CONTACTS
SUBJECTS
Atrial Fibrillation AF Proxysmal Occurred After Treadmill Stress Tes
2903 -
2903 - ..
2904 - Summary/Objective
2905 -
290501 - Follow up ref SDS B6 0000. ref SDS B5 0000.
290502 -
290503 -
290504 -
290505 - [On 200104 0900 submitted letter with copy of this letter
290506 - to Lauren, NP and PCP in this case. ref SDS B7 NE9N
290507 -
290508 - [On 200104 1533 received letter from Doctor Simpson saying
290509 - will go over everything during the meeting on 200108 1130.
290510 - ref SDS B8 NE9N
290512 - ..
290513 - [On 200107 1308 Jensen called and advised that Doctor
290514 - Simpson ordered EKG. Check in at Module 1 1100 for vitals,
290515 - then get EKG, and return to Module 1 for meeting with
290516 - Doctor Simpson at 1130. ref SDS C1 NE9N
290518 - ..
290519 - [On 200110 0830 Danis said she gave the letter on 191227
290520 - 1243 on delaying EGD scheduled for 200107, ref SDS B5 4R7J,
290521 - to Doctor Lee. ref SDS C5 EX6M
290522 -
290523 -
290524 -
290525 -
290527 - ..
2906 -
2907 -
2908 - Background
2909 -
290901 - On 191206 1425 letter to VAMCSF Cardiology Doctor Simpson, ref SDS A4
290902 - NE9N, notify possible afib symptoms. ref SDS A4 N874
290904 - ..
290905 - On 191207 0927 Doctor Simpson to order ECG [...electrocariogram...]
290906 - Zio test for AFib, after he returns to work following several weeks
290907 - out of the office. ref SDS A5 NE9N
290909 - ..
290910 - On 191213 0849 call from Tina - scheduled install Zio equipment for
290911 - heart monitoring test; meeting room 2A16 on 191216 1230. ref SDS A6
290912 - NE9N
290914 - ..
290915 - On 191216 1220 Exmeralda in Cardiology at VAMCSF installed Zio XT
290916 - heart monitor on left chest; she added 2 plastic tapes to secure the
290917 - unit against fall off in shower and perspiration during hiking.
290918 - ref SDS B0 AO7H
290920 - ..
290921 - On 191214 1138 letter to Doctor Simpson in Cardiology at VAMCSF,
290922 - ref SDS A8 NE9N, reports 8 weeks ago increased hiking route with steep
290923 - hills from 11 to 15 miles per day. ref SDS A8 MX58 About a week ago
290924 - increased hiking to 20+ miles per day in order to improve weight
290925 - control and to raise lipids toward HDL 80. ref SDS A8 MX61 Weight
290926 - increased after pausing hiking due to orthopedic pain left knee and
290927 - both feet, which was solved after receiving oxycodone and gabapentin,
290928 - and applying elastic bandage to left knee. ref SDS A8 MX64 Today,
290929 - before hiking felt chest swaying indicating afib. ref SDS A8 MY30
290930 - Research indicates walking can aid recovery from afib; during hike
290931 - today, will reduce level of effort back to 15 miles per day, and avoid
290932 - steeper hills. ref SDS A8 368M Ask about medication to treat afib.
290933 - ref SDS A8 MY38 Offer to walk with Doctor Simpson to assist recovery
290934 - from hip surgery. ref SDS A8 MY41
290936 - ..
290937 - On 191214 1138 at 1324 letter from Doctor Simpson in Cardiology at
290938 - VAMCSF says to do hiking that has led to symptoms. ref SDS A9 0K4L
290940 - ..
290941 - On 191228 1416 letter to Doctor Simpson notify Zio log reports chest
290942 - pain hiking with elastic bandage on left knee. ref SDS B2 NE9N 1st
290943 - episode hiking 12 miles through Golden Gate Park on 191220, chest pain
290944 - mild lasted on ly .25 miles. Occurred again next day hiking 20 miles
290945 - up Crystal Ranch Road. ref SDS B2 B652 Occurred next day on 191222, so
290946 - stopped at mile .75 and removed elastic bandage from left leg, pain
290947 - ended for rest of 20 mile hike and on subsequent hikes 20 mile past 6
290948 - days. ref SDS B2 B655 Today on 191228, chest pain occurred hiking up
290949 - mild hills without elastic bandage on left leg, so ended hike at 7
290950 - miles. ref SDS B2 B658 HR 150 - should be 45 - 55. ref SDS B2 B662
290951 - Seems like bypass saphenous graft failed under elevated load wearing
290952 - elastic bandage on left knee. ref SDS B2 B665 Pause hiking until hear
290953 - from the doctor. ref SDS B2 B668
290955 - ..
290956 - On 191228 1416 at 1534 letter from Doctor Simpson notifies he will
290957 - order treadmill stress test. ref SDS B2 RK6L
290959 - ..
290960 - On 191228 1416 at 1537 letter to Doctor Simpson notifies will submit
290961 - Zio XT device with afib data on Monday, 191230. ref SDS B2 WO6F
290963 - ..
290964 - On 191229 1243 received letter from Doctor Simpson notifies need to
290965 - get ECG test at VAMCSF before they can schedule treadmill stress test.
290966 - ref SDS B5 NE9N Further says to get care in the ER if chest pain
290967 - recurs at rest. ref SDS B5 NH77
290969 - ..
290970 - On 191229 1243 at 1256 letter to Doctor Simpson asks where and when to
290971 - get ECG test. ref SDS B5 YH8N Notifies so far chest pain has not
290972 - occurred at rest; has only occurred when hiking. ref SDS B5 YA48
290973 - Notifies of EGD procedure in GI Clinic at VAMC Sacramento on 200107,
290974 - and getting MRI studies on feet and knees at VAMCSF on 200109.
290975 - ref SDS B5 YA51
290977 - ..
290978 - On 191229 1243 at 1420 received letter from Doctor Simpson advising
290979 - ECG is done on 2nd floor building 203, and to arrive about 1000.
290980 - ref SDS B5 LG4J Recommends notifying GI Clinic to delay EGD until
290981 - after resolution of current Cardiology issue. ref SDS B5 6H6G
290983 - ..
290984 - On 191229 1243 at 1538 received letter from Doctor Simpson advising
290985 - ECG was done in this case at the end of Oct, so do not need a new one;
290986 - next step is for VA to schedule stress test. ref SDS B5 E17N
290988 - ..
290989 - On 191229 1243 at 1619 sent letter to Jessica on notifying Doctor Lee
290990 - to delay next EGD scheduled on 200107 0730 for a month until 200204
290991 - 0730. ref SDS B5 4R7J
290993 - ..
290994 - On 191229 1243 at 1700 letter thanks Doctor Simpson for advising ECG
290995 - not needed. ref SDS B5 M48J
290997 - ..
290998 - On 191229 1243 at 1946 letter notifies Doctor Simpson that feet
290999 - elevated on footrest seem swelled. Cellphone reports HR 38. That is
291000 - low for me. Don't feel dizzy or light headed; seems like afib event,
291001 - with chest swaying back and forth. ref SDS B5 MH6N
291003 - ..
291004 - On 191229 1243 at 1946 letter notifies Doctor Simpson Zio device was
291005 - mailed to company a day early on 191229. ref SDS B5 UA47
291007 - ..
291008 - On 191230 0930 received call from Tina in Cardiology at VAMCSF
291009 - scheduled treadmill stress test on 200103, ref SDS B6 NE9N, report
291010 - first at 0700 to ASU on 3rd floor Building 200 for IV, then go to
291011 - Neuclear Medicine on ground floor building 203. ref SDS B6 GE5K
291013 - ..
291014 - On 191230 0930 at 0938 received letter from Doctor Simpson in
291015 - Cardiology explaining symptoms reported last night are okay, since not
291016 - dizzy, until after stress test. ref SDS B6 GF3G
291018 - ..
291019 - On 191230 0930 at 0949 received letter Tina in Cardiology confirming
291020 - schedule for stress test on 200103 0700, and submitting instructions
291021 - to prepare for the test. ref SDS B6 Q76I
291023 - ..
291024 - On 191230 0930 at 1021 letter to Doctor Simpson in Cardiology at
291025 - VAMCSF reporting stress test has been scheduled on 200301 0700.
291026 - ref SDS B6 9W6F Reported mild chest pain at rest for 10 minutes, but
291027 - it resolved while writing the letter. ref SDS B6 JY39
291029 - ..
291030 - On 191230 0930 at 1114 received letter from Lauren, NP and PCP in this
291031 - case; she concurs patient should go to ER if chest pain persists at
291032 - rest, and should have a driver. ref SDS B6 2S4N
291034 - ..
291035 - On 191230 0930 at 1117 received call from Aladin who is Lauren's
291036 - assistent in Medical Practice; he indicated Lauren asked him to call
291037 - and get background on chest pain issue. ref SDS B6 578G Explained
291038 - background is reported in correspondence with Doctor Simpson in
291039 - Cardiology, and this has been copied to Lauren. ref SDS B6 5W6J
291041 - ..
291042 - On 191230 0930 at 1135 responded to Lauren citing call from her
291043 - assistent, Aladin, and reporting background on current issue is
291044 - reported in correspondence with Doctor Simpson in Cardiology, who is
291045 - directing the work, and that Lauren has been copied on all
291046 - correspondence. ref SDS B6 659K
291047 -
291048 -
291049 -
291051 - ..
2911 -
2912 -
2913 - Progress
2914 -
291401 - Arrived on campus OA 0520. Went to ASU. Waiting room was closed.
291402 - Walking down the hall met a nurse, who said ASU will open at 0600.
291404 - ..
291405 - Went to 3rd floor lounge. It was used for storage. Went to 2nd
291406 - floor Lounge. Several people were sleeping, so left. Went to 2nd
291407 - floor radiology waiting room. Worked there for 30 minutes, then went
291408 - to...
291410 - ..
2915 -
2916 -
2917 - 0602
2918 -
291801 - Arrived at...
291802 -
291803 - ASU on 3rd floor building 200
291805 - ..
291806 - There were 2 other patients already in ASU. Another arrived a few
291807 - minutes after me.
291809 - ..
291810 - The attendant checked me in for IV procedure at 0700.
291812 - ..
291813 - About 0620, a patient was called to get an IV for a stress test.
291815 - ..
291816 - Was able to work this morning in ASU waiting room for half hour or so.
291817 - Entered results of lab on 191223 1845. ref SDS B1 XC4F Started
291818 - entering results of most recent lab on 191228 1508. ref SDS B3 XC4F
291819 -
291821 - ..
2919 -
2920 -
2921 - 0642
2922 -
292201 - Emma called me into the procedure preparation room. This is where I
292202 - was prepped for angiogram procedure 10 years ago on 091020 0700.
292203 - ref SDS 4 PPXY Last year was prepared for minor back surgery on
292204 - 190204 1200. ref SDS 85 4N5M
292206 - ..
292207 - Emma set an IV for stress test. Asked her to use the left arm and
292208 - location Doctor Tucker uses because it has always been successful,
292209 - reported most recently for 12th PRP treatment on 191009 1500.
292210 - ref SDS 98 0U66
292212 - ..
292213 - Emma got good blood flow on first stick.
292214 -
292216 - ..
2923 -
2924 -
2925 - 0701
2926 -
292601 - After IV was set in ASU, Kathy and I went to Nucleare Medicine room 68
292602 - on ground floor building 203.
292604 - ..
292605 - On arriving there was another patient waiting for a stress test. We
292606 - had seen him in ASU earlier, per above. ref SDS 0 1F5O
292608 - ..
292609 - A doctor saw us through the windo in the door leading to the procedure
292610 - area. He came into the waiting room, and said to use the computer
292611 - check-in system. He further said there would be only a 20 minute
292612 - wait before the stress process would start.
292614 - ..
292615 - Used the computer system to check in. Then took the computer c23 and
292616 - keyboard out to the parking lot and stored them in them in the back of
292617 - the car.
292619 - ..
292620 - Turned out there was more like a 40 minute wait. Could have gotten
292621 - some work done in that time. Instead walked up and down the hallway
292622 - on the ground floor.
292623 -
292624 -
292626 - ..
