Dr. Roach

Dr. Keith Roach

DEAR DR. ROACH: I’m a 67-year-old man who developed typical atrial flutter two years ago, but I haven’t had any symptoms that I am aware of. I don’t have a history of heart problems. My heart rate was 117 bpm while experiencing atrial flutter.
My cardiologist recommended an ablation, as that can be curative. He specializes in electrophysiology. The ablation was successful for the flutter, and my heart rate was in the low 60s afterward.
Six months ago, atrial fibrillation (AFib) showed up, but again, there weren’t any real symptoms for me. My heart rate is nice and low, and I never really feel any problems … perhaps some fatigue. But at 67 years of age, it’s hard to separate that from just getting older. I’m on Xarelto and a low dose of carvedilol. My blood pressure is good.
Is it worth having an ablation of the pulmonary veins to try and stop the AFib? Or is it better to just live with an irregular heartbeat?
Apparently, it’s best to have an ablation sooner than later, so I’ll need to decide as soon as possible. — D.S.
ANSWER: Atrial flutter is an abnormally fast heart rhythm that starts in one of the top chambers of the heart, usually the right atrium. The heart rate in the atria is very fast, typically 240-300 bpm, which is faster than an adult heart can beat. It is common that every other impulse in the atria gets transmitted to the ventricle, so a pulse rate in the range of 120-150 bpm would be typical.
Catheter ablation prevents the progression of the fast impulse to the rest of the heart, and it is successful 65% to 100% of the time in various studies. Unfortunately, studies have also shown that somewhere between 7% and 44% of those who had a successful catheter ablation for atrial flutter will later have a recurrence or, more commonly, develop AFib.
This is called a chaotic arrythmia and can cause a fast heart rate, but more importantly, the lack of coordinated heart contractions in the atria can predispose people to the development of a clot in the atrium. The clot can then float downstream, where it can lodge and cause damage, especially a stroke. A percentage in the order of 5% of people per year with AFib will develop a stroke without treatment.
Treatment is designed to relieve symptoms and reduce stroke risk. Your cardiologist has already achieved those aims pretty well. The carvedilol is a beta blocker that helps keep the heart rate under control, and Xarelto is effective at reducing stroke risk.
In my opinion, there isn’t a compelling need to consider another treatment like an ablation, which has a small but still real potential for serious side effects. In fact, it is not 100% effective; about 70% to 75% of patients are symptom-free a year after the procedure. Many people need to continue anticoagulants like Xarelto even after a successful catheter ablation.
I recommend ablation for people who cannot tolerate medication treatment of their symptoms.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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