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Yes, was a very long rant to say very little.

Agree

Thank you so much for such a wonderful compliment. I really appreciate it! Yes, I find that understanding what an abnormal heart rhythm like AFib is and how it works to disrupt your normal rhythm source is best when patients visualize it. That is why during in-person consultations I actually have patients imagine the room we are in as the heart with the normal rhythm sources in the roof and the abnormal rhythm sources in a side wall. It always makes it easier for patients to understand the concepts. I’m a firm believer that everyone should be able to understand the basics of their heart problems if explained properly. So thank you again! When patients truly understand the facts and are empowered the way in which I hoped they would be, it makes all of the time and effort involved in doing this really worth it. And if you enjoyed this video, please feel to visit either my channel: @afibeducation or my website at: afibeducationcenter.com for more videos on every topic of AFib for even more detailed information.

How old are you if u don’t mind?

Hi Markmaniet7408: I’m 74 …

I appreciate your feedback. No, I have never personally had a heart rate of 265bpm, but over the twenty plus years of practicing Cardiac Electrophysiology, I have seen and taken care of plenty of patients who have. I never said that it was no big deal. In fact having fast heart rates in Afib even not up 265bpm can be extremely symptomatic and instill a lot of fear and panic in patients. This is why took the time to create 40+ videos on Afib with over half of them discussing in detail the specific pros and cons of the various treatments currently available to treat the symptoms caused by Afib. Long term treatments (for symptoms because AFib is not directly life threatening unless it causes a clot and a stroke) include just slowing it down with a simple rate controlling medication (least risky), putting the AFib cells actively to sleep with a stronger antiarrhythmic medication (more risky), or doing a procedure to try to map and get rid of these cells from the walls of the heart directly (most risk). Whether to just live with Afib and control the rate (least risky) versus try to suppress it for a few more years with a strong antiarrhythmic drug then accept when it is permanent (more risky) or trying to turn back the clock with an ablation (most risk) depends on your level of symptoms (the more symptoms you have the more aggressive a treatment you will desire), age (the older you are the more risky procedures become and vice versa), preferences (older people tend to be risk averse and younger people tend to be willing to accept more risk upfront for a longer lasting result), long term goals, and risk tolerance. Please see my videos: “What are the Symptoms of Afib?” and “How Do I Treat the Symptoms of AFib?” One of the main reasons I took the time to create this channel and these videos is precisely because I’ve seen many regular cardiologists still practice 30 year old medicine and not offer all treatment options. They put patients on a blood thinner to protect them from the small but very real risk of clots and strokes, but for the patient’s symptoms they just give them a simple rate controlling medication to slow down the speed of their Afib and tell them they won’t die and to just live with the symptoms. They won’t discuss other treatment options to try to get the patient out of AFib and they won’t refer the patient to a Cardiac Electrophysiologist (EP’s) to discuss these other options. However, the point of the “8 Myths” video was not to talk about symptoms or imply that patients with Afib can’t have severe symptoms. It was to discuss the myth that Afib by virtue of the fact that it can speed up your heart rate means that it is directly life threatening. And that is false. Unless your Afib causes a clot to form in your heart that breaks loose, floats to your head, blocks off blood supply to your brain, and causes a stroke, Afib will not directly kill you just by speeding your heart rate up. Again, this is not to say that if it makes your heart rate go at very fast speeds that you won’t be severely symptomatic. But having a lot of symptoms isn’t the same as directly dying from it. AFib is the most common abnormal heart rhythm out of the 13-15 different abnormal heart rhythms people can develop in their lifetime. Out of these there are 4 that are considered directly dangerous life threatening abnormal heart rhythms and these originate in the ventricles, the bottom chambers of the heart. Examples of these rhythms are “Ventricular Tachycardia, Ventricular Flutter, and Ventricular Fibrillation.” These rhythms can take over control of your heart and and make your heart rate speed up to a life threatening speed of over 300bpm. At this speed your heart is beating too fast to effectively pump blood because there isn’t enough time to fill up in-between heart beats so the blood pressure drops below 60mmHg which isn’t enough to perfuse the brain and other organs of the body. This causes immediate loss of consciousness and death within 20-30 minutes without chest compressions and defibrillator shocks for resuscitation, and is called a cardiac arrest. Atrial Fibrillation and Atrial Flutter are not capable of making the heart rate go at life threatening speeds of over 300bpm and as such they are not abnormal heart rhythms that can cause a life threatening cardiac arrest event. Even in the cases where Afib or Aflutter speeds the heart rate up enough such that the blood pressure does drop enough to make the patient feel lightheaded, it is rare that the blood pressure gets low enough to cause full syncope/loss of consciousness. This is why we treat patients mainly for symptoms because as long as one is protected from having a clot and a stroke from their Afib, they will not directly die just by having their Afib speed their heart rate up. The faster and more symptomatic your Afib is, the more aggressive a treatment option you may choose; the slower and less symptomatic your Afib episodes are, the less aggressive a treatment option you might go with. But the belief that Afib will kill you even if it doesn’t cause a stroke or that Afib is more life threatening the more symptoms you have is a myth, and I believe it is important that people understand this.