2927 -
2928 -
2929 - 0752
2930 -
293001 - Finally called for treadmill stress test scheduled by Tina in
293002 - Cardiology on 191230 0930, ref SDS B6 NE9N; and confirmed in her
293003 - letter later that day. ref SDS B6 Q76I
293005 - ..
293006 - This implements planning in Doctor Simpson's letter on 191229 1243,
293007 - ref SDS B5 NE9N, and followed up on 191230 0930. ref SDS B6 GF3G
293009 - ..
293010 - Met Robert. He had called yesterday, to advise about avoiding
293011 - caffeine the day before the test today.
293013 - ..
293014 - Went intially into a preparation room. Robert explained stress
293015 - testing procedure...
293016 -
293017 - 1. Nuclear imaging of chest.
293018 -
293019 - 2. Walking on treadmill testing stress on heart a increasing
293020 - speed and elevation.
293022 - ..
293023 - 3. Nuclear imaging of chest for changes caused by stress test.
293024 -
293026 - ..
293027 - Robert used the IV set by Emma earlier this morning in ASU, per above,
293028 - ref SDS 0 1F9I, to inject contrast medium for first Nuclear imaging.
293030 - ..
293031 - We then walked into another room. Sat in an adjustable chair,
293032 - similar to a dentist's chair. Robert positioned me on the char and
293033 - lowered an large imaging instrument across my chest. It actually
293034 - pressed against the chest. He started the test. It took about 7
293035 - minutes.
293037 - ..
293038 - He changed the position of the chair so I was laying more horizontal.
293039 - Needed pillow for my head. He also placed support under my knees,
293040 - because the left knee, which was treated with high concentration of
293041 - PRP on 190925 1330, ref SDS 97 UV6L; 2 weeks later there was a follow
293042 - up injection treatment with standard concentration of PRP, is still
293043 - stiff laying on a flat surface.
293045 - ..
293046 - This second Nuclear imaging took less time.
293047 -
293049 - ..
2931 -
2932 -
2933 - 0820
2934 -
293401 - Returned to patient waiting room until the treadmill testing room is
293402 - available after a prior patient completes their test.
293404 - ..
293405 - Kathy and I visited. I also walked up and down the hallway again.
293406 -
293408 - ..
2935 -
2936 -
2937 - 0914
2938 -
293801 - Doctor David Anderson called me for treadmill stress test.
293802 -
293803 - Anna prepared me for the test. She shaved hair from the chest and
293804 - attached 4 monitoring nodes to the chest.
293806 - ..
293807 - Layed on a gurney. Anna connected electrical lines to the 4 probes
293808 - and strapped equipment to my right side for tracking heart function
293809 - with EKG equipment. She also applied a cuff to the right arm to get
293810 - blood pressure.
293812 - ..
293813 - During preparation, Doctor Anderson asked about background on chest
293814 - pain issue?
293816 - ..
293817 - Explained patient history hiking 11 - 20+ miles the past 5 years to
293818 - raise HDL 30 at time of CABG x4 on 091022 0700. ref SDS 5 PQWU On
293819 - 191228 1030 stopped hiking because of chest pain after 7 miles,
293820 - reported in case study on 190101 0730. ref SDS 82 4F9L This was
293821 - continuation of chest pain from hiking initially reported 2 weeks
293822 - earlier on 191210. ref SDS 82 YTWS On 191223, after starting another
293823 - hike and feeling chest pain, removed elastic bandage from left knee at
293824 - about mile .75. ref SDS 82 RPVU Did rest of 21 mile hike without
293825 - further chest pain. May have felt afib symptoms later when at rest,
293826 - but not reported in the record. However, the hike on 191228, 6 days
293827 - after hiking 20+ miles per day without having recurrent chest pain,
293828 - then chest pain occurred again on that day. ref SDS 82 SSSY
293829 - Therefore, notified Doctor Simpson, leading to the test today.
293831 - ..
293832 - Stepped onto treadmill. Stress test began slow on flat incline.
293833 - After several minutes, Anna increased the pace and the slope. After
293834 - several more minutes she increased the pace and slope again. The
293835 - slope was fine, but the pace was faster than I normally hike. Still
293836 - seemed to be breathing through my nose.
293838 - ..
293839 - Doctor Anderson said the EKG shows normal sinus heart rhythm. No
293840 - indication of atrial fibrillation, and no indications of stenosis.
293841 -
293842 - [On 200108 1130 follow up EKG prior to meeting with Doctor
293843 - Simpson in Cardiology reported normal sinus heart rhythm
293844 - ref SDS C3 FG8F
293846 - ..
293847 - [On 200110 0830 EKG during EGD procedure and through
293848 - recovery while asleep in GI Clinic at VAMC in Sacramento
293849 - showed normal sinus heart rhythm. ref SDS C5 XU4J
293851 - ..
293852 - Was surprised not feeling any chest pressure nor pain at this faster
293853 - pace and slope. Doctor Anderson said the monitoring equipment was not
293854 - showing evidence of blocked arteries, including bypass grafts. Think
293855 - Anna increased pace and slope again. We continued the test another
293856 - few minutes. Could have switched to running. The doctor seemed to
293857 - say they had enough data to end the test. I felt tired at the pace
293858 - faster than I usually hike, so we stopped the treadmill.
293860 - ..
293861 - [On 200124 0705 cardiac catheterization IVUS angiogram
293862 - found no evidence blocked coronary artery bypass grafts;
293863 - found 1 branch vessel with 80-90% blockage; doctor
293864 - described best condition every seen 10 years after CABG;
293865 - told patient to keep doing whatever he is doing.
293866 - ref SDS C8 ME8G
293868 - ..
293869 - Layed on the gurney for Anna to remove the chest probes. Noticed
293870 - after a few seconds chest pressure and swaying left and right,
293871 - signalling another atrial fibrillation (AF) event. Reported this to
293872 - Doctor Anderson and Anna. They both advised that the monitoring
293873 - equipment was showing AF was occurring.
293874 -
293875 - [...above on 200103 0700 at 0914 research after the meeting
293876 - today, reports older men who exercise at high-intensity
293877 - experience atrial fibrillation after an exercise event,
293878 - e.g., hike, run. ref SDS 0 9G5M
293880 - ..
293881 - So the test indicates mixed results: no failures of bypass graft at
293882 - this time, 10 years after CABG x4 on 091022 0700, ref SDS 5 PQWU; but
293883 - AF occurs on heavy exercise.
293884 -
293885 - [On 200124 0705 cardiac catheterization IVUS angiogram
293886 - found all 4 bypass grafts 100% open ("0" stenosis) 11 years
293887 - after CABG x4 - exceptionally good coronary outcome; found
293888 - 1 branch vessel with 80-90% blockage; doctor described best
293889 - condition every seen 11 years after CABG; told patient to
293890 - keep doing whatever he is doing. ref SDS C8 ME8G
293892 - ..
293893 - The doctor said to leave and have something to eat. Then return in 40
293894 - minutes by 1100 for post-exercise Nucleare imaging.
293896 - ..
293897 - By this time, Doctor Anderson had left the test room, and another
293898 - doctor took his place.
293900 - ..
293901 - Met Doctor R Bamvi Fohtung, Clinical Fellow Cardiology.
293902 -
293903 - [On 200122 0423 Doctor Fohtung visited in hospital room
293904 - while waiting to be treated in Cath Lab with cardiac
293905 - catheritization, working with Doctor Shunk. ref SDS C6 PUXT
293907 - ..
293908 - Doctor Fohtung explained several points for afib patients to track...
293909 -
293910 - 1. Atrial fibrillation (AF) patients should go to ER if heart
293911 - rate goes extremely high.
293912 -
293913 - 2. Patients should go to ER if chest pain occurs at rest.
293915 - ..
293916 - Asked about hiking with afib. The doctor seemed to say there are no
293917 - limitations.
293919 - ..
293920 - He further explained there is a small part of the heart, the sinus
293921 - node (SN) in the right atrium that controls sinus heart rhythm. There
293922 - are other cells in the heart that also trigger heart pumping, however
293923 - the sinus node dominates heart rhythm. When patients suffer AF,
293924 - signals from these other cells overwhelm signals from the sinus node,
293925 - causing erratic pumping of the heart ventricals.
293926 -
293927 -
293928 -
2940 -
SUBJECTS
Atrial Fibrillation AF Research Types Paroxysmal Persistent Long Ter
5803 -
580401 - ..
580402 - Atrial Fibrillation AF Types Paroxysmal Persistent Long Term
580403 -
580404 - After the meeting research found...
580405 -
580406 - Medical News Today
580407 -
580408 - What are the types of atrial fibrillation?
580409 -
580410 - https://www.medicalnewstoday.com/articles/323618.php
580412 - ..
580413 - Atrial fibrillation is a type of arrhythmia, or irregular
580414 - heartbeat, that often causes the heart to beat at an
580415 - abnormally fast rate. Doctors need to determine which type of
580416 - atrial fibrillation a person has to choose the best treatment
580417 - option for them.
580419 - ..
580420 - The three main types of atrial fibrillation (A-fib) are
580421 -
580422 - 1. paroxysmal,
580423 - 2. persistent, and
580424 - 3. long-term persistent.
580426 - ..
580427 - Doctors also categorize A-fib as either valvular or
580428 - nonvalvular.
580430 - ..
580431 - A paroxysm is a sudden episode of a disease or symptom.
580433 - ..
580434 - In paroxysmal A-fib, the irregular rhythm starts suddenly and
580435 - resolves without treatment within 7 days. The episode may only
580436 - last a few seconds before it stops on its own.
580438 - ..
580439 - A person with this type of A-fib will have no noticeable
580440 - symptoms and may not require treatment to control their heart
580441 - rhythm. However, a doctor will often prescribe anticoagulation
580442 - medications to make it harder for the blood to form clots.
580443 - These drugs may help prevent a stroke.
580445 - ..
580446 - Episodes occur intermittently at irregular intervals in
580447 - paroxysmal A-fib.
580449 - ..
580450 - Approximately half of all cases of A-fib are paroxysmal.
580451 -
580452 -
580454 - ..
580455 - Hiking High-intensity Exercise after Age 40 Increases Risks Atrial Fibrillation (AF)
580456 - Overdosing on Exercise Age > 40 Increase Occurance AFib Atrial Fibrillation
580457 -
580458 -
580459 - Another article...
580460 -
580461 - Livescience
580462 -
580463 - 'Overdosing' on Exercise May Be Toxic to the Heart
580464 -
580465 - https://www.livescience.com/53964-extreme-exercise-linked-to-atrial-fibrillation.html
580467 - ..
580468 - By Christopher Wanjek March 07, 2016
580470 - ..
580471 - Slackers, rejoice! You knew you were right all along, didn't
580472 - you? Extreme exercise may be toxic to your heart, according to
580473 - a provocative review of studies set to appear in an upcoming
580474 - issue of the Canadian Journal of Cardiology.
580476 - ..
580477 - Pushing your body to the max day after day can stress your
580478 - heart and raise your risk for a type of abnormal heart rhythm
580479 - called atrial fibrillation, or A-fib, which ultimately can
580480 - lead to heart failure or a stroke, according to the review,
580481 - which analyzed 12 studies on A-fib in athletes and endurance
580482 - runners.
580484 - ..
580485 - Aligns with research on 191206 1425. ref SDS A4 5C6K
580487 - ..
580488 - Article continues...
580489 -
580490 - Extreme exercise is loosely defined as several hours of
580491 - vigorous exercise nearly every day - the type of exercise
580492 - expected from elite athletes and endurance athletes. This much
580493 - exercise could cause atrial fibrillation, according to Doctor
580494 - André La Gerche, a sports cardiologist at the Baker IDI Heart
580495 - and Diabetes Institute in Melbourne, Australia, and the author
580496 - of the new review study.
580498 - ..
580499 - So, how much exercise is too much?
580500 -
580501 - "The science is simply not good enough" to answer that
580502 - question, La Gerche told Live Science. "We have not
580503 - conclusively proven that too much exercise is bad - although
580504 - there are plenty of strong hints - and we are miles from being
580505 - able to know where the cutoff point is."
580506 -
580507 -
580508 -
580510 - ..
580511 - Another article...
580512 -
580513 - MDedge Cardiology
580514 -
580515 - Older recreational endurance athletes face sky-high AF risk
580516 -
580517 - https://www.mdedge.com/cardiology/article/132274/cardiology/older-recreational-endurance-athletes-face-sky-high-af-risk
580519 - ..
