Stewart

Atrial fibrillation

How a cardiologist copes with AF

Recently retired cardiologist Stewart has lived with atrial fibrillation for 20 years, and hopes that his observations might help others with AF. This is his story in his words.

First attack

In August 1997 (aged 48) I was attending a meeting of the Cardiac Society in Hobart. On the second day, I was feeling a bit under the weather with an early phase of what became a flu-like illness. But while sitting at a lunchtime lecture session, I suddenly noticed I had developed a rapid irregular heartbeat. As a cardiologist I was pretty sure what it was. 

I wasn’t unduly unwell, albeit slightly “wobbly” (good medical term that) and wondered what to do next. I realised that the exhibition of medical equipment was on the lower floor and it would include monitors that might confirm my self-diagnosis.

As I went down the escalator, I met a professor from Sydney I knew well, who said “How are you?” and he received the rather unexpected reply: “I think I’ve just gone into AF”. 

He felt my pulse and agreed. We managed after some difficulty to persuade one of the exhibitors to attach some electrodes from a monitor and confirmed that my heart rate was batting along at about 170 beats per minute. I then had the embarrassing experience of leaving the conference in a wheelchair with a monitor on my lap to be driven to the Royal Hobart Hospital – where of course there were no cardiologists as they were all at the conference. 

I was processed efficiently in the Emergency Department and even had a rapid echocardiogram confirming normal cardiac anatomy. I was able to suggest my own preferred treatment of an intravenous injection of flecainide which worked and reverted me to normal “sinus” rhythm. 

I was released and able to walk back across the road to my hotel where I spent the rest of the night experiencing a high temperature and rigors (shivering) due to the now fully developed ‘flu infection.  In retrospect, I had a cluster of risk factors for AF – a few glasses of bubbly at the reception the night before, a very strong coffee that morning, and the infection.

I felt better the next day and was able to fly as booked to Sydney where I was to spend the night. As I boarded the plane, the palpitation restarted which had me worried as I was due to fly the next day to Auckland, meet up with my wife and head on to a holiday in Fiji where I realised medical facilities would be somewhat scanty... 

I went for a brief walk to pick up some requested shopping and was very relieved to find that the AF had again resolved, this time without specific treatment. I had an uneventful night and decided to carry on with travel plans, met my wife in Auckland and proceeded to Fiji.

The first few days of the holiday were blighted by a sore throat and streaming nose (which rather restricted my intended underwater activity) but this eventually cleared up and I had no recurrence of the AF for nearly a year.

Second and subsequent attacks

The next attack came out of the blue while out for a walk. It was not unduly limiting, just worrying as it indicated that the previous attack wasn’t just a “one-off” and it settled after an hour or two.

Over the next few years or so, attacks would again occur without warning but the pattern was the same. I was certainly aware of them and they felt uncomfortable but I was able to carry on working or undertaking non-strenuous physical activity.

My main worry was that I might go for a tramp, develop an attack and then find it difficult to get home. However, I found that moderate exercise was a reliable terminator of attacks and proved this by getting technician colleagues to test me on a treadmill (which reassuringly also showed no suggestion of coronary disease). 

Medical advice

Although an “expert in the field” myself, I felt that I should keep my GP informed and also had a few consultations with a specialist with a particular interest in cardiac rhythm abnormalities.

As the attacks became more frequent, I started taking a regular beta-blocker tablet which kept the heart rate under control during attacks and an anti-arrhythmic agent which may have reduced the frequency of attacks. 

In those days, it was conventional to take daily low-dose aspirin when full anticoagulation was not required so I have continued this even though evidence has emerged that it is not particularly effective. Other evidence suggesting it might have some value in protecting against heart attacks has also been questioned for those in whom risk levels are low, but it has also been suggested that it might protect against colon cancer. Since it has given me no problems, I have continued it. 

As with many fellow-sufferers, attacks became more frequent although gradually less disturbing.  Medication has helped control symptoms to the extent that I no longer know if I’m in AF or normal rhythm unless I actually check my pulse. When I do, I realise that I now spend more time in AF than in normal rhythm. Even when in AF I can continue medical work or exercise without restriction. I have recently consulted another expert colleague and had a review echocardiogram to establish that the structure and function of my heart remains normal. 

Management choices

The two particular items of discussion have been the issue of anticoagulation and whether to undergo an “ablation” procedure. 

• Anticoagulation

Risks of stroke are regarded as the main issue for people with either permanent or paroxysmal AF and there are risk scores which are now used for all patients to help determine if the risks of stroke are greater than the risks of complications of the medication. 

I clocked up one point on the ‘CHA₂DS₂VASc’ score when I passed the age of 65, but the need for anticoagulation remains doubtful in the absence of other risk factors such as blood pressure, diabetes, previous stroke or other heart disease. 

The risks and inconvenience of anticoagulant medication have reduced with the introduction of new agents which offer a welcome alternative to warfarin, so I may convert my aspirin to a new agent before I clock my second risk point at the age of 75.

• Ablation

For the last decade or two, there has been increasing interest in performing a procedure which isolates the areas of the heart which trigger AF. 

Unlike some other analogous procedures for different rhythm problems, which are simple and often fully effective, ablation for AF requires multiple targeted radiofrequency burns of tissue in the wall of the left atrium. Early procedures were occasionally complicated and some consequences were quite serious. These are less common now but happen enough to suggest reserving the procedure for those with severe symptoms, although there are enthusiastic colleagues who feel indications should be wider. 

Many patients require a second procedure within a few years and the longer-term duration of any benefit is as yet unknown. Since my symptoms have remained non-disabling and the long-term effects of ablation are still to be clarified, I have opted not to take that route.

Managing other patients with AF

As AF is very common, not surprisingly I have frequently found myself consulted professionally by fellow sufferers. My personal experience colours me in both good and bad ways.

It is often comforting to patients to learn that their cardiologist also has the same condition and copes well with it, but I do need to bear in mind that everyone with the condition has their own particular pattern of attacks and I cannot make assumptions that a patient will have similar experiences to my own. 

I have seen the whole spectrum of symptoms from those who are completely unaware of their attacks of AF to others who are completely prostrated when they occur. 

Apart from the variability of symptoms, some may not tolerate drug therapy so well or have factors in life which make the need to be free of attacks more important. I found an information sheet written by an American cardiologist with AF that I adapted for use in my AF patients and it is generally much appreciated. It starts with “I’m sorry you have AF, welcome to the club – it has many members” (I added “including elite athletes and cardiologists”).  Another quote – “Worrying about AF is like worrying about wrinkles and grey hair.”

It stresses the importance of anticoagulation for those at significant risk of stroke, and the need to be thoughtful before opting for an ablation procedure. It appears to be a useful addition to standard patient-focused literature on AF. Of course I also strongly recommend the AF section of the NZ Heart Foundation’s website.

Developing AF was something of a blow to the body image – as a cardiologist having a cardiac problem at what I regard as a “young” age almost confers a sense of shame – even if there are few relevant lifestyle risk factors I need to feel guilty about. 

I have been the sort of person who “gets on with things” even if this sometimes means giving less attention to personal medical issues than I ought to. I am also a very open person and most colleagues (and some patients) know about my condition. 

Episodes rarely disabled me significantly and symptoms are now negligible.  So, apart from that first somewhat embarrassing and public episode, it has been a condition I have accepted and can even take positives from in sympathising with my patients.

Shared March 2017