Over my twenty plus years of practicing in this field, I can not tell you how many times I see patients who have minimal or no symptoms from their Afib but be terrified that they might have an episode while sleeping or an asymptomatic episode and not know it, and therefore just die. This is often exacerbated by non-Cardiologists who sometimes overreact. Often patients tell me their Afib was first diagnosed because they had mild palpitations and they went to an Urgent Care Clinic or their Primary Care Doctor and was found to be in new-onset Afib at 120bpm and were told to get to the hospital right away else they will die! Terrified they rush to the hospital only to have the ER docs give them IV Diltiazem (a rate controlling medication) to slow their heart rate but it doesn’t put the Afib back to sleep. Then they admit them overnight waiting for the Afib to go back to sleep on its own which in the early stages usually happens after an hour or two. And now the patient is terrified they could at any moment lose consciousness and just die. Similarly, I’ve seen plenty of less scrupulous Electrophysiologists in my field prey on this lack of information to bully patients into Afib ablation procedures because they make more money to do a procedure than to put the patient on meds. I’ve seen patients show up to the hospital with Afib, have it go back to sleep after a day on its own, then have an EP consulted. But instead of explaining that because the pt is on a blood thinner for their Afib they won’t have a clot and a stroke and die from their Afib, that Afib is mostly treated for symptoms, and then find out how much Afib episodes the patient is having, how symptomatic it is, and then based on the patient’s age, risk tolerance, and preferences, help the patient decide the best long term treatment for their symptoms: whether that be just slowing the Afib down with a simple rate controlling medication, keeping it asleep with a stronger antiarrhythmic medication (AAD), or considering an AF ablation to try to get rid of it temporarily from the inside; instead they spend less than 5 minutes with the patient and essentially tell them that they need an AF ablation and that they need to do it before the patient leaves the hospital implying that if they don’t they will die. This is just someone bullying a patient into a procedure to make money. And unfortunately I’ve seen it happen a lot. Then they end up doing the ablation but the EP doesn’t do a very good job (they rush through the procedure doing a mediocre job so they can put on as many procedures a day as possible in order to make more money) and they end up doing it 3-5 times over a period of time, and then they put them on an AAD to suppress the remaining Afib and they tell the patient that that is the best that can be done. I had a patient come to me for a second opinion after having 3 AF ablations by another EP who was currently planning a fourth. His question was should he undergo a fourth ablation? After taking an hour to explain that Afib was not directly life threatening as long as he stayed on his blood thinner and didn’t have a stroke, and after discussing the pros and cons of the various long term treatments for Afib, I asked him, “I assume you must have a lot of symptoms considering they did three ablations on you?” Surprised the patient replied, “I can’t even feel when I’m in Afib!” I then asked why then did he undergo three ablations. His response? “Well, they didn’t explain anything to me and they made me feel that if I didn’t have the ablations I would die.” This happens because this field is so specialized that even regular Cardiologists don’t really know what we do let alone patients, so docs get away with it. And also because under the current system of reimbursement we get paid for doing something, not for getting a specific result. For example, I might spend twenty years experimenting and learning advanced techniques in order to get rid of Afib even in the most advanced stages and as such I block out 3-4 hours for a pt’s procedure and end up ablating 5-6 out of 6 walls to successfully ablate their persistent or longstanding persistent Afib into normal sinus rhythm, and 3 months later after everything settles down they are off any antiarrhythmic medication spending zero or minimal time in Afib. Another EP, even those just a couple years out of training, could block out 1 hour because they are just planning on electrically isolating that first wall, the pulmonary veins, irregardless of whether that is enough to get rid of all of that pt’s Afib, and as a result they can put on 4 procedures instead of my 2, and get the 2nd, 3rd, or even 4th redo’s and make 3-6 times the money for getting a worse result. This is because we all use the same billing code from the health insurances which again pays us for doing something not for getting a specific result. It is assumed that we all do the same thing and get the same results, which personally I don’t think is true for any profession on the planet. It’s unfortunate, because it often feels like one is penalized for trying to do the ethical thing of only doing a procedure if after explaining things thoroughly to the pt it is decided that it is the right thing to do; and if doing a procedure is deemed needed, doing it in such a way where only one procedure is necessary most of the time. Again, this is one of the main reasons I created this channel and website so as to empower patients to hopefully not be bullied into unnecessary procedures and to know if their doc is practicing 30 year old medicine and not giving them all available treatment options. Thanks for watching!