580520 - Publish date: February 27, 2017
580521 - By Bruce Jancin
580523 - ..
580524 - EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
580526 - ..
580527 - SNOWMASS, COLO. - Aging men who engage in high-intensity/high
580528 - -volume aerobic exercise have a greater risk of atrial
580529 - fibrillation, N A Mark Estes III, MD, said at the Annual
580530 - Cardiovascular Conference at Snowmass.
580532 - ..
580533 - "I see a very large number of former collegiate or professional
580534 - athletes who come to me in their 40s, 50s, and 60s having
580535 - recently developed A-fib. These are mainly men who've been
580536 - doing high-intensity endurance exercise," said Dr Estes,
580537 - professor of medicine and director of the New England Cardiac
580538 - Arrhythmia Center at Tufts University in Boston.
580540 - ..
580541 - Thirty-day event monitors in these men typically show a pattern
580542 - of very rapid, symptomatic atrial fibrillation (AF) arising at
580543 - peak exercise or, even more commonly, immediately afterwards.
580545 - ..
580546 - This seemed to occur today, after treadmill stress test, per above.
580547 - ref SDS 0 QO5O
580549 - ..
580550 - Article continues...
580551 -
580552 - This is an aspect of the athletic heart syndrome that has gone
580553 - understudied and underappreciated, according to Dr Estes, who
580554 - asserted, "The best available evidence suggests that exercise,
580555 - if excessive, is probably harmful. I know that's heresy."
580557 - ..
580558 - Aligns with research on 191206, ref SDS A4 5C6K, showing aging
580559 - athletes doing high-intensity endurance exercise (hiking/running)
580560 - cause "cardiac remodeling" that leads to paroxysmal atrial
580561 - fibrillation. ref SDS A4 I44M
580563 - ..
580564 - Cardiac remodeling is further explained as enlargement of atrial wall
580565 - in the same article citing left atrial size on 191206 1425.
580566 - ref SDS A4 5767
580567 -
580568 - [On 200122 1414 ECHO ultra sound examination found left
580569 - atrium mildly dilated. ref SDS C7 MW6N
580571 - ..
580572 - [On 200122 0423 Doctor Cara Pellegrinni is a cardio
580573 - Electrophysiologist, who visited while in the hospital
580574 - pending cardiac catheritization, and explained prospects
580575 - for treatment with ablation surgery to recover from
580576 - paroxysmal atrial fibrillation (PAF). ref SDS C6 MN4O
580578 - ..
580579 - He is coauthor of a forthcoming review on this topic to be
580580 - published in the Journal of the American College of Cardiology
580581 - - Electrophysiology. In it, he and his coauthors analyzed more
580582 - than a half dozen published observational epidemiologic studies
580583 - and concluded that the collective data show a classic J-shaped
580584 - curve describes the relationship between physical activity
580585 - level and risk of developing AF, but only in men. The risk is
580586 - roughly 25% lower in men who regularly engage in moderate
580587 - physical activity as defined in American Heart
580588 - Association/American College of Cardiology guidelines, compared
580589 - with that of sedentary men. But the AF risk shoots up
580590 - dramatically in men who focus on intense exercise.
580592 - ..
580593 - "As you get into the high-intensity/high-endurance end of the
580594 - spectrum - typically more than 5 hours per week at greater
580595 - than 80% of peak heart rate - the risk of A-fib increases up
580596 - to 10-fold," according to Dr Estes.
580598 - ..
580599 - "These are new data. They are important data. I think these
580600 - data should impact the way we counsel people about exercise,
580601 - particularly men who like to get into that high-intensity/high-
580602 - endurance range," the cardiologist continued.
580604 - ..
580605 - "You can't tell these people to stop exercising," Dr Estes
580606 - replied. "It's so much a part of their identity. Their
580607 - endorphin levels go down, and they feel depressed."
580609 - ..
580610 - For these patients he stresses what he called "the virtue of
580611 - moderation."
580612 -
580613 - "If they have clinically important symptoms, many times we'll
580614 - decondition them. Often their symptoms will improve, and, in
580615 - some instances, the A-fib will actually clear up and we don't
580616 - even need to go to any medical therapy," Dr Estes said.
580618 - ..
580619 - This "decondition" line of care for AF aligns with research on
580620 - managing patient athletes who develop AF symptoms, to rest, reported
580621 - on 191206 1425. ref SDS A4 D63I
580623 - ..
580624 - Article continues...
580625 -
580626 - His exercise prescription for deconditioning such patients is
580627 - "basically nothing more than a moderate jog, a 10-minute mile.
580628 - They should be able to carry on a conversation, with a peak
580629 - heart rate no more than 60% of their maximum."
580631 - ..
580632 - If drug therapy is required, he favors rate control with beta
580633 - blockers, as these patients generally dont tolerate
580634 - antiarrhythmic agents very well.
580636 - ..
580637 - "Our threshold for AF ablation in these people is quite low
580638 - because the response rate is high in paroxysmal AF in the
580639 - absence of underlying structural heart disease," he added.
580640 -
580641 - [On 200122 0423 Doctor Cara Pellegrinni is a cardio
580642 - Electrophysiologist, who visited while in the hospital
580643 - pending cardiac catheritization, and explained prospects
580644 - for treatment with ablation surgery to recover from
580645 - paroxysmal atrial fibrillation (PAF). ref SDS C6 MN4O
580646 -
580647 - However, nothing here should be construed as saying exercise
580648 - is bad for you. Athletes, even drug-taking cyclists and
580649 - football players, actually live longer than similar
580650 - nonathletes, said Dr. Vogel, a cardiologist at the University
580651 - of Colorado, Denver.
580653 - ..
580654 - Dr Estes was quick to agree.
580655 -
580656 - The cardiovascular benefits of exercise resoundingly
580657 - overwhelm the adverse effects in that small group that
580658 - experiences adverse effects, he said.
580659 -
580661 - ..
580662 - Another article...
580663 -
580664 - PMC
580665 - ATM Annals of Trnaslational Medicine
580666 -
580667 - Ann Transl Med. 2017 Jan; 5(1): 24.
580668 - doi: 10.21037/atm.2017.01.02
580670 - ..
580671 - PMCID: PMC5253281
580672 - PMID: 28164109
580673 -
580675 - ..
580676 - Exercising recommendations for paroxysmal AF in young and
580677 - middle-aged athletes (PAFIYAMA) syndrome
580678 - ---------------------------------------------------------
580679 -
580680 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253281/
580681 -
580682 - We have recently described a new syndrome: strenuous endurance
580683 - exercise-related atrial fibrillation (AF) under the acronym of
580684 - ?paroxysmal AF in young and middle-aged athletes?
580685 - (?PAFIYAMA?). Provided that other risk factors for AF and
580686 - underlying conditions have been excluded (1), the diagnostic
580687 - criteria for this syndrome entail a number of conditions,
580688 - classified as major and minor. An enhanced risk of AF has been
580689 - clearly documented in endurance athletes (top-class, elite and
580690 - recreational) (2-5), and such risk typically ranges between
580691 - 1.2- to 15-fold compared to the general, sedentary population
580692 - (the better cardiovascular fitness, the higher incidence of AF)
580693 - (6-11).
580695 - ..
580696 - Anecdotally, the last author of this manuscript (F
580697 - Sanchis-Gomar), a physician himself, was a competitive
580698 - endurance cyclist for 10 years and a paradigm of PAFIYAMA
580699 - syndrome. Briefly, he has suffered from left atrial
580700 - enlargement and a first episode of paroxysmal AF early in life,
580701 - at the age of 26 years. After 5 years of recurrent episodes,
580702 - pulmonary vein isolation by trans-venous cryoablation seemed to
580703 - be the only successful treatment. Although he has suffered no
580704 - more AF episodes since then, high-intensity exercise would be
580705 - no longer advisable.
580707 - ..
580708 - Question is whether the doctor has followed this advise, and if not,
580709 - has he suffered recurrent PAF after high-intensity exercise??
580711 - ..
580712 - Article continues...
580713 -
580714 - The real incidence of PAFIYAMA syndrome may be much higher than
580715 - expected, and the cases that have been diagnosed so far may
580716 - only represent the "tip of the iceberg". Nevertheless, the
580717 - potential clinical implications and the impact on patients?
580718 - lifestyle at diagnosis are both meaningful, so that PAFIYAMA
580719 - syndrome may soon become a public healthcare issue if one
580720 - considers the large number of subjects regularly performing
580721 - endurance exercise (i.e., medium-distance running, cycling,
580722 - mountain walking, etc.). In general, these patients have no
580723 - information about the best management of their condition, and
580724 - several doubts immediately emerge at diagnosis: Will I be able
580725 - to continue training or practicing physical exercise?
580727 - ..
580728 - If yes, How? How much? What type, frequency and intensity?
580730 - ..
580731 - To date, exercising recommendations for these patients are
580732 - totally lacking, so putting these subjects at large risk of
580733 - developing cardiac rhythm disturbances needing to be managed by
580734 - invasive therapies, i.e., oral anticoagulation, antiarrhythmic
580735 - drug therapy (flecainide, propafenone, amiodarone or sotalol,
580736 - among others) or ablation. Taking together the aforementioned
580737 - considerations, and based on our previous experience, we
580738 - purpose the following preliminary recommendations:
580739 -
580740 - 1. The first and obvious recommendation is increasing public
580741 - awareness of this syndrome;
580743 - ..
580744 - 2. Do not allow that PAFIYAMA syndrome impedes you from
580745 - exercising and living a fulfilling and active life;
580747 - ..
580748 - 3. Modulation of physical exercise seems the best approach for
580749 - significantly limiting the number and the intensity of the
580750 - crises, particularly in those subjects with recent
580751 - diagnosis of PAFIYAMA syndrome with atrial dilation;
580753 - ..
580754 - 4. Regular exercise may be safe in patients with PAFIYAMA
580755 - syndrome, although it depends of individual circumstances,
580756 - i.e., frequency, duration, precipitating factors, symptoms
580757 - associated, modes of termination of AF, among others
580758 - (cardiologist with sports medicine expertise should be
580759 - consulted);
580761 - ..
580762 - 5. Discussion with a cardiologist may be advisable about the
580763 - ?pill-in-the-pocket? strategy while exercising.
580764 - Importantly, following the ESC Guidelines on AF (12), it
580765 - should be kept in mind that patients should refrain from
580766 - exercise while AF episode persist and/or resting for at
580767 - least 6?8 hours after having taken the drug (i.e., two
580768 - half-lives of the antiarrhythmic drug), either flecainide
580769 - or propafenone;
580771 - ..
580772 - 6. Light to moderate intensity endurance exercise has been
580773 - shown to be even protective for chronic AF (13).
580774 - Accordingly, a minimum of 150 min/wk of light to
580775 - moderate-intensity aerobic exercise is beneficial, and
580776 - hence, recommended;
580778 - ..
580779 - 7. Aerobic exercise training program should be tailored
580780 - regarding intensity, time (duration) and frequency. The
580781 - intensity and the duration of exercise seems to be critical
580782 - in exercise-induced atrial remodeling (14), i.e., more
580783 - training, more atrial remodelation. Accordingly, we
580784 - recommend adapting/reducing intensity, duration and
580785 - frequency of aerobic training in those patients recently
580786 - diagnosed. One option to easily calculate the optimal
580787 - intensity is decreasing a step of those stages described
580788 - below: light [<3 metabolic equivalents (METs)], moderate
580789 - (3?6 METs), and vigorous (>6 METs).
580791 - ..
580792 - 8. In any event, the training intensity should not exceed 85%
580793 - of the peak heart rate (HR). As for duration (time) and
580794 - frequency, 200 min/wk and 3?5 days/wk are the maximum
580795 - recommended because its demonstrated benefits (15);
580797 - ..
580798 - Patient exercised at this level for 6 years (2003 - 2009), and this
580799 - yielded HDL 30, at the time patient required CABG x4.
580801 - ..
580802 - After heart surgery on 091022 0700, ref SDS 5 MO5O, patient continued
580803 - hiking 200 minutes/week and 4 - 6 days/week. HDL was raised to 40s.
