THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: January 3, 2020 07:00 AM Friday;
VA ASU for IV then Neuclear Medicine Stress test evaluate chest pain.
2...Atrial Fibrillation AF Types Paroxysmal Persistent Long Term
3...Hiking High-intensity Exercise after Age 40 Increases Risks Atrial Fibrillation (AF)
4...Overdosing on Exercise Age > 40 Increase Occurance AFib Atrial Fibrillation
........Exercising recommendations for paroxysmal AF in young and
........middle-aged athletes (PAFIYAMA) syndrome
5...Paroxysmal Atrial Fibrillatrion Lowers HDL and LDL Cholesterol
........Association Between Blood Lipid Profiles and Atrial
........Fibrillation: A Case-Control Study
........Cholesterol paradox in patients with paroxysmal atrial
........Recurrent Atrial Fibrillation After Catheter Ablation: Considerations
........For Repeat Ablation And Strategies To Optimize Success
6...Progress Notes Doctor Lee Telecon
7...Progress Notes Release of Information ROI Treadmill Stress Test 200103
Click here to comment!
1...What level is "chronically elevated" HDL that causes AF?
2...The doctor said this case might be amenable to AFib ablation.
Atrial Fibrillation AF Proxysmal Occurred After Treadmill Stress Tes
2903 - ..
2904 - Summary/Objective
290501 - Follow up ref SDS B6 0000. ref SDS B5 0000.
290505 - [On 200104 0900 submitted letter with copy of this letter
290506 - to Lauren, NP and PCP in this case. ref SDS B7 NE9N
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
290527 - ..
2908 - Background
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
291051 - ..
2913 - Progress
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 - ..
2917 - 0602
291801 - Arrived at...
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
291821 - ..
2921 - 0642
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.
292216 - ..
2925 - 0701
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.
292626 - ..
2929 - 0752
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...
293017 - 1. Nuclear imaging of chest.
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.
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.
293049 - ..
2933 - 0820
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.
293408 - ..
2937 - 0914
293801 - Doctor David Anderson called me for treadmill stress test.
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.
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.
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.
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.
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...
293910 - 1. Atrial fibrillation (AF) patients should go to ER if heart
293911 - rate goes extremely high.
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.
Atrial Fibrillation AF Research Types Paroxysmal Persistent Long Ter
580401 - ..
580402 - Atrial Fibrillation AF Types Paroxysmal Persistent Long Term
580404 - After the meeting research found...
580406 - Medical News Today
580408 - What are the types of atrial fibrillation?
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
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.
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
580459 - Another article...
580461 - Livescience
580463 - 'Overdosing' on Exercise May Be Toxic to the Heart
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...
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?
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."
580510 - ..
580511 - Another article...
580513 - MDedge Cardiology
580515 - Older recreational endurance athletes face sky-high AF risk
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...
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
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."
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...
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.
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
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.
580656 - The cardiovascular benefits of exercise resoundingly
580657 - overwhelm the adverse effects in that small group that
580658 - experiences adverse effects, he said.
580661 - ..
580662 - Another article...
580664 - PMC
580665 - ATM Annals of Trnaslational Medicine
580667 - Ann Transl Med. 2017 Jan; 5(1): 24.
580668 - doi: 10.21037/atm.2017.01.02
580670 - ..
580671 - PMCID: PMC5253281
580672 - PMID: 28164109
580675 - ..
580676 - Exercising recommendations for paroxysmal AF in young and
580677 - middle-aged athletes (PAFIYAMA) syndrome
580678 - ---------------------------------------------------------
580680 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253281/
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...
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:
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...
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...
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...
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.
Paroxysmal Atrial Fibrillation AF Lowers HDL LDL Cholesterol
710401 - ..
710402 - Paroxysmal Atrial Fibrillatrion Lowers HDL and LDL Cholesterol
710405 - Another article...
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
710427 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024732/
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.
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 . 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 . 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 . 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 . 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?
710517 - Discussion
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).
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 ,
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 .
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 - . 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 . 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.
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...
710602 - PubMed
710604 - Copyright 2000 S. Karger AG, Basel
710606 - PMID: 10640793 DOI: 10.1159/000006942
710608 - ..
710609 - Cholesterol paradox in patients with paroxysmal atrial
710610 - fibrillation
710611 - ------------------------------------------------------
710613 - https://www.ncbi.nlm.nih.gov/pubmed/10640793
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.
Atrial Fibrillation Recurs 3+ Months After Ablation 20% - 40% Resear
900401 - ..
900402 - Another article...
