One of the joys of writing this blog is the communication it allows me with discerning individuals and patients across the planet. One such reader, Mark Goldstein, discovered he was in atrial fibrillation after purchasing an Apple Watch 4.
He now utilizes both the Kardia Mobile ECG and the Apple Watch to aid in his personal monitoring of his atrial fibrillation and has been actively pursuing a rhythm control strategy under the care of his electrophysiologist.
I asked him to share with my readers his experience which recently culminated in an ablation.
What follows is his description with my editorial comments in green.
December 2018 I bought a crazy, expensive Apple Watch. That watch may have saved my life. I spend much of my days at a treaddesk (a combination desk and treadmill). I was curious to find out how much exercise I was doing. I bought the watch, put it on, and starting walking as I do almost every day. Two hours later the watch had an alarm. It was warning me about something called “atrial fibrillation,” It said, “your heart has shown signs of an irregular rhythm.” What! I never heard of afib before. I quickly learned about it. Heart palpitations, no. Pain/pressure in the chest, no. Sweaty, faint, dizzy, etc., no, no. no. I checked the box for tired but I assumed it was because of the amount of exercise I was doing.
The next day I was fortunate that I had a physical scheduled a year ago. I told my doctor that my “crazy, expensive watch” thinks I have afib. My doctor laughed, telling me about how he had checked and probed every part of my body for the last 20 years (the probing part I remembered well). As the exam was concluding, he was puzzled by the afib warning so he grabbed my wrist to check my pulse. A few seconds later he was asking the nurse to give me an EKG. Darn, the watch was correct (and for me it was correct 99% of the time when I had afib and when I was normal – praise to Apple).
(This is a great example of how atrial fibrillation can be missed by the routine office physical examination. Some patients, especially those with non-rapid heart rates (due to rate slowing meds like beta-blockers or to intrinsically slow conduction of electrical impulses) are minimally symptomatic and their pulses don’t feel that irregular. Because the first symptom of afib can be stroke I am an advocate of screening)
Shortly I got to meet a cardiologist (like Dr. Pearson, they are all nice people). Another EKG, afib confirmed. As we were talking about my symptoms or lack of symptoms, he said that afib was a bit like Eskimo’s describing snow. Each snowflake is unique and each afib patient is unique. I was in persistent afib. Probably had been in this state for two or three years since my heart rate jumped while sleeping, exercising, and at rest.
(Each afib experience is unique but not all cardiologists are nice people. Mark has been fortunate.)
The treatment plan was a cardioversion, an electrical shock to the heart, or as my cardiologist described it “like rebooting a computer.”
(See my post on cardioversion here.)
As a tech person, I understood that. The risk of not fixing my afib was five times the likelihood of a stroke. The risks were minimal so I chose the cardioversion.
(A common misconception is that ablation or cardioversion eliminates or substantially lowers the risk of stroke in afib. This is not the case. I’ll devote a future post to delve into this issue.)
Cardioversion one lasted four days before my Apple Watch started to detect afib.
(I’ve described in detail how helpful patient utilization of personal ECG monitoring is in letting me know the rhythm status of patients prior to and following cardioversion here.)
The cardiologist next step was cardioversion two along with a drug to help with rhythm control. Number two lasted a month before I saw my heart rate jump again. I thought something was wrong even though my watch was not detecting afib. Another EKG, this time the result was aflutter. The cardioversions were indeed like a reboot of the computer. If you have a virus on your computer, a reboot may be a temporary fix but eventually the virus will return.
(There are many drugs whose purpose is to suppress the recurrence of atrial fibrillation. Mark was prescribed the extended release version of propafenone, a Type IC antiarrhythmic drug (AAD) similar in efficacy and side effects to flecainide. Type IC AADs should only be used in patients with normal left ventricular function (which was demonstrated in Mark by an echo) and without significant coronary artery disease (typically proven by a negative stress test).
To Ablate Or Not To Ablate
Now I got to meet an electrocardiologist. He said my afib would return and recommended an ablation. He said it was unlikely to be a permanent cure but it would help.
The aflutter disappeared after a day or so. I thought my afib was gone too but should I have an ablation? Ablations are relatively safe but since I was afib free why have the procedure?
I purchased the new Kardia Mobile six-lead portable EKG, a miracle of technology. Highly recommended for peace of mind. Just like my watch, I was seeing normal sinus rhythm. So why get an ablation?
A cardiologist had a YouTube video talking about the decision to have an ablation or any medical procedure. How will it affect the quality of your life or the quantity (how long will you live). This was a simple analysis and I like simple. I heard from my cardiologist that the evidence is that an ablation will unlikely extend my life nor will it reduce my lifespan. It was likely to not affect my lifespan. I confirmed this via independent research (be an informed patient, your outcomes will be better). See Dr Pearson’s articles about the CABANA study and the scientific evidence on ablation). So an ablation and quantity of life were neutral.