580804 - Research indicated hiking could raise HDL > 60, which would regress
580805 - stenosis/plaque in blood vessels rapidly. 131125 0005, ref SDS 17 6S7F
580806 - Also reported in the same record. ref SDS 17 XY7L Explanation of
580807 - "reverse cholesterol transport" with HDL and EPCs is in another
580808 - article. ref SDS 17 HG7N
580810 - ..
580811 - In Welch, this has been achieved hiking 200 - 400 miles per month
580812 - which takes 180 - 300 minutes per day.
580814 - ..
580815 - Article continues...
580816 -
580817 - 9. Aerobic exercise should be performed in sessions of no less
580818 - than 10 minutes of duration;
580820 - ..
580821 - 10. A HR monitor should always be employed: if the pulse is too
580822 - high, symptoms are more likely. A reliable approach to
580823 - bring back the pulse rate should be identified;
580825 - ..
580826 - Would like to get HR monitor that tracks when PAF occurs and when
580827 - sinus restores.
580829 - ..
580830 - Article continues...
580831 -
580832 - 11. When exercise causes palpitations, chest pain, severe
580833 - breathlessness or exhaustion, it may be better to cease
580834 - physical activity and refer to a cardiologist;
580836 - ..
580837 - Patient does not experience these symptoms.
580839 - ..
580840 - Article continues...
580841 -
580842 - 12. Muscle-strengthening activities involving the bulk of the
580843 - muscles (legs, arms, back, chest, abdomen, and shoulders)
580844 - are highly recommended (typically, 2 days/wk);
580846 - ..
580847 - 13. Alcoholic and/or energy drinks consumption should be always
580848 - avoided, especially during exercise. Both are risk factors,
580849 - alone or in combination;
580851 - ..
580852 - 14. These recommendations may be obviously challenging and
580853 - improbably (if not impossible) to be followed by
580854 - professional athletes. In such cases, antiarrhythmic drug
580855 - and/or ablation may be the first line therapy counseled.
580857 - ..
580858 - Supranational collaborative studies should also be urgently
580859 - planned to accurately defining the real incidence of PAFIYAMA
580860 - syndrome in exercising subjects, meant to identifying reliable
580861 - predictive factors and diagnostic biomarkers (16), which may
580862 - help to timely identifying a subset of subjects at increased
580863 - risk for this condition. This would ultimately allow to
580864 - safeguard athletes? health and prevent unnecessary healthcare
580865 - expenditures in a world with increasingly limited resources.
580866 -
580867 -
580868 -
580869 -
5809 -
SUBJECTS
Paroxysmal Atrial Fibrillation AF Lowers HDL LDL Cholesterol
7103 -
710401 - ..
710402 - Paroxysmal Atrial Fibrillatrion Lowers HDL and LDL Cholesterol
710403 -
710404 -
710405 - Another article...
710406 -
710407 - PMC
710409 - ..
710410 - Medical Science Monitor
710412 - ..
710413 - Med Sci Monit. 2018; 24: 3903?3908.
710415 - ..
710416 - Published online 2018 Jun 9. doi: 10.12659/MSM.907580
710418 - ..
710419 - PMCID: PMC6024732
710420 - PMID: 29885277
710422 - ..
710423 - Association Between Blood Lipid Profiles and Atrial
710424 - Fibrillation: A Case-Control Study
710425 -
710426 -
710427 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024732/
710428 -
710429 - Abstract
710430 - Background
710432 - ..
710433 - Dyslipidemia is the most frequent comorbidity in patients with
710434 - cardiovascular disease. However, studies examining the
710435 - relationship between blood lipid profiles and AF have produced
710436 - inconsistent results.
710438 - ..
710439 - Material/Methods
710441 - ..
710442 - A total of 651 patients were enrolled into 3 groups: Healthy
710443 - controls (n=64), Paroxysmal AF (PAF; n=270), and Continuous AF
710444 - (CAF; n=317). All enrolled patients underwent routine baseline
710445 - 12-lead electrocardiography (ECG) and 24-h dynamic ECG along
710446 - with blood testing, which included the following: complete
710447 - metabolic panel, hepatic function, renal function, circulating
710448 - thyroxine, fasting high-density lipoprotein cholesterol
710449 - (HDL-C), low-density lipoprotein cholesterol (LDL-C),
710450 - triglycerides (TG), and total cholesterol (TC).
710452 - ..
710453 - Results
710455 - ..
710456 - Patients with AF had significantly higher levels of
710457 - triglycerides (TG), lower levels of LDL-C-c, and lower levels
710458 - of HDL-C (p<0.05). TC (OR 0.979, p<0.9247) and TG (OR 0.945,
710459 - p<0.6496) were negatively and linearly associated with PAF,
710460 - while TG (OR 0.807, p=0.2042), LDL-C (OR 0.334, p=0.0036), and
710461 - HDL-C (OR 0.136, p=0.0002) were negatively and linearly
710462 - associated with CAF.
710464 - ..
710465 - Conclusions
710467 - ..
710468 - Compared to healthy controls, patients with AF had lower blood
710469 - lipid levels, especially LDL-c and HDL-c levels.
710470 - Hypolipoproteinemia may increase patient susceptibility to
710471 - developing AF.
710472 -
710473 - [On 191228 1508 significant drop in lipid levels correlates
710474 - with onset and worsening of paroxysmal atrial fibrillation
710475 - (PAF). ref SDS B4 5C7M
710477 - ..
710478 - Background
710480 - ..
710481 - The annual prevalence of atrial fibrillation (AF) has steadily
710482 - increased over the past 75 years, especially in the younger
710483 - population. By 2050, the overall prevalence of AF is expected
710484 - to triple that which was observed in 2006 [1]. In addition,
710485 - the incidence of AF-related ischemic stroke has tripled for
710486 - patients ?80 years of age over the past 25 years despite the
710487 - introduction of anticoagulants; these numbers are expected to
710488 - triple again by 2050.
710490 - ..
710491 - Improved prevention strategies for AF and its sequelae remain
710492 - an important global public health priority [2]. Studies have
710493 - shown that age, sex, obesity, cardiovascular disease, and
710494 - diabetes mellitus are closely related to the occurrence of
710495 - atrial fibrillation [3,4]. Dyslipidemia is a major contributor
710496 - to the development of atherosclerosis and coronary heart
710497 - disease, both of which are closely related to the development
710498 - of AF. High levels of low-density lipoprotein cholesterol
710499 - (LDL-C) and low levels of high-density lipoprotein cholesterol
710500 - (HDL-C) are also closely associated with the eventual
710501 - development of coronary artery disease [5]. The role of
710502 - dyslipidemia in the development of other cardiac conditions,
710503 - such as atrial fibrillation (AF), is less clear. Few
710504 - longitudinal studies have been published on this topic, and
710505 - these studies have produced inconsistent results [6?9].
710507 - ..
710508 - One prior study found that chronically elevated plasma
710509 - concentrations HDL-C may increase the risk of AF [10]. The
710510 - purpose of the present study was to investigate the
710511 - relationship between blood lipid profiles and the corresponding
710512 - increased risk of AF.
710514 - ..
710515 - What level is "chronically elevated" HDL that causes AF?
710516 -
710517 - Discussion
710518 -
710519 - Our results showed that low serum levels of LDL-C and HDL-C
710520 - were present in patients with AF, irrespective of the type of
710521 - AF. For PAF, low serum levels of TC and TG were found, whereas
710522 - low serum levels of TG, LDL-C, and HDL-C were found in patients
710523 - with CAF. These findings suggest that hypolipoproteinemia may
710524 - be an independent risk factor for both PAF and CAF.
710526 - ..
710527 - This correlates with lab on 191228, where TC, TG, LDL and HDL all
710528 - fell dramatically from lab 5 days earlier, despite hiking at high
710529 - intensity level (i.e., 19 miles per day).
710530 -
710531 -
710532 - Factors such as advancing age, female sex, obesity, metabolic
710533 - syndrome, and hypertension are well-documented risk factors
710534 - for the development of AF, suggesting that a strong link may
710535 - exist between atherosclerosis and AF [10,27]. In our study,
710536 - blood lipid levels, especially LDL-C levels, were negatively
710537 - associated with cardiovascular diseases, although these
710538 - relationships were found to be the opposite in AF. There are
710539 - several possible mechanisms to explain this phenomenon.
710540 - Firstly, epidemiologic studies have demonstrated significant
710541 - increases in the prevalence of AF with increasing age [1],
710542 - while other studies have found that blood lipid levels
710543 - generally decrease in patients older than 60 years.
710545 - ..
710546 - A separate study reported that increasing age and decreasing
710547 - blood lipid level may result in AF because of left atrial
710548 - enlargement, abnormal SA node conduction, and degeneration of
710549 - the myocardium [28].
710551 - ..
710552 - Secondly, hyperthyroidism is a well-known independent risk
710553 - factor for AF. Thyroxine stimulates cholesterol synthesis by
710554 - inducing HMG-CoA activity, promotes liver cholesterol
710555 - breakdown, and eventually lowers circulating levels of LDL-C.
710557 - ..
710558 - Thirdly, a previous study confirmed that chronic inflammation
710559 - and oxidative stress are also important risk factors for AF
710560 - [29]. Lipoproteins (HDL-C and LDL-C) can be anti-inflammatory,
710561 - particularly against bacterial endotoxins within the systemic
710562 - circulation [7,8,29,30].
710564 - ..
710565 - Fourthly, because low plasma levels of HDL-C have been shown to
710566 - predispose to hypertrophic cardiomyopathy [31?34], and
710567 - therefore AF, abnormally low baseline levels of HDL-C may have
710568 - indirectly produced an increased risk of AF due to structural
710569 - changes in the atria rather than changes in lipid profiles.
710571 - ..
710572 - Fifthly, the inverse association between LDL-C levels and AF
710573 - has been attributed to the stabilizing effect of cholesterol on
710574 - myocardial cell membranes, which may impact ion channel density
710575 - and function and other aspects of membrane excitability
710576 - [35?37]. Another prospective study with 23 738 healthy
710577 - subjects found that the negative correlation between LDL-C and
710578 - AF is also found in other atherogenic lipoproteins, suggesting
710579 - that these correlations are unlikely to be mediated by direct
710580 - cholesterol effects [25]. There are several causes that could
710581 - explain inconsistent results between studies, such as lack of
710582 - adjustment for confounding risk factors, differences in
710583 - population and regional characteristics, and the choice of
710584 - covariables in models.
710586 - ..
710587 - Conclusions
710589 - ..
710590 - When compared to healthy controls, patients with AF had lower
710591 - blood lipid levels, especially LDL-c and HDL-c levels.
710592 - Hypolipoproteinemia may increase patient susceptibility to
710593 - developing AF.
710594 -
710595 - [On 191228 1508 significant drop in lipid levels correlates
710596 - with onset and worsening of paroxysmal atrial fibrillation
710597 - (PAF). ref SDS B4 5C7M
710599 - ..
710600 - Another article...
710601 -
710602 - PubMed
710603 -
710604 - Copyright 2000 S. Karger AG, Basel
710605 -
710606 - PMID: 10640793 DOI: 10.1159/000006942
710608 - ..
710609 - Cholesterol paradox in patients with paroxysmal atrial
710610 - fibrillation
710611 - ------------------------------------------------------
710612 -
710613 - https://www.ncbi.nlm.nih.gov/pubmed/10640793
710614 -
710615 - Abstract (only)
710617 - ..
710618 - The associations among lipids, lipoproteins and PAF were
710619 - examined in a case-control study, in which cases and controls
710620 - were defined as those with/without definite ECG-detectable
710621 - PAF, respectively. CHD patients were excluded from the study.
710623 - ..
710624 - In conclusion, low serum levels of TC and TG were found in PAF
710625 - patients, while reduced HDL-C may cause PAF.
710626 -
710627 -
710628 -
7107 -
SUBJECTS
Atrial Fibrillation Recurs 3+ Months After Ablation 20% - 40% Resear
9003 -
900401 - ..
900402 - Another article...
900403 -
900404 - NCBI
900405 - PMC
900406 -
900407 - Journal of Atrial Fibrillation
900408 -
900409 - 2016 June - July; 9(1): 1427
900410 - Published online 2016 June 30. doi
900412 - ..
900413 - PMCID PMC5089515
900414 - PMID: 27909521
900416 - ..