900404 - NCBI
900405 - PMC
900407 - Journal of Atrial Fibrillation
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
900420 - Andrew E Darby, MD, FHRS
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. 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. 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. 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. 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. 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]). 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.
900554 - ..
900555 - Table 1
900557 - ..
900558 - Risk factors for atrial fibrillation recurrence after ablation
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
900570 - structural cardiomyopathy; valvular heart disease
900571 - changes
900573 - ..
900574 - Hypertension; obesity; obstructive sleep apnea/sleep
900575 - Clinical disordered breathing; metabolic syndrome; thyroid disease
900576 - features
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.
900613 - ..
900614 - Figure 1
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)
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%). 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. 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. 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. 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.
900670 - ..
900671 - Rigorous testing to confirm bidirectional (entrance and exit)
900672 - conduction block post-ablation improves long-term success
900673 - rates. 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.
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. 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.
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]). 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.
900714 - ..
900715 - Figure 2
900716 - Rational approach to a repeat AF ablation procedure
900718 - ..
900719 - PVs electrically isolated
900721 - No Re-isolate PVs and confirm
900722 - entrance and exit block
900723 - Yes
900727 - ..
900728 - Non-PV trigger(s)?
900730 - Yes Ablate non-PV
900731 - triggers(s)
900732 - No
900736 - ..
900737 - Inducible atrial flutter?
900739 - Yes
900740 - Ablate atrial flutter
900742 - No
900745 - ..
900746 - Anatomical non-PV ablation Figure 2
900750 - ..
900751 - Figure 3
900753 - ...[shows imate of heart with pulmonary veins and arteries
900754 - protruding...]
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
900787 - ..
Atrial Fibrillation AF Proxysmal Occurred After Treadmill Stress Tes
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.
AG0509 - ..
AG08 - 1058
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.
AG0906 - ..
AG12 - 1120
AG1301 - Was released from Nuclear imaging.
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.
AG1312 - ..
AG16 - 1155
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.
AG1734 - ..
AG20 - 1217
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.
AG2123 - [On 200108 1130 catheter ablation to treat paroxysml atrial
AG2124 - fibrillation was reviewed following meeting with Doctor
AG2125 - Simpson. ref SDS C4 6Y4N
AG2128 - ..
AG2129 - Doctor Simpson has prescribed...
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.
AG2159 - ..
AG24 - 1306
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.
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.
AG2525 - ..
AG28 - 1310
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.
AG2912 - ..
AG32 - 1347
AG3301 - Went back to Pharmacy.
AG3303 - Received medications.
AG3307 - ..
AG36 - 1402
AG3701 - Before leaving the hospital took 1 each of medications while walking
AG3702 - through main lobby.
AG3704 - ..
AG3705 - Drove home to Concord.
AG3709 - ..
AG40 - 1719
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
AG4108 - ..
AG44 - 1818
AG4501 - Submitted letter to Doctor Simpson in VAMCSF Cardiology with copy to
AG4502 - Lauren, NP and PCP, saying...
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.
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!!!
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.
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.
AG4602 - ..
AG49 - 1948
AG5001 - Doctor Lee called.
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
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.
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.
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
AG5076 - ..
AG5077 - Progress Notes Doctor Lee Telecon
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.
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.
AG5112 - gi symptoms:
AG5114 - build up of saliva, but solid food still passing (including meat).
AG5116 - ..
AG5117 - recommend:
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.
AG5126 - /es/ Randall E. Lee, MD
AG5127 - Staff Physician, Gastroenterology
AG5128 - Signed: 01/03/2020 20:02
AG5134 - ..
AG54 - 2027
AG5501 - Sent another letter to Doctor Simpson in Cardiology at VAMCSF, and
AG5502 - saying...
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
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...
AG5555 - 4. Hope you are doing well.
AG5557 - ..
AG5558 - 5. Best,
Default Null Subject Account for Blank Record
AH0401 - ..
AH0402 - Progress Notes Release of Information ROI Treadmill Stress Test 200103
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...
AH0413 - https://www.myhealth.va.gov/mhv-portal-web/track-health
AH0415 - ..
AH0416 - Customer....
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.
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
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
AH0496 - -------------------------------------------------------------------------
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...
AH0548 - PMC
AH0550 - Achieving an Exercise Workload of ?10 METS Predicts a Very
AH0551 - Low Risk of Inducible Ischemia:
AH0553 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826719/
AH0555 - ..
AH0556 - Progress Notes continue...
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.
AH0566 - ..
AH0567 - Progress Notes continue...
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