@@afibeducation Thank you so much for the detailed reply. In my case I was extremely symptomatic and it destroyed my quality of life. This went on for 3 years until I met with an EP who completely understood my situation. The cardiologist diagnosed A Flutter and Tachycardia. When I then learned of electrophysiologist's I went for a second opinion. Two separate EPS said they could see nothing to suggest the original diagnosis and said I had A Fib. and went onto a waiting list for ablation which I had in June of this year and I have been in NSR ever since that day. One more point, before the ablation I went into A fib every night at around 2 am and would self convert in about 2 hours this went on for 6 or 7 months, some days I would go into afib 4 or 5 times and self convert in about an hour and a half but.....before I converted I would just about pass out or some times did pass out, I learned these were called pauses. When in ER and they caught the pauses on the EKG we saw the pauses were average 9 seconds long and 1 was 18 seconds! I ended up with a pace maker the next day and no pauses since. I often wonder if I had have had the successful ablation before the pace maker if the pace maker would have been needed? I will see this July at the annual pace maker appointment if it has been pacing since I had the successful ablation Once again thank you for the reply

I’m glad that you were able to get definitive treatment by an Electrophysiologist for your highly symptomatic AFib and that they were able to get you a good result such that your condition is currently well treated. The “pauses” you were having are called “conversion pauses.” So what happens is that someone is having symptomatic AFib due to the rapid rates the AFib makes the heart go at when it is in control. So the patient gets placed on simple rate controlling medications to slow down the AFib rates to treat the symptoms of palpitations. But when the AFib goes back to sleep and your normal rhythm takes back control of your heart, it isn’t making your heart go at a super fast speed. Your normal rhythm tells your heart to go at the speed your brain wants which is much slower. However, you are still on the rate controlling medication given to slow your AFib speed down. The medication doesn’t know whether you are in AFib or not; it just slows any rhythm down. So it will slow your normal rhythm which is going at a normal speed down too. The problem is that as we get older our normal rhythm source, the sinus node, gets older too and often starts to tell our heart to go at relatively slower speeds. If your normal rhythm source gets so old and diseased that it sends out signals telling the heart to go at speeds slow enough to cause symptoms on its own then a permanent pacemaker is inserted to treat the slow heart rates. The way a pacemaker works is simple: when the patients own rhythm is making the heart go at too slow a speed (we usually program it at 60bpm so anything below that) then the pacemaker sends an artificial signal to the heart at the faster speed of 60bpm. In the heart whenever there are two sources of electricity fighting for control, the faster source always overrides the slower source and takes over. So in the case of the pacemaker, if the normal rhythm speed is going at say 40bpm and the pacemaker paces at 60bpm, then the pacemaker is the faster speed and it takes over control. If the normal rhythm speeds up to over 60bpm then it will be the faster source and will take over control at that speed. This is why a pacemaker is not a direct treatment for AFib because if the AFib wakes up and