900417 - Recurrent Atrial Fibrillation After Catheter Ablation: Considerations
900418 - For Repeat Ablation And Strategies To Optimize Success
900419 -
900420 - Andrew E Darby, MD, FHRS
900421 -
900422 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089515/#idm140499477397840title
900424 - ..
900425 - Abstract
900427 - ..
900428 - Recurrent AF after catheter ablation occurs in at least 20 to
900429 - 40% of patients. Repeat ablation is primarily considered for
900430 - those with symptomatic AF recurrences (often drug-refactory)
900431 - occurring at least 3 months or more post-ablation. Pulmonary
900432 - vein reconnection is almost universally encountered, and
900433 - repeat isolation of electrically connected pulmonary veins
900434 - should be the primary ablation strategy. Beyond repeat PVI and
900435 - possible ablation of non-PV triggers, there is little to no
900436 - evidence that additional substrate modification improves
900437 - outcomes. In addition to repeat ablation, it is critical to
900438 - address and treat comorbid conditions which increase
900439 - arrhythmia risk post-ablation. Specifically, obesity,
900440 - hypertension, and sleep-disordered breathing should be
900441 - targeted and modified to increase the likelihood of success.
900443 - ..
900444 - Keywords: Atrial Fibrillation Ablation, Repeat Catheter
900445 - Ablation, Pulmonary Vein Reconnection, Atrial Fibrillation
900446 - Lifestyle Modification
900448 - ..
900449 - Introduction
900451 - ..
900452 - Catheter ablation of atrial fibrillation (AF) has become an
900453 - increasingly frequent procedure per-formed in electrophysiology
900454 - laboratories worldwide. It is most often performed for
900455 - maintenance of sinus rhythm in patients with symptomatic,
900456 - drug-refractory paroxysmal or persistent AF or as an initial
900457 - rhythm control strategy in lieu of anti-arrhythmic drug therapy
900458 - in patients with paroxys-mal AF.[1] The increased efficacy of
900459 - catheter ablation over anti-arrhythmic drug therapy to
900460 - main-tain sinus rhythm has been demonstrated in a number of
900461 - randomized, controlled trials and meta-analyses.[2-12]
900462 - Unfortunately, recurrent atrial fibrillation or atrial
900463 - tachycardia after an index AF ab-lation procedure results in
900464 - repeat ablation in 20 to 40% of patients.[13] A number of
900465 - dilemmas are presented by patients with recurrent AF after
900466 - catheter ablation: Which patients should be considered for a
900467 - second procedure and when should repeat ablation be performed?
900468 - What is the optimal approach to ablation in a patient
900469 - undergoing a repeat procedure? What additional interventions
900470 - may reduce the likelihood of recurrence post-ablation? The
900471 - purpose of this review is to summarize the available relevant
900472 - data surrounding repeat ablation for atrial fibrillation and
900473 - identify areas needing further investigation.
900475 - ..
900476 - Rationale For Repeat Catheter Ablation
900478 - ..
900479 - The primary ablation strategy for AF is creation of electrical
900480 - isolation of all pulmonary veins (PVs) with demonstration of
900481 - bidirectional (entrance and exit) conduction block
900482 - post-ablation.[1] The most commonly reported finding at repeat
900483 - catheter ablation is resumption of conduction to (and from)
900484 - previously targeted pulmonary veins.[14-17] Durable PV
900485 - isolation (PVI) may be so difficult to achieve after a single
900486 - AF ablation that some have reported recovery of conduction in 1
900487 - or more PVs in all patients undergoing repeat ablation.[18-19]
900488 - Amazingly, pulmonary vein reconnection has been identified in
900489 - up to 92% of patients undergoing a third or greater
900490 - procedure.[20] Electrical isolation of the pulmonary veins is
900491 - more likely to be permanent after a repeat ablation procedure.
900492 - Consequently, one rationale for repeat ablation is to ?finish?
900493 - what was started during the first procedure and attempt to
900494 - ensure permanent electrical isolation of all pulmonary veins.
900495 - In addition, studies have shown incremental success with higher
900496 - rates of long-term freedom from AF with repeat ablation
900497 - possibly resulting from a higher rate of permanent PV
900498 - isolation.[12,19,21]
900500 - ..
900501 - Timing Of Repeat Catheter Ablation
900503 - ..
900504 - Among patients with recurrent arrhythmias post-ablation, there
900505 - are a number of considerations impacting patient management.
900506 - First, the patient?s symptoms should heavily influence
900507 - subsequent management strategies. Patients with minimal to no
900508 - symptoms who are adequately rate-controlled may be suitable
900509 - for a rate-control and anticoagulation strategy rather than
900510 - continuing to pursue sinus rhythm. The timing of recurrence
900511 - is also important when considering a repeat procedure.
900512 - Recurrent arrhythmias within the first two to three months
900513 - post-ablation may resolve spontaneously or not recur after
900514 - cardioversion so a repeat procedure is often deferred in this
900515 - timeframe.[1] The mechanism of recurrent arrhythmia (AF versus
900516 - atrial tachycardia/flutter) may also play a role in
900517 - decision-making. Patients typically considered for repeat
900518 - ablation have recurrent, symptomatic AF more than 3 months
900519 - after initial ablation. Early repeat ablation may be
900520 - considered for recurrent arrhythmia (particularly atrial
900521 - tachycardia or atrial flutter) that is difficult to manage
900522 - medically and recurs despite cardioversion. Recurrent atrial
900523 - flutter or tachycardia post-ablation may be better managed
900524 - with a repeat procedure as such arrhythmias can be difficult
900525 - to rate control, frequently recur after cardioversion, and are
900526 - often due to gaps in areas of prior ablation and have a
900527 - relatively high success rate with repeat ablation. The focus
900528 - of this re-view is recurrent atrial fibrillation after
900529 - catheter ablation and not management of post-ablation atrial
900530 - flutter or tachycardia.
900532 - ..
900533 - An additional consideration is the likelihood of success with
900534 - repeat catheter ablation. Factors shown to negatively impact
900535 - recurrence rates include left atrial properties (volume,
900536 - fibrosis), associated systemic disease (hypertension,
900537 - obstructive sleep apnea), concomitant heart disease
900538 - (particularly mitral valve disease and hypertrophic
900539 - cardiomyopathy), and duration of atrial fibrillation (e.g.,
900540 - longstanding persistent AF has a higher recurrence rate than
900541 - paroxysmal AF, [table 1]).[1] Patients with multiple negative
900542 - prognostic factors for recurrence perhaps are best managed
900543 - medically (if possible) rather than exposed to the risks of
900544 - ablation with low likelihood of success. It would not be
900545 - appropriate to pursue repeat ablation in asymptomatic patients
900546 - with the hope of obviating need for long-term oral
900547 - anticoagulation when the CHA2DS2-VASc score indicates a
900548 - moderate to high risk of stroke. Repeat catheter ablation is
900549 - most commonly accepted for patients with well-documented
900550 - arrhythmia recurrences who are symptomatic (despite a trial of
900551 - anti-arrhythmic drug therapy) and are more than 3 months
900552 - removed from the initial proce-dure.[1]
900554 - ..
900555 - Table 1
900557 - ..
900558 - Risk factors for atrial fibrillation recurrence after ablation
900559 -
900560 - Age Risk factors for atrial fibrillation recurrence after ablation
900562 - ..
900563 - AF duration (Longstanding persistent > persistent > paroxysmal)
900564 - and type
900566 - ..
900567 - Cardiac Left atrial dilatation; left ventricular function; hypertrophic
900568 -
900569 -
900570 - structural cardiomyopathy; valvular heart disease
900571 - changes
900572 -
900573 - ..
900574 - Hypertension; obesity; obstructive sleep apnea/sleep
900575 - Clinical disordered breathing; metabolic syndrome; thyroid disease
900576 - features
900577 -
900579 - ..
900580 - Strategies For Repeat Catheter Ablation
900582 - ..
900583 - When AF recurs after PVI and PV reconnection is identified at
900584 - repeat ablation it seems prudent to re-isolate any reconnected
900585 - PVs. If the PVs have reconnected, however, how does one know
900586 - that PV reconnection is the cause of recurrent arrhythmia?
900587 - Going a step further, should additional ablation beyond repeat
900588 - PVI be performed? If the PVs have not reconnected what
900589 - ablation strategy should be employed? Considerations include
900590 - using different energy deliv-ery sources to repeat PVI (e.g.,
900591 - using cryoablation if radiofrequency was used initially),
900592 - creation of linear lesions in the left and/or right atrium,
900593 - isolation of the superior vena cava or coronary si-nus,
900594 - ablation at atrial sites with fractionated electrograms during
900595 - AF, ablation at sites of vagal in-puts to the atria, and
900596 - targeting non-PV triggers ([figure 1]). It is important to
900597 - note there are no randomized controlled trials addressing
900598 - these issues in patients with recurrent AF. The data
900599 - re-porting outcomes with repeat AF ablation are derived from
900600 - retrospective and observational co-hort and case-control
900601 - studies. The most recent consensus statement on catheter
900602 - ablation of AF suggests the first step when performing a
900603 - repeat procedure is to check each PV for electrical
900604 - reconduction followed by reisolation of PVs as necessary as
900605 - there is data showing reasonably good outcomes with repeat PVI
900606 - alone.[1,15] If there is little to no evidence of PV
900607 - reconduction, non-PV foci should be sought and consideration
900608 - should be given to modification of the ar-rhythmogenic
900609 - substrate although no particular linear lesion set or
900610 - alternative ablation approach is recommended in the
900611 - guidelines.[1]
900613 - ..
900614 - Figure 1
900615 -
900616 - ...[shows 3 images (labeled a, b and c) of oblong circles with
900617 - lines signifying lesions on pulmonary veins.
900619 - ..
900620 - Potential ablation strategies during repeat AF procedures: a)
900621 - repeat pulmonary vein isolation only with confirmation of
900622 - entrance and exit block from each vein; b) pulmonary vein
900623 - isolation with ad-ditional linear lesions (posterior wall
900624 - isolation with linear lesions connecting the superior and
900625 - infe-rior pulmonary veins; mitral isthmus ablation; +/- right
900626 - atrial linear lesions); c) pulmonary vein iso-lation and
900627 - ablation of non-pulmonary vein triggers (i = coronary sinus;
900628 - ii = LA posterior wall (and left atrial appendage, not
900629 - pictured); iii = fossa ovalis/interatrial septum; iv = crista
900630 - terminalis/right atrium; v = superior vena cava)
900631 -
900633 - ..
900634 - Techniques To Enhance Durability Of Pulmonary Vein Isolation
900636 - ..
900637 - As pulmonary vein reconnection is near universal among patients
900638 - undergoing repeat ab-lation, it is prudent when re-isolating
900639 - PVs to employ techniques shown to increase the likelihood of
900640 - durable PVI. This is more likely to occur with the delivery of
900641 - contiguous, transmural lesions regardless of the energy deliver
900642 - system. It is postulated that improved acute lesion delivery
900643 - will translate to enhanced long-term outcomes. A number of
900644 - procedural techniques have been ad-vocated to improve the
900645 - likelihood of transmural lesion formation thereby increasing
900646 - the likelihood of durable PVI and (hopefully) freedom from
900647 - arrhythmia. General anesthesia compared to con-scious sedation
900648 - lowers reconnection rates among patients with recurrences who
900649 - underwent re-peat ablation (19 vs 42%).[22] Efforts to minimize
900650 - respiratory motion, particularly using high-frequency jet
900651 - ventilation, have also been shown to improve freedom from AF
900652 - at 1 year post-ablation.[23] Catheter stability may be further
900653 - enhanced by manipulation through a steerable sheath, and use
900654 - of such technology has been shown to improve short-term AF
900655 - freedom rates post-ablation.[24] Ablation using multi-pore
900656 - irrigated tip catheter technologies results in lower
900657 - peri-procedural PV reconnection rates compared to standard
900658 - irrigated tip catheters.[25] Contact force sensing
900659 - technologies provide continuous feedback regarding catheter
900660 - contact force and stability, and ablating with a contact force
900661 - > 10 grams is associated with a lower likelihood of acute
900662 - pul-monary vein reconnection and improved outcomes at 1
900663 - year.[26,27] Pulmonary vein reconnection rates were no
900664 - different between standard radiofrequency ablation (using an
900665 - open-irrigation RF catheter) and the first generation
900666 - cryoballoon system among patients presenting for repeat
900667 - abla-tion in a small study of 50 patients with paroxysmal
900668 - AF.[28]
900670 - ..
