is itself a major risk
factor for AFib. Left uncontrolled, high blood
pressure can cause changes to the heart that can
trigger AFib. That’s why it’s so important to
control high blood pressure, whether you’re at risk
for AFib or you already have it.
77 AFib
and diabetes: According to one study,
diabetes can raise the risk of getting AFib by as
much as 40 percent. Scientists aren’t sure why this
is, but one possible reason is the inflammation
related to diabetes, which may in turn trigger AFib.
Other research points to a heightened risk of death
when AFib and diabetes occur together — an
increased risk of as much as 61 percent.
77 AFib
and obesity: Over time, obesity places strain
on the heart, which can in turn weaken the heart’s
condition. According to one study, people who are
obese face a 50 percent increase in the risk of
getting AFib. However, losing weight reduces the
risk of AFib and its possible complications.
77 AFib
and stress: If it isn’t controlled effectively,
stress can increase the risk of getting AFib, and
when they occur together, the combination can
make AFib worse.
77 AFib
and sleep apnea: In obstructive sleep apnea
(OSA), the airway of a sleeping person becomes
narrowed, blocked or floppy, which causes airflow
to pause or decrease. At least 1 in 15 Americans has
OSA, and people who have AFib are more likely to
have OSA than are those who don’t have AFib.
That’s not all: In patients who have both, OSA can
make AFib worse. Scientists don’t know exactly
how the two conditions affect each other, but the
evidence that they are interconnected is strong.
77 Medication
contraindications: When two or more
medicines affect the way each works, it’s
sometimes referred to as “contraindications.” The
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FEATURE
COMPLICATED AFIB AND STROKE:
WHAT YOU NEED TO KNOW
medications commonly used to treat AFib and
other common chronic conditions can affect
each other, both in terms of effectiveness and
side effects. For example, some beta-blockers
and calcium-channel blockers that are used to
treat AFib can make heart failure worse. Also,
several types of medication can interfere with
warfarin. The best way to manage this is to
work closely with your doctor to stay on top of
your medications and dosages so that they
work best for you.
Living with AFib
These are all reasons why it’s so important to
manage AFib effectively. How you do that will
ultimately depend on such factors as your age, your
heart’s condition, your stroke risk and the severity of
your AFib symptoms.
By managing your AFib — through healthy diet,
physical activity, stress management, and if necessary
medical procedures and medications — you can live a
full, active life with AFib.
AFib and Mended Hearts: Getting the Word Out
For Mended Hearts Chapter 94 member and visitor Neal
Gregory, the onset of atrial fibrillation (AFib) came at an
inopportune time. “I was diagnosed on an August day after a
garden party, and we were standing around there, sipping
and snacking, and I suddenly got very dizzy,” Gregory
recalled. “I had to sit down,
even thought I was going to
pass out totally. So I went to
see my primary care doctor the
next morning. He administered
an EKG, and I had another
episode right there.”
Bill Stark, President of
Mended Hearts Chapter 281,
encountered AFib in October
2002. “I had it happen about five
days after surgery, a triple
bypass,” he recalled. “The first
thing that happened after
Neal Gregory
surgery, I was due to be
released from the hospital — and my heart felt like it was
jumping out of my chest, like a ‘floppy fish.’”
Mended Hearts has expanded its outreach to meet the
needs of an increasing variety of heart patients, and these
two men have been at the forefront of that effort. Both Neal
and Bill have been visiting AFib patients and relating their
own experiences with the condition. Bill Stark’s been visiting
AFib patients for about 5 years now. “We see around 30
patients a month with AFib, and I’d say we get referrals to
about double that amount,” he said. Neal Gregory sees AFib
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Spring 2014
patients as part of his regular visiting rounds. “I’ve been
visiting at George Washington University Hospital, but I
recently added MedStar Washington Hospital Center to my
visiting. I go one day a week
to each,” he said.
The new Mended Hearts
online Complicated AFib
guides — one for patients,
one for caregivers — have
helped with those efforts.
“I’ve used it and shared it with
others, as well,” said Neal.
“It’s one of the tools that
we’ve found very helpful to
learn about this disease and
its complications.”
Both Neal and Bill are
Bill Stark
happy to report that they have
their AFib under control now, thanks to better diet, more
physical activity and medical interventions. Bill has been on
the medication amiodarone since his diagnosis in the
hospital. “I’ve had a couple of occasions where I tried to
come off the amiodarone, but I wound up popping back into
AFib,” he said. “And I’ve had two incidents I know of where I
got dehydrated, and that put me back into AFib, too. But
that’s been 11 years ago.” Neal hasn’t had another
occurrence of AFib since that first event. “I have a blood
thinner and other medication. An ablation was tried, but it
didn’t work. I got a pacemaker, and now I get that checked
twice a year. I’ve had no problems since.”