Importance Of Quality Of Life
Quality of life was more interesting. Could I do the things wanted to do with my life? Did afib affect my day-to-day life? Could I walk up a couple of flights of stairs without breathing hard? Was I getting tired at 10AM? Could I exercise? At the time, the answer was easy. I could do everything I wanted to do. The afib affect was just about zero except for blood thinner drugs which I suspect I will take forever. No ablation.
Then “the day.” I woke and checked my sleep app on my phone. Heart rate at night jumped. Hmm! I went to the gym. My heart rate while walking jumped too. I did 30 seconds of high-intensity exercise and my heart rate monitor said 205 beats per minute. My heart was beating so hard I had to sit for five minutes. I knew something was wrong. Then I climbed a couple of flights of stairs, something that would never bother me. I felt a shortness of breath. I knew my afib was back. I also knew that the quality of my life was now being affected. I could not do things I wanted to do. My watch and Kardia Mobile EKG confirmed what I knew.
I called my electrocardiologist and scheduled an ablation. He was right. Afib would return.
(Mark tells me that he was taken off his propafenone one month after the second cardioversion because “the PA said I no longer needed it since I was in sinus rhythm.” My practice would have been to continue the propafenone as long as well tolerated and effective in suppressing afib recurrence. In my experience, the recurrence of Mark’s afib may not have been a failure of medical therapy. I treat patients similar to Mark by continuing the anti-arrhythmic drug since the minimal risks are lowered by regular monitoring and I regularly see maintenance of SR.”)
(Other antiarrhythmic medications were mentioned to Mark but as they required a 3 day hospital stay he was not interested.)
Stay tuned: Part two Of Mark’s post will be about the ablation procedure which he recently underwent.
Skeptically Yours,
-ACP
Mark Goldstein works in the field of cybersecurity in the WashingtonDC area and can be contacted at https://www.linkedin.com/in/markhgoldstein/
15 thoughts on “Atrial Fibrillation Detection, Personal ECG Monitoring and Ablation: A Patient's Story”
RE Sleep Apnea and Afib: You might ask your critical care colleagues (that’s who diagnosed mine) if they have any idea what percentage of apnea patients have afib.
I have purchased the Kardia Mobile ECG thinking it would be of an assist, but have only once gotten a “may be in afib” reading from it. All other readings are “inconclusive.” Watching my heart beat in real time, and comparing it to my husband’s, I can see that I just have an odd rhythm all the way around, but my EP says I’m doing fine. More recently purchased an Apple Watch and get the same response (inconclusive) when taking my heart rate. I really wish I got a better response from one or the other, but no such luck. (My heart issues may all be related to my congenital defect, though both parents have issues with afib. I may just be a victim of the genetic lottery on that front.)
It’s hard for me to tell when I’m in afib, though the last time I jumped into it (Sep 2018), I actually nailed it to the day. I knew I was off and had to beg off from canvassing for the election. Confirmed by my next office visit and interrogation of my pacemaker. After 3 1/2 years, Flecainide had stopped working.
After a second cardioversion in Nov 2018, I’m on Dofetilide and Xarelto. Seem to be doing fine. A few blips here and there, so keeping my fingers crossed.
Sometimes inconclusive results from Kardia are due to low voltage recordings due to a vertically oriented heart. In such cases, utilizing a lead II recording often yields better results. I took about this on posts on this site. Basically you want to have one of the electrodes touching your leg and the other electrod in your right hand. I have a few patients who have frequent APCs which confuse the algorithm consistently.
Would that explain the same phenomenon with my Apple watch?
Yes. The Apple Watch is only capable of Lead I recordings
My experience has been very similar to Mark’s except I did not opt for an ablation. I was put on flecainide just prior to my second cardioversion, the first having lasted only a few days. I had already established a regular walking routine by this time, had changed my diet, and was losing weight. My afib remained under control. After about 6 months I asked my cardiologist if I could try reducing the flecainide dose. He approved, and all went well. After another few months he suggested I might try going off flecainide altogether which I did. Some months later the afib returned so back on flecainide. I’ve been successfully monitoring afib with an Apple 3 watch and the Kardia band ever since the band came on the market and have been off and on flecainide several times. Several months ago I was diagnosed with moderate sleep apnea, one likely cause of my afib. I’m still working at getting that under control – problems with the equipment. So I’m choosing to stay on flecainide until I feel the apnea condition is much improved. Then I’ll ask about trying to go off the antiarrhymic.