900671 - Rigorous testing to confirm bidirectional (entrance and exit)
900672 - conduction block post-ablation improves long-term success
900673 - rates.[29] A reasonable post-ablation wait period to assess
900674 - for acute PV electrical reconnection seems to improve
900675 - outcomes, and a study of 181 patients sug-gests waiting at
900676 - least 35 minutes after acute isolation is the optimal
900677 - observation time.[30]
900679 - ..
900680 - Assessing for non-capture along the circumferential lesion set
900681 - is one method for testing the integ-rity of the ablation line,
900682 - and re-ablating sites of pace capture resulted in greater AF
900683 - freedom (83 vs 52%) at 1-year follow-up in a prospective
900684 - study.[31] Administration of adenosine to assess for dormant
900685 - conduction can be useful for identifying gaps in the ablation
900686 - line and pulmonary veins with higher risk of reconnection.[32]
900687 - Additional ablation of acutely reconnected pulmonary veins
900688 - after adenosine administration may or may not improve
900689 - long-term outcomes as data is mixed.[33,34]
900691 - ..
900692 - It is important to note that none of these approaches has been
900693 - systematically studied to determine their true impact on
900694 - promoting durable pulmonary vein isolation. It is also worth
900695 - noting that absence of AF recurrence does not necessarily
900696 - indicate permanent pulmonary vein isola-tion, and PV
900697 - reconnection noted at repeat procedure may be incidental and
900698 - not causative with regard to arrhythmia recurrence. That being
900699 - said our initial approach during a repeat AF ablation
900700 - procedure is to first and foremost ensure pulmonary vein
900701 - isolation by ablating any reconnected pulmonary veins and
900702 - confirming bidirectional conduction block ([figures 2] and
900703 - [?[3]).3]). Our standard approach is to use a contact force
900704 - sensing catheter within a steerable sheath guided by an
900705 - elec-troanatomic mapping system and intracardiac
900706 - echocardiography. A circular mapping catheter is used to
900707 - confirm bidirectional conduction block, and adenosine is
900708 - routinely administered with re-ablation of any sites
900709 - exhibiting dormant conduction. A comprehensive EP study is
900710 - then per-formed to assess for other inducible arrhythmias or
900711 - non-PV triggers with additional ablation as needed.
900712 -
900714 - ..
900715 - Figure 2
900716 - Rational approach to a repeat AF ablation procedure
900718 - ..
900719 - PVs electrically isolated
900720 -
900721 - No Re-isolate PVs and confirm
900722 - entrance and exit block
900723 - Yes
900724 -
900725 -
900727 - ..
900728 - Non-PV trigger(s)?
900729 -
900730 - Yes Ablate non-PV
900731 - triggers(s)
900732 - No
900733 -
900734 -
900736 - ..
900737 - Inducible atrial flutter?
900738 -
900739 - Yes
900740 - Ablate atrial flutter
900741 -
900742 - No
900743 -
900745 - ..
900746 - Anatomical non-PV ablation Figure 2
900747 -
900748 -
900750 - ..
900751 - Figure 3
900752 -
900753 - ...[shows imate of heart with pulmonary veins and arteries
900754 - protruding...]
900755 -
900757 - ..
900758 - Illustrative case of a 47 year-old man undergoing repeat
900759 - catheter ablation for atrial fibrillation. Paroxysmal AF had
900760 - been diagnosed 2 years prior, and the patient underwent
900761 - catheter ablation approximately 12 months earlier at another
900762 - institution. He was AF free for nearly 9 months but then began
900763 - having recurrent symptoms with paroxysmal AF documented. a)
900764 - baseline rhythm at the start of the procedure under general
900765 - anesthesia; frequent short bursts of AF noted; b) dis-played
900766 - are 3 surface ECG leads and intracardiac recordings from a
900767 - decapolar catheter in the coronary sinus (labeled cs 9,10
900768 - through cs 1,2) and a circular mapping catheter (labeled Las
900769 - 19,20 through Las 1,2) placed in the right superior pulmonary
900770 - vein; note the delayed pulmonary vein potential (star) and
900771 - initiation of AF triggered by spontaneous firing from the RSPV
900772 - (asterisk); the other 3 PVs remained electrically isolated
900773 - from the prior procedure; c) electroanatomic map with a
900774 - posterior view of the left atrium; the RSPV was re-isolated
900775 - using RF ablation and addition-al tags were placed at sites
900776 - around the remaining pulmonary veins were there was bipolar
900777 - volt-age < 0.2 mV and no pace capture; 4) the circular mapping
900778 - catheter in the right superior pulmo-nary vein demonstrates AF
900779 - in the RSPV with exit block while the atria remain in sinus
900780 - rhythm
900781 -
900782 -
900783 -
900784 -
900785 -
900787 - ..
9008 -
900801 -
9009 -
SUBJECTS
Atrial Fibrillation AF Proxysmal Occurred After Treadmill Stress Tes
AG03 -
AG04 - 1020
AG0501 - ..
AG0502 - Kathy and I walked to the cafeteria. Ordered scrambled eggs, sausage
AG0503 - and orange juice.
AG0505 - ..
AG0506 - Walked back to Nuclear Medicine.
AG0507 -
AG0509 - ..
AG06 -
AG07 -
AG08 - 1058
AG09 -
AG0901 - Another tech or nurse took me back into the Nuclear imaging. This was
AG0902 - similar to the initial imaging procedure, per above, ref SDS 0 RG7H,
AG0903 - except imaging lasted only about 4 minutes instead of 7.
AG0904 -
AG0906 - ..
AG10 -
AG11 -
AG12 - 1120
AG13 -
AG1301 - Was released from Nuclear imaging.
AG1302 -
AG1303 - We walked to the car and started home. Stopped along the beach for
AG1304 - Kathy to enjoy the ocean for about 10 minutes.
AG1306 - ..
AG1307 - Then continued driving home.
AG1308 -
AG1309 -
AG1310 -
AG1312 - ..
AG14 -
AG15 -
AG16 - 1155
AG17 -
AG1701 - Driving through Golden Gate Park heading for the Bay Bridge, received
AG1702 - call on cellphone from Doctor Anderson.
AG1704 - ..
AG1705 - The doctor asked if we are still on campus?
AG1707 - ..
AG1708 - Explained we were driving home through Golden Gate Park.
AG1710 - ..
AG1711 - He explained having reported initial test results to Doctor Simpson,
AG1712 - and that he has prescribed medication to start today. He asked us to
AG1713 - return to the hospital and meet him for consultation and to then get
AG1714 - medicine from the Pharmacy to begin treatment today.
AG1716 - ..
AG1717 - He wants to meet at Cardiology waiting room on 2nd floor Building 203.
AG1719 - ..
AG1720 - Turned around at the next intersection on John F Kennedy Drive, which
AG1721 - was nearing Stanyon. Drove back to VAMCSF.
AG1723 - ..
AG1724 - Kathy stopped the car. I got out and walked to Building 203, while
AG1725 - she looked for parking.
AG1727 - ..
AG1728 - Nearing building 203, noticed slight chest pressure, similar to hiking
AG1729 - up Cuneo and Crystal Ranch Road, and after the stress test this
AG1730 - morning, per above. ref SDS 0 TT3T Seemed to be having another afib
AG1731 - event.
AG1732 -
AG1734 - ..
AG18 -
AG19 -
AG20 - 1217
AG21 -
AG2101 - Went to Cardiology on 2nd floor building 203. The attendant went to
AG2102 - look for Doctor Anderson. She returned and said he as gone to lunch
AG2103 - and will return in an hour or so.
AG2105 - ..
AG2106 - Left Cardiology and walked to Nuclear Medicine.
AG2108 - ..
AG2109 - Robert came out and said he just talked to Doctor Anderson. He is
AG2110 - returning from lunch and will meet us in Cardiology.
AG2112 - ..
AG2113 - Walking back to Cardiology, met Doctor Anderson coming through the
AG2114 - lobby doors on ground floor.
AG2116 - ..
AG2117 - We discussed the case there in the lobby of building 203.
AG2119 - ..
AG2120 - The doctor said this case might be amenable to AFib ablation.
AG2121 -
AG2122 -
AG2123 - [On 200108 1130 catheter ablation to treat paroxysml atrial
AG2124 - fibrillation was reviewed following meeting with Doctor
AG2125 - Simpson. ref SDS C4 6Y4N
AG2126 -
AG2128 - ..
AG2129 - Doctor Simpson has prescribed...
AG2130 -
AG2131 - Apixaban blood thinner to avoid clots
AG2132 - Metoprolol Succinate 25 mg avoid HR spikes
AG2133 - Omeprazole aid digestion apixaban and metoprolol
AG2135 - ..
AG2136 - These medications manage paroxysmal atrial fibrillation (PAF),
AG2137 - diagnosed, during the treadmill stress test earlier this mornning, per
AG2138 - above. ref SDS 0 TT3T Metoprolol may support hiking at physical
AG2139 - limits without triggering AF, presented in the letter to Doctor
AG2140 - Simpson a few weeks ago on 191214 1138. ref SDS A7 MY38
AG2142 - ..
AG2143 - Explained I am already taking Pantoprazole and Famotidine for PPI to
AG2144 - aid digestion. Also take Mylanta and calcium carbonate (Tums).
AG2146 - ..
AG2147 - Doctor Anderson said this is not reported in the records at VAMCSF.
AG2149 - ..
AG2150 - Explained these medications are provided by VAMC in Sacramento,
AG2151 - prescribed by Doctor Lee in the GI Clinic treating me for achalasia
AG2152 - since 2005.
AG2154 - ..
AG2155 - Doctor Anderson said he will cancel prescription for PPI.
AG2156 -
AG2157 -
AG2159 - ..
AG22 -
AG23 -
AG24 - 1306
AG25 -
AG2501 - Walked with Doctor Anderson to building 200 and Module 1 on the ground
AG2502 - floor. He found Francis. She scheduled meeting with Doctor Simpson
AG2503 - next Wednesday on 200108 1130.
AG2504 -
AG2505 - [On 200107 1308 Jensen called and advised that Doctor
AG2506 - Simpson ordered EKG. Check in at Module 1 1100 for vitals,
AG2507 - then get EKG, and return to Module 1 for meeting with
AG2508 - Doctor Simpson at 1130. ref SDS C1 NE9N
AG2510 - ..
AG2511 - The clerk in Module 1 had difficulty using the computer to schedule
AG2512 - the meeting with Doctor Simpson. Francis walked around to the back of
AG2513 - the counter to assist the clerk.
AG2515 - ..
AG2516 - They worked together for about 10 minutes. Francis wrote the
AG2517 - schedule for meeting with Doctor Simpson on a sheet of paper and
AG2518 - handed it to me. She said the VA will issue a printed schedule in
AG2519 - the mail to confirm the meeting.
AG2520 -
AG2521 -
AG2522 -
AG2523 -
AG2525 - ..
AG26 -
AG27 -
AG28 - 1310
AG29 -
AG2901 - Went to the Pharmacy, also, on the ground floor of building 200. The
AG2902 - attendant said the prescription ordered by Doctor Simpson will be
AG2903 - ready in about 30 minutes.
AG2905 - ..
AG2906 - Went to cafeteria. Ordered hamburger and macaroni salad and a coke.
AG2908 - ..
AG2909 - Ate half hamburger and some of macaroni salad.
AG2910 -
AG2912 - ..
AG30 -
AG31 -
AG32 - 1347
AG33 -
AG3301 - Went back to Pharmacy.
AG3302 -
AG3303 - Received medications.
AG3304 -
AG3305 -
AG3307 - ..
AG34 -
AG35 -
AG36 - 1402
AG37 -
AG3701 - Before leaving the hospital took 1 each of medications while walking
AG3702 - through main lobby.
AG3704 - ..
AG3705 - Drove home to Concord.
AG3706 -
AG3707 -
AG3709 - ..
AG38 -
AG39 -
AG40 - 1719
AG41 -
AG4101 - Received telephone call from the VA meeting scheduling system. The
AG4102 - message confirmed there is a meeting scheduled with Doctor Simpson on
AG4103 - Wednesday, 200108 1130, per meeting with Francis earlier today at the
AG4104 - VA, see above. ref SDS 0 IG6H
AG4105 -
AG4106 -
AG4108 - ..