takes over control of the heart at say 130bpm then the only way the pacemaker could take over control would be to pace at a faster speed which wouldn’t help the problem. So what likely happened with you is that your normal rhythm is starting to get slower as you’ve gotten older but not slow enough to cause symptoms and require a pacemaker in its own right. But on the rate controlling medication given to slow down your AFib episodes, when you were back in your normal rhythm that would be slowed down too such that you would have “conversion pauses.” A conversion pauses is the transition between your AFib and your normal rhythm. When your AFib goes back to sleep your normal rhythm wakes back up to take back over control; this usually only takes 1-2 seconds. But if your normal rhythm source is diseased at all and now slowed down on the rate controlling medication making it even slower, you can have significant pauses of 5, 9, or even over 10 seconds that can cause lightheadedness or actually loss of consciousness (syncope) from no heart beat and blood flow. At this point you had several options: you could have placed a simple pacemaker implant which kicks in and paces when the heart rate goes too slow (see my video “Will a Pacemaker Treat My Afib?”) then use the rate controlling medication to keep the heart rate controlled when you went into Afib and just tolerate it (less risky). Another option would’ve been to use a stronger Antiarrhythmic drug (AAD) to temporarily keep the AFib asleep (more risky), or try to “turn back the clock” on your AFib to an earlier stage with an ablation (most risky). Some of the AAD meds don’t slow your heart rate down at all so if your Afib was suppressed and kept asleep completely (which depending on the strength of the AAD and your stage of AF progression can sometimes last for years at a time) then you wouldn’t have needed the rate controlling medication and maybe you wouldn’t have needed a pacemaker. The same goes for the ablation. If they were successful in turning the clock completely back to zero such that you weren’t going in and out of AFib anymore (remember this is never a permanent cure and that AFib can always slowly grow back), then you wouldn’t need the rate controlling medication and therefore you might not have any further conversion pauses and not need a pacemaker. Of course if they didn’t get rid of all of your AFib with the ablation (remember the results of the ablation are not “all or nothing” and the amount of AFib gotten rid of and how much one “turns the clock back to an earlier stage” depends on the skill of the doc doing the procedure, the current stage of progression or your AFib, and whether or not they do complex or advanced ablations) and you were still going in and out of AFib even a little bit you would still have conversion pauses on the rate controlling medication and still have symptoms and need a pacemaker. Similarly, if even after using an AAD to suppress your AFib or doing a successful ablation and then getting you off the rate controlling medication, you still have slow symptomatic heart rates or pauses in your normal rhythm at baseline then a pacemaker would still be indicated. I hope this helps!

@@afibeducation Very good info I was on Sotalol the whole time during these pauses but have been off Sotalol 6 weeks after the ablation So no Sotalol now for 5 months now and when doing my BP and pulse in the morning after awakening my pulse is generally 72 Thank You so much. My pace maker is set at 60

Belching is one of my triggers also. 71 and learning to adjust my lifestyle to avoid triggers.

