When Diagnosis Isn’t Obvious
I hadn’t slept more than a couple of restless hours due to an early flight, so later during a meeting when the dull headache I’d had since waking grew to a sharp pounding, I wasn’t surprised. When I began to see spots and my field of vision narrowed to a small tunnel, I still wasn’t alarmed; aspirin and hydrating have always done the job. But a moment later, when I stumbled midsentence to find the words and was unable to speak for ten seconds, I knew something was wrong.
The guy across the table from me asked if I was okay. I was able to say that I didn’t think so. He asked, do you have aspirin? Yes, I replied. As I reached for my bag, I realized my left arm was mildly numb. I shook it off, found the aspirin and within a couple of minutes, everything but the dull headache had vanished. We finished our meeting almost as if nothing had happened, but I was definitely shaken up.
I immediately called my best friend, an emergency medicine physician, who said, “Go to an ED right now. You might have had a TIA.” My tests at the hospital were normal, and I was released the next day. The neurologist concluded (though with some consternation) that the cause of my symptoms was a complex migraine. My ED doctor friend didn’t buy it: “You’ve had Afib for 20 years. How could it not be a TIA?” The staff cardiologist said he wasn’t qualified to make the call and asked to speak with my electrophysiologist. The EP felt that I should be anticoagulated. If this was a TIA, my CHA2DS2-VASc score had just jumped from zero to two.
Back home in Austin, my internist of ten years agreed with the neurologist, insisting that this wasn’t a TIA. So I consulted a second EP who was also familiar with my history. He too agreed with the neurologist, but took the middle ground on anticoagulation. “Look,” he said, “you are so symptomatic that Afib wakes you up at night. You have been monitored countless times over the years and practically know to the minute when you are in Afib. It typically lasts a couple of hours. Why don’t you use rivaroxaban as a pill-in-the-pocket strategy?”
Hmmm. A pill in the pocket for anticoagulation? The staff cardiologist and first EP didn’t like the idea much. I conducted a literature search and didn’t find any published studies, so I decided to ask one more cardiologist — a physician from the UK whom I’d known for years. “Oh yes,” he said, “though there isn’t any clinical evidence, that approach isn’t uncommon in the UK.” Six doctors and three opinions later, I still wasn’t sure which approach to take.
Afib and Dementia
My 80-year-old mother was diagnosed with Afib eight years ago during a routine physical. She jokes that I gave it to her. She has no symptoms. She tolerates warfarin well, plays tennis a couple of times a week, and is actively engaged in advocacy for political and non-profit causes. Eight years ago, a rate control strategy seemed like a good bet. Now the growing body of literature about dementia and Afib has me wondering. I recently heard Intermountain Healthcare electrophysiologist Dr. John Day, speaking at the 2015 AF Symposium in Orlando, describe a study he was involved with by Jacobs et al.1 The authors concluded that rate-controlled patients on warfarin who remained within their therapeutic range at least 75% of the time were less likely to develop dementia than patients who didn’t stay in their therapeutic range. My mom comes from hearty stock that commonly live well into their 90s. Whenever I see her and take her pulse, it is irregular. With the rate control approach coming under more scrutiny in long-term Afib patients, I have to ask myself: Is this strategy putting her at risk for dementia? Would it make sense to have her switch to a NOAC? After all of this time in Afib, what is the likelihood that an ablation (and maintaining sinus rhythm) would be successful in an 80-year-old?
After listening to Dr. Day on the subject, I am relieved — my mom was 68% in therapeutic range over the past year, and this is something that can be improved upon. Nonetheless, this possible link between Afib and dementia is a nagging concern.
Dr. Prashanthan Sanders, an electrophysiologist from Australia, recently published a study that demonstrated a reduction of Afib and the reversal of fibrosis in the atrium in a cohort of patients who engaged in intensive lifestyle changes.2 Not surprisingly, I was all ears. While I don’t share many of the risk factors common to this study group (although Dr. Sanders joked with me that my playing professional basketball in the past was a risk factor in itself), I strongly feel that lifestyle modifications had helped me keep Afib at bay for the past 20 years.
My vascular event was a catalyst for me, forcing me to become more honest about how often I was having Afib. I changed from a pill-in-the-pocket flecainide strategy to a daily dose, and I take a novel anticoagulant. I also finally admitted what I’d reluctantly known for some time — that even one alcoholic drink could trigger Afib. In the 12 months prior to my event, I’d had 10 brief episodes. I’ve since cut alcohol use to a trickle, leading to dramatic results: my number of Afib episodes has dropped by two-thirds over a six-month timeframe. These results are encouraging to me, and may lend credence to Dr. Sanders’ conclusions that perhaps Afib doesn’t beget Afib in all cases.
TIA or no TIA, I know I had an ‘event’ and no longer consider my CHA2DS2-VASc score as zero, though based on physician feedback, I’m not completely sure it is a two. Meanwhile, I keep in close contact with my physicians, devour the evolving literature on Afib, and keep an eye on the research of Drs. Day and Sanders. When Mahatma Gandhi was asked why he wasn’t more consistent, he replied: “I honor the truth, I don’t honor consistency. As my understanding of the truth changes, I’ll change my opinion.” From my perspective, this approach seems remarkably applicable to deciphering the emerging science and evolving treatment approaches for atrial fibrillation.
Jon Darsee is the executive vice president of corporate sales and payer relations of iRhythm Technologies, Inc., a healthcare information services provider and creator of the ZIO Patch and the ZIO Service.
Click here to see his previous article in EP Lab Digest.
- Jacobs V, Woller SC, Stevens S, et al. Time outside of therapeutic range in atrial fibrillation patients is associated with long-term risk of dementia. Heart Rhythm. 2014;11(12):2206-2213.
- Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA. 2013;310(19):2050-2060.