AG42 -
AG43 -
AG44 - 1818
AG45 -
AG4501 - Submitted letter to Doctor Simpson in VAMCSF Cardiology with copy to
AG4502 - Lauren, NP and PCP, saying...
AG4503 -
AG4504 - 1. Subject: [EXTERNAL] SECURE Afib Preliminary Diagnosis Chest Pain Treatment Plan Drugs
AG4505 - Date: 2020-01-03, 18:36
AG4513 - ..
AG4514 - 2. Dear Doctor Simpson,
AG4516 - ..
AG4517 - 3. Very pleased did treadmill stress test today, at high level in
AG4518 - Nuclear Medicine, without chest pain symptoms that occurred the
AG4519 - past few weeks hiking hills in Concord. After the test laying
AG4520 - on the gurney for removal of test equipment, I felt slight
AG4521 - chest pressure and afib symptoms. Doctor Anderson and Anna
AG4522 - commented they saw afib symptoms on the monitoring equipment.
AG4523 - Further, initial impressions of nuclear imaging found no
AG4524 - evidence of bypass graft failures.
AG4525 -
AG4526 - [On 200104 1533 received letter from Doctor Simpson saying
AG4527 - will go over everything during the meeting on 200108 1130.
AG4528 - ref SDS B8 NE9N
AG4530 - ..
AG4531 - 4. Driving home through Golden Gate Park, received call from
AG4532 - Doctor Anderson. He related contact with you developing
AG4533 - prescription, and asked us to return for meeting on next steps,
AG4534 - and to receive medications from the Pharmacy to begin taking
AG4535 - today.
AG4537 - ..
AG4538 - 5. On returning to the campus, saw the doctor coming through the
AG4539 - lobby doors of building 203. We discussed the case there in
AG4540 - the lobby. I mentioned feeling afib again after exiting the
AG4541 - car and walking from the parking lot into building 203. Doctor
AG4542 - Anderson confirmed initial diagnosis from test data is afib,
AG4543 - and there is no evidence of bypass graft failure. I asked
AG4544 - several times, if I am safe to continue hiking at current
AG4545 - levels of 10 - 20 miles per day. I understood the doctor to
AG4546 - say yes. Whew! What good news!!!
AG4547 -
AG4548 - [On 200104 1533 received letter from Doctor Simpson saying
AG4549 - will go over everything during the meeting on 200108 1130.
AG4550 - ref SDS B8 NE9N
AG4552 - ..
AG4553 - 6. He related your prescription to take Metoprolol Succinate 25mg
AG4554 - SA 60 Tab - take 1 tablet every day. You also prescribed
AG4555 - Apixaban 5 mg 60 tab - take 1 tablet twice a day.
AG4557 - ..
AG4558 - 7. Went to the Pharmacy and received the medications. Took 1 each
AG4559 - of these drugs. Afib symptoms resolved within 20 minutes.
AG4560 - That is not new. These symptoms seem to occur randomly and
AG4561 - last 5 - 30+ minutes. It is new that afib symptoms have not
AG4562 - recurred since taking the pills OA 1400, at least so far this
AG4563 - evening.
AG4565 - ..
AG4566 - 8. Doctor Anderson was very helpful coordinating with Module 1
AG4567 - staff to schedule a meeting with you next week on 201008 1130.
AG4568 -
AG4569 - [On 200104 1533 received letter from Doctor Simpson saying
AG4570 - will go over everything during the meeting on 200108 1130.
AG4571 - ref SDS B8 NE9N
AG4573 - ..
AG4574 - 9. Since it now appears minor chest pain reported in recent days
AG4575 - does not rise to the level of surgery, and can be controlled
AG4576 - with medications, I called Doctor Lee's office at the VA
AG4577 - Medical Center in Sacramento. They confirmed I am still
AG4578 - scheduled for EGD dilation on 200107 0830, the day before I
AG4579 - meet with you in San Francisco. With your permission, I would
AG4580 - like to have this procedure done at that time. While waiting
AG4581 - in Nuclear Medicine for the test proc to begin, I had to
AG4582 - relieve saliva (bubbles) from my throat 4 - 5 times. This
AG4583 - indicates LESV is shutting down.
AG4585 - ..
AG4586 - 10. Again, your support is greatly appreciated. Everyone on the
AG4587 - medical team did a great job today.
AG4589 - ..
AG4590 - 11. Thanks very much for taking good care of me.
AG4591 -
AG4596 -
AG4597 -
AG4598 -
AG4599 -
AG4600 -
AG4602 - ..
AG47 -
AG48 -
AG49 - 1948
AG50 -
AG5001 - Doctor Lee called.
AG5002 -
AG5003 - He did not travel anywhere with his family during the holidays. His
AG5004 - parents both need regular attention now. His daughter returns to
AG5005 - Lowell in Chicago next week. He is not traveling with her back to
AG5006 - school.
AG5008 - ..
AG5009 - The doctor did not seem to have received the letter sent to Jessica,
AG5010 - Danis and to Gracie, submitted on 191229, saying Doctor Simpson
AG5011 - suggested deferring EGD until after the treadmill stress test today,
AG5012 - reported on 191229 1243, ref SDS B5 4R7J, and citing Doctor Simpson's
AG5013 - letter earlier that day. ref SDS B5 6H6G
AG5014 -
AG5015 - [On 200110 0830 Danis said she gave the letter on 191227
AG5016 - 1243 on delaying EGD scheduled for 200107, ref SDS B5 4R7J,
AG5017 - to Doctor Lee. ref SDS C5 EX6M
AG5019 - ..
AG5020 - Doctor Lee has read progress notes for the treadmill stress test that
AG5021 - diagnosed atrial fibrillation earlier today, per above. ref SDS 0 QO5O
AG5023 - ..
AG5024 - The doctor is concerned about doing EGD dilation procedure next week
AG5025 - scheduled on 200107 0830, because of new medications prescribed to
AG5026 - manage AF. He mentioned Metoprolol Succinate 25 mg that lowers heart
AG5027 - rate, and noted patient history during EGD under sedation with versed
AG5028 - is already in the 40s.
AG5029 -
AG5030 - [...below on 200103 0700 at 2027 letter notifies Doctor
AG5031 - Simpson that Doctor Lee deferred EGD scheduled on 200107,
AG5032 - until after he reviews Doctor Simpson's progress notes for
AG5033 - meeting on 200108. ref SDS 0 RZ4M
AG5035 - ..
AG5036 - He did not mention Apixaban blood thinner to avoid clots.
AG5037 -
AG5039 - ..
AG5040 - Doctor Lee decided to defer EGD. He will read Doctor Simpson's
AG5041 - progress notes for the meeting on 200108 1130, then call Wednesday
AG5042 - evening to schedule the next EGD as an overbook on Friday, 200110 or
AG5043 - the following week, to keep us on schedule.
AG5045 - ..
AG5046 - The doctor will call to advise Wednesday evening because Apixaban
AG5047 - blood thinner to manage stroke risk will have to be paused after
AG5048 - Tuesday evening, in order to meet protocol to pause 48 hours in
AG5049 - advance of a procedure that may involve bleeding.
AG5051 - ..
AG5052 - [On 200104 1533 received letter from Doctor Simpson asking
AG5053 - patient to contact Doctor Lee and ask what he is worried
AG5054 - about giving versed for sedation to perform EGD procedure,
AG5055 - while patient is also taking Metoprolol. ref SDS B9 8N9F
AG5057 - ..
AG5058 - [On 200105 1018 letter notifies Doctor Simpson that Doctor
AG5059 - Lee does not support communication with patient; can ask a
AG5060 - nurse to try requesting Doctor Lee call, or drive to
AG5061 - Sacramento and request meeting with Doctor Lee. ref SDS C0
AG5062 - NE9N Speculate Doctor Lee concerned about pausing Apixaban
AG5063 - blood thinner before EGD. ref SDS C0 OO90 Report initial
AG5064 - history taking Metropolo shows no evident impact on BP; HR
AG5065 - seems lower in 40s. ref SDS C0 OO9S
AG5067 - ..
AG5068 - [On 200107 1501 letter from Doctor Simpson cites
AG5069 - recommendation to pause Apixaban 48 hours prior to EGD
AG5070 - procedure; he will discuss protocol on holding Metropolol,
AG5071 - when we meet in Module 1 Cardiology Clinic at VAMCSF on
AG5072 - 200108 1130. ref SDS C2 NE9N
AG5073 -
AG5074 -
AG5076 - ..
AG5077 - Progress Notes Doctor Lee Telecon
AG5078 -
AG5079 -
AG5080 - =========================================================================
AG5081 - Date/Time: 03 Jan 2020 @ 1952
AG5082 - Note Title: Gastroenterology Attending F/U Note 60127
AG5083 - Location: No CA Healthcare Sys-Martinez
AG5084 - Signed By: LEE,RANDALL E
AG5085 - Co-signed By: LEE,RANDALL E
AG5086 - Date/Time Signed: 03 Jan 2020 @ 2002
AG5087 - -------------------------------------------------------------------------
AG5089 - ..
AG5090 - LOCAL TITLE: Gastroenterology Attending F/U Note 60127
AG5091 - STANDARD TITLE: GASTROENTEROLOGY ATTENDING NOTE
AG5092 - DATE OF NOTE: JAN 03, 2020@19:52 ENTRY DATE: JAN 03, 2020@19:52:51
AG5093 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
AG5094 - URGENCY: STATUS: COMPLETED
AG5096 - ..
AG5097 - Reviewed chart. called patient.
AG5099 - ..
AG5100 - 11/12/2019 EGD & dilation for achalasia complicated by
AG5101 - recurrent GERD stricture: dilated to 20mm.
AG5102 -
AG5103 - next scheduled 1/7/2020.
AG5105 - ..
AG5106 - Recent cardiac evaluation at SFVA for evaluation of exertional
AG5107 - chest discomfort: non-ischemic myocardial perfusion scan, but +
AG5108 - atrial fibrillation with RVR. metoprolol and apixaban started.
AG5109 - will have cardiology f/u next week. some concern regarding
AG5110 - beta-blockade with preexisting sinus bradycardia.
AG5111 -
AG5112 - gi symptoms:
AG5113 -
AG5114 - build up of saliva, but solid food still passing (including meat).
AG5116 - ..
AG5117 - recommend:
AG5118 -
AG5119 - postpone next EGD and dilation until after cardiac status more
AG5120 - stable, but not too long lest esophageal lumen close.
AG5122 - ..
AG5123 - will need to discontinue apixaban prior to anticipated
AG5124 - esophageal dilation. check SFVA cardiology note next week.
AG5125 -
AG5126 - /es/ Randall E. Lee, MD
AG5127 - Staff Physician, Gastroenterology
AG5128 - Signed: 01/03/2020 20:02
AG5129 -
AG5130 -
AG5131 -
AG5132 -
AG5134 - ..
AG52 -
AG53 -
AG54 - 2027
AG55 -
AG5501 - Sent another letter to Doctor Simpson in Cardiology at VAMCSF, and
AG5502 - saying...
AG5503 -
AG5504 - 1. Subject: Re: [EXTERNAL] SECURE Afib Preliminary Diagnosis Chest Pain Treatment Plan Drugs
AG5505 - Date: 2020-01-03, 20:33
AG5509 - ..
AG5510 - 2. Dear Doctor Simpson,
AG5512 - ..
AG5513 - 3. Doctor Lee just called. He has read progress notes from the
AG5514 - stress test today, including initial medications prescribed.
AG5515 - He decided to defer EGD procedure scheduled in the GI Clinic at
AG5516 - VAMC in Sacramento on 200107, until after you and I meet the
AG5517 - next day on 200108. One concern he raised was taking
AG5518 - Metoprolol prior to getting versed for conscious sedation. He
AG5519 - plans to review your progress notes for the meeting on
AG5520 - Wednesday, then call and let me know if he can overbook an EGD
AG5521 - procedure on Thursday or Friday.
AG5523 - ..
AG5524 - References call from Doctor Lee, per above. ref SDS 0 UO7O
AG5525 -
AG5526 - [On 200104 0900 submitted letter with copy of this letter
AG5527 - to Lauren, NP and PCP in this case. ref SDS B7 NE9N
AG5529 - ..
