Answer:

Diltiazem and metoprolol are typically used in conjunction with flecainide to lessen the risk of side effects one might experience with that medication. The risk of such side effects is relatively low except for patients with abnormal anatomy or function of the heart, particularly patients who have had documented coronary artery disease and heart attacks. Given your history - this may be worthwhile investigating further. The heart rate itself is not too concerning if you have no associated symptoms such as dizziness, loss of consciousness or fatigue. Another issue to address is that of systemic anticoagulation. Most studies comparing rate and rhythm control strategies - i.e. having you in atrial fibrillation but on a medicine like Toprol or diltiazem to make sure your heart rate is around 80 bpm or less at rest versus having you on a medicine like Flecainide with the goal of keeping you in normal rhythm - showed more strokes in patients who were treated with the goal of rhythm control, but who were not on coumadin.

Answer:

Extra beats are typically benign in that these are not usually associated with abnormal heart function or stroke. Nevertheless, they may be quite bothersome, particularly to a prior AF patient, typically 'tuned in' into any heart rhythm anomaly. Extra beats are frequently managed conservatively with or without a medication along the lines of metoprolol. In certain cases, when extra beats are hard to control and the patient is symptomatic, an ablation procedure can be carried out, but the success depends heavily on the source and frequency of the extra-beats and is less certain than the success of AF ablation. Some patients have significant anxiety related to the extra beats or to the fear of having an irregular heart rate episode. Many if these patients may benefit from medications like citalopram and behavioural therapy.

Answer:

Among patients with 'lone' atrial fibrillation, such as yourself, the frequency and severity of symptoms related to atrial fibrillation may wax and wane over time but based on registry data, AF typically does not go away but rather progresses over time at different rates for different patients. Some patients do report a relationship between their symptoms and stress levels, time of year, menstrual periods, and menopause. Unfortunately, to my knowledge, a specific connection with these factors across multiple patients has not been made. We know that the arrhythmias related to atrial fibrillation arise in certain areas of the heart like the pulmonary vein, the posterior wall of the left atrium, superior vena cava, coronary sinus, intreratrial septum and the crista terminalis. What we do not know is why they arise there. We know that by ablating these areas we may decrease the likelihood of a patient having such an arrhythmia, but in the process we likely modify the final common pathway of the arrhythmia rather than the causative factor per-se. The most prevalent theory linking these parts of the heart to arrhythmia generation explains this relationship via greater vagal / parasympathetic innervation of the heart in the areas described. The theory then suggests that heightened vagal input to these areas of the heart via local autonomic ganglia leads to arrhythmia initiation and maintenance and some investigators have targeted autonomic ganglia directly. Practically, however, pulmonary veins remain the easiest target for an intervention with reasonable clinical and cost effective outcomes.

Answer:

You are probably looking at about 60% freedom from symptomatic AF off antiarrhythmic drugs at 1-2 years following a single ablation procedure and 75-80% after up to 2 ablation procedures. Ablation procedures are typically performed about 3 or more months apart to allow the changes from the first ablation to take place. Some people may have to undergo more than two procedures to control their AF. Most of our current evidence supports ablation in patients with symptomatic AF or with evidence of tachycardia mediated cardiomyopathy - demonstrable worsening of heart function while out of rhythm. In patients with normal heart function, no significant symptoms from AF who are well rate controlled - that is their heart rate at rest is around 80 bpm or less and with moderate exertion it is 100-120 bpm - there may be less benefit to ablation vs medical management.
You could write to Dr Natale's office. To my knowledge he does not practice in Wisconsin. There are many competent electrophysiologists in Wisconsin with many years of experience.

Answer:

This sounds like a reasonable group of medications for a patient such as yourself. Some cardiomyopathy patients may also be treated with one or two types of water pills and an ACE inhibitor or an angiotensin receptor antagonist. Tikosyn is a great antiarrhtyhmic medication but patients with slow heart rate may be more prone to side effects with it. In that respect it is important for you to moke sure your heart rate is reasonable, greater than 55-60 beats per minute while on Coreg and digoxin. It is also important to see whether your cardiomyopathy is not related to coronary artery disease and may warrant angioplasty, bypass surgery and/or defibrillator placement. If the cardiomyopathy is related to atrial fibrillation, there is some evidence that it may improve with ablation. I am not sure what the question is however.