I believe that you have “vagal” triggers for your AFib. But remember, the basic premise is that AFib is made up of abnormal cells/sources that form in the walls of the left upper chamber of your heart, the left atrium, and these cells wake up randomly and take over control of your heart electrically away from your normal source of electricity that you are born with that is located in the right upper chamber of your heart. When the AFib cells are in control they make your heart go at faster speeds that can be symptomatic. They also increase the chances of a blood clot forming in your heart that can break loose, go to your brain, and cause a stroke. As one gets older the AFib cells/triggers/sources keep developing, growing, and spreading to more and more walls of the left atrium. The more walls you have AFib cells on, the more AFib cells you have total, the stronger they become, the more they want to wake up, and the longer they stay awake before going back to sleep. When you have them on all 6 walls of that chamber they are strong enough to be awake 100% of the time and that is when your AFib is called "Permanent AFib" because no medication, no ablation no matter how advanced, and even a simple electrical shock (cardioversion) won't get the AFib gone or back to sleep. You will be in AFib 100% from that point forwards, but as long as one stays on their anticoagulation and doesn't have a stroke, you will never directly die from AFib because it is not directly life threatening. However, symptom-wise the best we can do at that point is just use a simple medicine to slow the AFib down to a point where the pt can tolerate the palpitations. But there are things that can cause the AFib cells to grow and spread faster on top of just aging. These would be things like poorly controlled high blood pressure, untreated sleep apnea, poorly controlled diabetes, being overweight, and being too sedentary. While visceral fat isn’t a direct trigger for AFib, being overweight causes your AFib cells to grow and progress faster. Losing weight, even 10% of your current body weight, has been proven to not only slow the rate of progression of AFib, but can sometimes cause some remodeling of your heart walls such that your AFib may even regress to an earlier stage. Although trying to “reverse” your AFib back to zero is unlikely and the amount of regression is likely dependent on what stage of AFib you are currently at. Please see my videos on “Can I Prevent Afib?” and “Stages of AFib Explained.” Now at any given Stage of AFib the AFib is waking up more or less based on how much of it you have in the walls of the left atrium. In the early stages when you don’t have that much AFib, maybe half a wall to 1-2 walls worth, your AFib isn’t waking up very much. That is the stage where “triggers” of AFib make the most difference. Things like stress, stimulants, caffeine, and alcohol can often wake up your AFib more than it would otherwise. Avoiding these agents will definitely decrease the amount of "triggered" AFib episodes, but remember based on whatever stage of progression of AFib you are currently at (early, mid, late) will determine how many AFib cells you have inside your heart presently and they can wake up randomly on their own even without a "trigger" with the more AFib cells you have on the more walls of that left upper chamber of the heart (the more advanced stage of AFib progression) leading to you having more AFib episodes and a greater percentage of time spent in AFib overall. But it is also true that there are “non-stress” triggers that sometimes wake up AFib. These would be the so-called “vagal” triggers which it sounds like you have. Remember, your brain controls everything in your body through your autonomic nervous system which is comprised of either sympathetic stimulation (the “Fight or Flight response” where you see a Tiger and your heart rate increases, pupils dilate to take in more light to see the Tiger better, and blood pressure increases to be ready for action) or parasympathetic or vagal stimulation (this is the rest response where your body gets you ready to sleep or eat by slowing your heart rate, decreasing your blood pressure, constricting your pupils to take in less light, and increasing digestive juices to breakdown food). While AFib is usually woken up by sympathetic stimulation that “revs” the body up, in some people it is woken up more by vagal/parasympathetic stimulation that “slows” the body down. These would be things like eating, abdominal discomfort, resting, holding one’s breath and bearing down, etc. Vagal AFib refers to the “triggers” that wake up your AFib, not the speed the AFib makes your heart speed up to when it is awake. Whether your heart rate is “slow” when your AFib is awake has more to do with whatever speed your AFib chooses to make your heart rate go to at that moment or whether you are on rate controlling meds to artificially slow your heart rate down in AFib. So if you are in an early stage of AFib and notice that your AFib seems to be triggered more by sympathetic stimulation triggers, then avoiding those could mean you have less AFib episodes overall. If you notice your AFib seems to be triggered more by vagal/parasympathetic stimulation triggers like resting, eating, holding your breath, etc. then avoiding those triggers could mean you have less AFib episodes overall. But remember, avoiding triggers is not the same as “reversing” your AFib or curing it. If you have AFib cells/sources in your heart even at an early stage, they can wake up on their own based on how much of them you have in your heart at that particular stage. By avoiding known triggers of AFib, you are simply not waking them up more than they would wake up otherwise. But this only helps in the early stages of AFib. In the later stages of AFib, which naturally occurs as one gets older, when they are waking up a lot on their own already, then avoiding the triggers may be less helpful. For example, if you are at an early stage of AFib and it is normally waking up 1-2% of the time on it’s own but you do certain triggers that wake it up 10-15% of the time, then obviously avoiding those triggers will markedly reduce how much AFib episodes you are having. But if you progress over time to a later stage where your AFib is waking up 50-60% of the time on its own then doing triggers and waking it up 70% of the time may make less of a symptomatic difference at that point because it is mostly awake already. I hope this helps!