AG5530 - [On 200104 1533 received letter from Doctor Simpson asking
AG5531 - patient to contact Doctor Lee and ask what he is worried
AG5532 - about giving versed for sedation to perform EGD procedure,
AG5533 - while patient is also taking Metoprolol. ref SDS B9 8N9F
AG5535 - ..
AG5536 - [On 200105 1018 letter notifies Doctor Simpson that Doctor
AG5537 - Lee does not support communication with patient; can ask a
AG5538 - nurse to try requesting Doctor Lee to call, or drive to
AG5539 - Sacramento and request meeting with Doctor Lee. ref SDS C0
AG5540 - NE9N Speculate Doctor Lee concerned about pausing Apixaban
AG5541 - blood thinner before EGD. ref SDS C0 OO90 Report initial
AG5542 - history taking Metropolo shows no evident impact on BP; HR
AG5543 - seems lower in 40s. ref SDS C0 OO9S
AG5545 - ..
AG5546 - [On 200107 1501 letter from Doctor Simpson cites
AG5547 - recommendation to pause Apixaban 48 hours prior to EGD
AG5548 - procedure; he will discuss protocol on holding Metropolol,
AG5549 - when we meet in Module Cardiology Clinic at VAMCSF on
AG5550 - 200108 1130. ref SDS C2 R68O
AG5552 - ..
AG5553 - Letter to Doctor Simpson continues...
AG5554 -
AG5555 - 4. Hope you are doing well.
AG5557 - ..
AG5558 - 5. Best,
AG5559 -
AG5564 -
AG5565 -
AG5566 -
AG5567 -
AG5568 -
AG56 -
SUBJECTS
Default Null Subject Account for Blank Record
AH03 -
AH0401 - ..
AH0402 - Progress Notes Release of Information ROI Treadmill Stress Test 200103
AH0403 -
AH0405 - ..
AH0406 - Download medical records Treadmill Stress test for coronary and blood
AH0407 - vessel stenosis (blockages) causing chest pain and atrial fibrillation
AH0408 - found in Zio XT 2-week heart monitoring examination.
AH0410 - ..
AH0411 - Medical records stored on VA computers accessed from website at...
AH0412 -
AH0413 - https://www.myhealth.va.gov/mhv-portal-web/track-health
AH0415 - ..
AH0416 - Customer....
AH0417 -
AH0420 -
AH0421 -
AH0422 - =========================================================================
AH0423 - Date/Time: 03 Jan 2020 @ 1507
AH0424 - Note Title: CARDIOLOGY CONTACT NOTE (MED)
AH0425 - Location: San Francisco CA VAMC
AH0426 - Signed By: ANDERSON,DAVID R
AH0427 - Co-signed By: ANDERSON,DAVID R
AH0428 - Date/Time Signed: 03 Jan 2020 @ 1520
AH0429 - -------------------------------------------------------------------------
AH0431 - ..
AH0432 - LOCAL TITLE: CARDIOLOGY CONTACT NOTE (MED)
AH0433 - STANDARD TITLE: CARDIOLOGY NOTE
AH0434 - DATE OF NOTE: JAN 03, 2020@15:07 ENTRY DATE: JAN 03, 2020@15:07:25
AH0435 - AUTHOR: ANDERSON,DAVID R EXP COSIGNER:
AH0436 - URGENCY: STATUS: COMPLETED
AH0438 - ..
AH0439 - The attending physician for this patient care encounter is Dr.
AH0440 - Simpson/Shunk.
AH0442 - ..
AH0443 - Mr Welch is a 74 man hx of CAD sp CABG (2009, 4V LIMA to LAD
AH0444 - and 3 SVG) presented for exercise stress testing in the setting
AH0445 - of exertional CP (chest pain). Is a hiker and has noticed
AH0446 - increased CP with hills. Is worried that one of his "vein
AH0447 - grafts is occluded now that they are 10 years old."
AH0449 - ..
AH0450 - ETT was borderline for ST changes and pt didn't have CP as he
AH0451 - has walking with much higher exertional level. He "felt very
AH0452 - excited that his CP did not come back and that he was able to
AH0453 - do more work-load than in the past." Nuclear portion of the
AH0454 - test was fair in quality and after some discussion decided that
AH0455 - the overall read would be "negative for inducible ischemia with
AH0456 - attenuation artifact of the inferior wall." See final report
AH0457 - for more details.
AH0459 - ..
AH0460 - At termination of testing and into recovery the patient
AH0461 - developed AF with RVR 130-150s. Interestingly he only then
AH0462 - noted similar CP while walking (this is the pain that he
AH0463 - discussed with Dr Simpson the initially prompted the ETT
AH0464 - consult).
AH0466 - ..
AH0467 - In recovery heart rates improved into the 110s range, however
AH0468 - remained in AF. Denied further CP with HRs in the 110s and was
AH0469 - able to walk without SOB, dizziness or lightheadedness.
AH0471 - ..
AH0472 - Discussed with Dr Simpson and given hx of post-operative AF and
AH0473 - rates > 110 started on metoprolol succinate 25 mg PO daily and
AH0474 - CHaDs-Vasc 3 warrants AC. In sinus patient does have a resting
AH0475 - HR ~ 50s so will have to be careful with b- blocker. Discussed
AH0476 - this with patient and will note HRs prior to visit next week.
AH0477 -
AH0478 -
AH0479 - - metoprolol 25 mg succinate PO daily
AH0480 - - apixaban 5 mg PO BID
AH0481 - - referral to AC clinic placed for apixaban
AH0482 - - continue ASA and PPI as prescribed
AH0483 - - f/u scheduled with Dr Simpson for next Wed 1/8 1130am slot f/u
AH0484 -
AH0485 - /es/ David R Anderson, M.D.
AH0486 - Resident Physician UC# 97206
AH0487 - Signed: 01/03/2020 15:20
AH0489 - ..
AH0490 - Receipt Acknowledged By:
AH0491 - 01/16/2020 16:19 /es/ KENDRICK A SHUNK, MD, PhD
AH0492 - CHIEF, INTERVENTIONAL CARDIOLOGY (1760418230)
AH0493 - 01/07/2020 10:23 /es/ Paul C. Simpson MD
AH0494 - Attending MD Cardiology, NPI 1548374093
AH0495 -
AH0496 - -------------------------------------------------------------------------
AH0497 -
AH0498 -
AH0499 - =========================================================================
AH0500 - 1. Date/Time: 03 Jan 2020 @ 1036
AH0501 - Note Title: CARDIOLOGY EXERCISE ECG STRESS TEST REPORT
AH0502 - Location: San Francisco CA VAMC
AH0503 - Signed By: SHUNK,KENDRICK A
AH0504 - Co-signed By: SHUNK,KENDRICK A
AH0505 - Date/Time Signed: 06 Jan 2020 @ 1156
AH0506 - -------------------------------------------------------------------------
AH0508 - ..
AH0509 - LOCAL TITLE: CARDIOLOGY EXERCISE ECG STRESS TEST REPORT
AH0510 - STANDARD TITLE: CARDIOLOGY DIAGNOSTIC STUDY CONSULT
AH0511 - DATE OF NOTE: JAN 03, 2020@10:36 ENTRY DATE: JAN 03, 2020@10:38:52
AH0512 - AUTHOR: SHUNK,KENDRICK A EXP COSIGNER:
AH0513 - URGENCY: STATUS: COMPLETED
AH0515 - ..
AH0516 - Cardiology Exercise ECG Stress Test Report
AH0518 - ..
AH0519 - Patient Name: WELCH,RODNEY CHARLES
AH0520 - Patient ID: 561-72-0144
AH0521 - Referring MD/NP: Dr. Paul Simpson
AH0522 - Date of Referral: Dec 29,2019
AH0523 - Date of Test: Jan 3,2020
AH0524 - Supervising NP or Cardiology Fellow: Dave Anderson/Raymond Bamvi Fohtung
AH0526 - ..
AH0527 - Indication: New onset angina s/p CABG
AH0529 - ..
AH0530 - Exercise Protocol: Standard Bruce
AH0532 - ..
AH0533 - Resting ECG Reading: Normal sinus rhythm. Rare PACs.
AH0535 - ..
AH0536 - Resting BP: 151/70 Resting HR: 64
AH0537 - Maximum BP: 196/74 Peak HR: 141 (96% maximum predicted HR)
AH0539 - ..
AH0540 - Duration of Exercise: 8 minutes
AH0542 - ..
AH0543 - Maximum Workload Achieved: 10.10 METs
AH0545 - ..
AH0546 - Research found...
AH0547 -
AH0548 - PMC
AH0549 -
AH0550 - Achieving an Exercise Workload of ?10 METS Predicts a Very
AH0551 - Low Risk of Inducible Ischemia:
AH0552 -
AH0553 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826719/
AH0555 - ..
AH0556 - Progress Notes continue...
AH0557 -
AH0558 - Symptoms during exercise: Typical chest pain
AH0560 - ..
AH0561 - Actually, there was no chest pain during the test, reported by Doctor
AH0562 - Anderson, per above. ref SDS 0 T265 Chest pain occurred after the
AH0563 - test, typical of PAF.
AH0564 -
AH0566 - ..
AH0567 - Progress Notes continue...
AH0568 -
AH0569 - Reason for Termination of Test: Maximal heart rate achieved
AH0571 - ..
AH0572 - ST changes during infusion or in recovery:
AH0573 - [ ]Flat ST depression of mm in leads
AH0575 - ..
AH0576 - [X]Slowly upsloping ST depression of V5/V6 mm in
AH0577 - leads
AH0578 - [ ]ST elevation of mm in leads
AH0580 - ..
AH0581 - [ ]Downsloping ST depression of mm in leads
AH0583 - ..
AH0584 - [ ]Rapidly upsloping ST depression
AH0585 - [ ]No ST changes from baseline
AH0587 - ..
AH0588 - Arrhythmias during exercise or in recovery:
AH0589 - Rare PACs during exercise. During recovery, patient went into afib with RVR
AH0590 - with rates in the 130s-140s. During this time, he had 1mm flat ST depressions in
AH0591 - the pre-cordial leads.
AH0593 - ..
AH0594 - Duke prognostic treadmill score = 1.5
AH0595 - Exercise time (minutes based on the Bruce protocol) -
AH0596 - (5 x maximum ST segment deviation in mm) -
AH0597 - (4 x exercise angina [0 = none, 1 = nonlimiting, and 2 = exercise
AH0598 - limiting])
AH0599 - Patients are classified as low, moderate, or high risk according to the
AH0600 - score:
AH0601 - " Low-risk - score >= +5
AH0602 - " Moderate-risk - score from -10 to +4
AH0603 - " High-risk - score = < -11
AH0605 - ..
AH0606 - Impression:
AH0607 - This stress test is
AH0608 - [ ]Negative for ischemia
AH0609 - [ ]Abnormal due to:
AH0610 - [ ]Flat or downsloping ST depression
AH0611 - [ ]ST elevation
AH0612 - [ ]Ventricular arrhythmia
AH0613 - [ ]Hemodynamic instability
AH0614 - [X]Borderline due to:
AH0615 - [X]Slowly upsloping ST depression
AH0616 - [ ]Uninterpretable due to:
AH0617 - [ ]Resting ST abnormalities
AH0618 - [ ]Left bundle branch block or left ventricular
AH0619 - hypertrophy on resting ECG
AH0620 - [ ]Significant baseline artifact
AH0621 - [ ]Failure to achieve 85% of maximum predicted heart rate
AH0623 - ..
AH0624 - The results of radionuclide myocardial perfusion imaging are available
AH0625 - under the Reports/Imaging section of CPRS. The findings of the ECG and
AH0626 - imaging portions of the stress test may be discordant (ie negative ECG and
AH0627 - positive imaging or positive ECG and negative imaging).
AH0628 -
AH0629 - /es/ KENDRICK A SHUNK, MD, PhD
AH0630 - CHIEF, INTERVENTIONAL CARDIOLOGY (1760418230)
AH0631 - Signed: 01/06/2020 11:56
AH0632 -
AH0633 - -------------------------------------------------------------------------
AH0634 -
AH0635 -
AH0636 -
AH0637 -
AH0638 -
AH0639 -
AH0640 -
AH0641 -
AH0642 -
AH0643 -
AH0644 -
AH07 -