Dr. Pearson, do you have any idea what percentage of afib patients have sleep apnea? Mine was not discovered until 4 years after my afib diagnosis and then only because I requested being tested. Also, for sleep apnea patients with afib, what is the range of probabilities that controlling the apnea will control or partially control the afib, assuming other conditions such as high blood pressure, high cholesterol, etc. are under control?
Jane
Jane,
We consider sleep apnea as a possible trigger in our PAF patients. We take a good history but don’t routinely screen with testing at this. I’ve been actively evaluating various sleep apnea home testing devices. My favorite currently is the WatchPAT. If episodes of PAF consistently begin during sleep then we discuss referral for a sleep evaluation.
Your final questions are great ones and I fear the answers are not yet known. ” do you have any idea what percentage of afib patients have sleep apnea? Mine was not discovered until 4 years after my afib diagnosis and then only because I requested being tested. Also, for sleep apnea patients with afib, what is the range of probabilities that controlling the apnea will control or partially control the afib, assuming other conditions such as high blood pressure, high cholesterol, etc. are under control?”
The problem is sorting out the independent contribution of sleep apnea to PAF. Observational studies show an association but we need some RCTs.
As the article noted, my experience is almost exactly the same. I presented at the U. of KS Hospital as what turned out to be their first confirmed identification of an Afib with Kardia. After similar results, I am scheduled for an ablation. Need to study this some more after your article. Wow. Thanks.
Your blog on Heimlich Maneuver Blog. While reading your Blog on Subject article I wondered what your patients which have had TAVR,.Stents,,and Pacemaker installed. Under your direction I have had all three installed this year
Would a Linq monitor be appropriate for this patient or is the Apple device sufficient?
A Linq is a type of internal loop recorder (ILR) thus requires a procedure (minor) for insertion. It continually monitors but patient is unaware of what is going on. Abnormalities are transmitted if they reach a certain trigger threshold to the company and then to the physician monitoring them.
They would be more useful for patients who are totally unaware of their afib. Personally, I don’t use them for monitoring PAF.
Predominantly I have them inserted for evaluation of patients with unexplained stroke or syncope.
For patients who have symptomatic episodes of AF, a Kardia mobile ECG or Apple Watch would be better, less invasive, and much less costly.
ILRs are worthy of a whole series of post discussions which I hope to get to some day.
Dr Anthony,
That is a very helpful explanation. I’m in the exact opposite situation; I have a Linq device in my chest looking to see if afib was the cause of the stroke I had three years ago. I had an overnight EKG, a two week Holter monitor and now 9 months with the Linq device and so far no afib. My Vascular Neurologist (Dr. Ashis Tayal Allegheny Health Network Pittsburgh PA) wants to see a year with the Linq device before he takes me off the warfarin and switches me to a low aspirin dose.
Thank you for your very informative blog.
Philip Thackray
Renfrew, PA USA
Philip,
Glad I could be of help. You mentioned your “vascular neurologist.”
I’m aware of a few neurologists in St. Louis who have been trained as interventionalists and for acute stroke patients they perform angiography acutely and can retrieve clots from arteries to the brain. I’m taking care of a few patients who were treated that way and had dramatic resolution of stroke symptoms rapidly. It’s a pretty exciting development. Is this what happened in your case?
Dr Anthony,
I thought that I left a comment several days ago but it did not appear. So, I’ll try again.
Whatever else Dr Tayal does, for me we are only trying to access if afib caused my stroke and, if not, get me off of warfarin and on to low dose aspirin.
The medical intervention you describe sure sounds state of the art but my treatment proceeded more conventionally. When I had my stroke (blockage in two places) in July of 2016 I received a timely tPA treatment and luckily I have no physical symptoms. But I did develop a mild case of epilepsy, (auras and a few focal seizures) so I’m on Vimpat.
As far as looking for afib, in my case, I had an overnight EKG; two weeks with a Holter monitor and now 9 months with the Linq device and so far no afib.
Philip Thackray
The topic of searching for occult afib in patients with cryptogenic stroke is a fascinating one. Very complicated. The skeptic in me worries that several biases are affecting the data interpretation. Companies that make internal loop recorders like Linq would really like to increase sales by spreading the word that you can find more afib if you monitor patient for longer periods of time. They sponsor lots of dinners/conferences/talks and influence docs that way. Companies that make blood thinners would really like to find more afib as well-more afib means more sales. At the ACC annual meetings I see on the program lots of talks/lunches/dinners (I don’t attend) sponsored by combo of a pacemaker company/anticoagulant company with the goal of “increasing awareness” of occult afib as a cause of cryptogenic stroke. The doctors giving these presentations are receiving lots of money from the companies to give these talks and if the talks spin wasnt heavily in favor of how important it was to put loop recorders in and search for really long periods of time you know those doctors wouldn’t be giving those talks.