Thank you for your feedback. In regards to the background music it is difficult to know the right thing to do. While some people clearly find it annoying, others have said they love it and wish it was more aggressive. Another option for you would be to turn on the subtitles and turn off the sound. That way you can just read what I am saying.

​@@afibeducation thank you for your response but I stick to my guns., for me it is a question of what you prioritize. In real life teachers instructors and professors never play music while they are speaking.,

@@afibeducation Love the comments on TH-cam. He is listening to a top level elecrophysiologist for free and complaining about background music. You can't make this stuff up.

You are very welcome! Thanks!!

Thank you for watching and for your positive feedback. I’m glad you are finding the information helpful and empowering. In regards to having a glass of wine during the holidays, it depends on how symptomatic one is if their Afib wakes up. Alcohol can definitely trigger episodes of Afib due to a direct toxic effect on the heart, but that doesn’t mean that it will every time. It depends on your underlying stage of Afib progression and how well your Afib is being treated (eg. If you are on an antiarrhythmic medication with adequate suppression or post a successful Afib ablation you might not have any issues drinking wine). If you find that your Afib doesn’t necessarily wake up with a little bit of wine then go for it. But just know that it could trigger an episode and decide if you are okay with that if it were to happen. Remember, as long as you stay on your blood thinner and are protected from clots and strokes, we are just dealing with symptoms. An occasional glass of wine shouldn’t cause your Afib to significantly progress faster on top of aging, but regular alcohol intake can definitely progress your Afib stage quicker as it contributes to generalized inflammation in the heart that can accelerate Afib development. I hope this helps!

I’m glad you are still doing well! As I said, while left atrial appendage closure devices won’t reduce one’s risk of clots and strokes in AFib quite as well as a blood thinner because the left atrial appendage is where only 90% of clots form not 100%, it still markedly reduces the risk without using a blood thinner and there are many patients who have valid reasons not to be on a blood thinner (either they have documented bleeding issues or are at high risk for bleeding issues or they fall a lot and can hit and bleed into their head which would be more dangerous than a stroke). In the old days (ie. Prior to 2016 when the Watchman first got FDA approved) we had to make tough decisions and simply “pick your poison.” Oh, you have a 3% risk of stroke from your AFib but an 8% risk of having another severe GI bleed so I guess we will stop your blood thinner and hope for the best. That kind of thing. But now we have choices which is good. The only thing I have a problem with is that a number of less scrupulous EP’s are telling their referring docs and patients that a left atrial appendage closure device is equivalent protection to a blood thinner and so why not do a one time procedure (because it is a relatively straightforward and easy procedure to do) and never have to hassle with blood thinners ever again? Then they put on 6 Watchman implants a day which makes them a ton of money (because one makes more money to do a procedure than to prescribe a medication), and the patients think they are fully protected from stroke off of their blood thinner. Disturbing but unfortunately it happens a lot. Thanks for watching!