Answer:

There are a number of drugs and re-ablation procedures available to your electrophysiologist. It would be best to visit with him/her to discuss the specifics of your personal treatment.

Answer:

It is true - there is data on reverse remodelling of the atria ('shrinking') both in successfully ablated and successfully medically treated patients. That said, the second scenario of atrial fibrillation getting better over time is unlikely in those with 'lone' AF, but may happen in patients with well defined triggers for their arrhythmia - lung disease, thyroid dysfunction, heart surgery, excessive alcohol or caffeine intake and so forth. These patients may indeed be 'cured' without an antiarrhtyhmic drug or an invasive procedure, but unfortunately represent the minority of AF patients. Among patients with 'lone' atrial fibrillation the frequency and severity of symptoms may wax and wane over time but based on registry data, AF typically does not go away but rather progresses over time at different rates for different patients.
The atria usually do not return to normal size, but of course there are exceptions. The AF usually does not spontaneously resolve, but of course there are exceptions.

Answer:

There are several issues at play here. First of all your body mass index or BMI is 30.2, in the range of obesity. This is likely associated with your sleep apnea, hypertension and possibly diabetes down the road. If your systolic blood pressure is consistently elevated to greater than 160 mmHg, you are putting yourself at a greater risk of heart attacks and strokes. You should clearly consider weight loss to a BMI of 24.9 or less and better blood pressure control. Extra beats are typically benign in that these are not usually associated with abnormal heart function or stroke. Nevertheless, they may be quite bothersome, particularly to a prior AF patient, typically 'tuned in' into any heart rhythm anomaly. Extra beats are frequently managed conservatively with or without a medication along the lines of metoprolol. In certain cases, when extra beats are hard to control and the patient is symptomatic, an ablation procedure can be carried out, but the success depends heavily on the source and frequency of the extra-beats and is less certain than the success of AF ablation particularly with relatively infrequent extra beats (fewer than about 5-10000 / 24 hours) or frequent extra beats coming from multiple areas of the heart. Some patients have significant anxiety related to the extra beats or to the fear of having an irregular heart rate episode. Many if these patients may benefit from medications like citalopram and behavioural therapy. I would recommend risk factor modification and a 'pill-in-the-pocket' approach first prior to going for a full on EP study with view to ablation. 'Pill-in-the-pocket' approach involves having several doses of a medication know to convert atrial fibrillation to sinus rhythm such as flecainide or propafenone and taking these at home if you had another AF episode to see whether you can convert your AF without having to go in for a cardioversion. We do recommend that the first couple of times these medications should be taken under medical observation and if safe and effective you may continue with this strategy independently.
I doubt that an EP would study you.

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It is unfortunate that your mother has gone through so much trouble in the last few years. It is likely that most of her fatigue is related to the cancer and cancer therapy as well as underlying poor heart muscle function which has lead to heart failure in the first place, as opposed to arrhythmia. She may be anemic and / or have thyroid dysfunction as well which would not help her feel any better and should be ruled out and treated as necessary. As far as arrhythmia, she needs to be able to take blood thinners in order to be eligible for ablation. In lieu of ablation she may benefit from an antiarrhythmic medication such as Tikosyn which would be unlikely to make her more tired, affect her lungs or put her at a significant risk given her history of heart failure, provided that her kidneys are working well. Furthermore, she may need her pacemaker set with a higher heart rate to give her more energy. She may benefit from another water pill - furosemide - in addition to spironolactone, an ACE inhibitor or an angiotensin receptor antagonist and a nitrate. If the source of her heart failure has not been worked up, she may need an angiogram to make sure she does not need angioplasty to help improve circulation to the heart.
There are a number of antiarrhythmic drugs available to her cardiologist for use if appropriate.