My life has taken a. turn for the better. AF Answers. A Patient Education Handbook on Electrophysiology

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1 My life has taken a turn for the better. AF Answers A Patient Education Handbook on Electrophysiology

2 My episodes of atrial fibrillation (AF) kept me from fully enjoying what I was accustomed to doing. It was like having to push through a wall there was a fatigue level that was always present. There were times that I would be teaching needlework classes and I was not able to teach the way I really wanted to teach. When the episode finally passed, the class had already ended. After my procedure, life has improved because I do not worry about my AF any longer. I have had a complete return of my energy. I have been able to return to everything that I have wanted to do and am able to continue with my designing and needlework without any complications. My life has taken a turn for the better. I feel like I ve been given another hundred thousand miles or 10 year warranty. Emie Bishop Wife, Mother, Grandmother, Skilled Needle Worker, Arrhythmia Patient Like Emie, many patients find relief from symptoms of an arrhythmia with a cardiac treatment plan. This brochure will provide an overview of the causes, diagnosis and treatment of various arrhythmias. As you read this please keep in mind that every patient is different and each treatment option carries specific risks and benefits. Not all treatment options are appropriate for every patient. All treatment results and outcomes are specific to the individual patient, and results may vary. With the advice of your physician and the information contained within this brochure you can learn about your treatment options.

3 What is Atrial Fibrillation? Atrial fibrillation (AF) is the most common type of abnormal heart rhythm and is found in approximately seven million people around the world. Atrial fibrillation is a very fast and disorganized heartbeat that occurs in the upper chambers of the heart (the atria). During AF, the atria may beat between 350 and 600 times per minute, making them appear to quiver (fibrillate) rather than beat. As a result, the heart loses its ability to pump efficiently. What are the symptoms of Atrial Fibrillation? The symptoms of AF include: Palpitations Irregular heart beat Shortness of breath, chest discomfort Dizziness Yet many people who have AF do not experience these outward symptoms. Regardless, anyone with AF is at risk for one of its most dangerous side effects: stroke. Because of the extremely fast beating of the atria, the heart s pumping action does not work properly and blood is not completely emptied from the heart s chambers. This can cause it to pool and develop blood clots. If a clot breaks free, it may result in a stroke. People who have atrial fibrillation are five times more likely to have a stroke than people who do not have AF. 1 What causes Atrial Fibrillation? Several conditions can contribute to the development of AF, including: High blood pressure Coronary artery disease Chronic lung disease How will my physician determine if I have Atrial Fibrillation? The first step in diagnosing AF is a thorough medical history and physical exam. It is important to let your physician know about your symptoms and provide information on when they began, how long they last and what they feel like. In addition, your physician may choose to use one or more tests. These may include: Electrocardiogram An electrocardiogram (ECG) is a simple test to record your heart s electrical activity. Electrodes are placed on the arms and chest and connected to a machine that records electrical activity on graph paper. The test may be performed while you are resting or during exercise. Holter monitor A Holter monitor is a small portable device used to make a recording of your heart s electrical activity for an extended period of time 24 to 48 hours. The information can be used to detect a rhythm problem that may occur during your normal daily activities. Tilt-table test A tilt-table test is used to monitor your blood pressure, heart rate and heart rhythm as you are moved from a horizontal position to an upright position. The test can be used to help determine the cause of symptoms that you may be experiencing, such as fainting or light-headedness. Electrophysiology study An electrophysiology (EP) study can help confirm the type of rhythm problem you have. An EP test is performed by an electrophysiologist. The procedure is minimally invasive and is performed under local anesthesia. During the test, electrode catheters are introduced through a blood vessel, advanced into the heart and used to stimulate the heart with electrical impulses. Your heart s electrical activity during the test is monitored, recorded and then used by your physician to determine the best treatment option. Heart failure Cardiomyopathy (damaged heart muscle) Congenital heart disease (heart disease you are born with) Pulmonary embolism (a blood clot in the vessels of the lungs) The risk and severity of AF also increases with age. According to a major clinical study, at age 40 years and older, the lifetime risk for development of AF is high (one in four) even without a history of heart attack or heart failure. 2 1 American Heart Association, Benjamin EJ, et al: Independent Risk Factors for Atrial Fibrillation in a Population-Based Cohort: The Framingham Heart Study

4 What treatment options are available? The goals of an AF treatment plan are to: Restore a normal heart rhythm Control your heart rate Reduce your stroke risk Help you return to a healthy, active life Your physician will work with you to develop a treatment plan. The treatment prescribed will depend on the severity of your AF, your symptoms and your lifestyle. Treatment options can be placed in two categories: suppressive and curative. Suppressive therapies work to suppress, or control, symptoms; curative therapies are designed to eliminate the cause of the condition and have the potential to cure. Available treatment options include: Supressive therapies Catheter ablation procedure For many patients, there are different types of arrhythmias. One method available to diagnose and treat an arrhythmia is an electrophysiology study and ablation. An EP study can help determine the origin of a patient s arrhythmia and may indicate a patient s potential response to therapy. Precision and extreme accuracy in EP testing are crucial to providing arrhythmia patients with an accurate diagnosis. During an EP study, a physician inserts several long, flexible wires with electrodes at the tip, called electrode catheters, through either blood vessels in the arm or near the groin into a patient s heart. These catheters collect electrical information from inside the heart and then display this data on several monitors for the EP team to see. Once the arrhythmia is diagnosed, your physician will discuss whether you are a candidate for catheter ablation and what approach is right for you. Drugs Several different types of medicine can be used to treat AF. Some medicines can be used to help restore and maintain a normal heart rhythm. These types of medicines are known as antiarrhythmics. Other medicines may be prescribed to control your heart rate. Anticoagulant medicines are often prescribed for people with AF to help reduce the risk of blood clots forming and causing a stroke. Electrical cardioversion Occasional episodes of AF can be treated electrically with a procedure called cardioversion. During the procedure, an electrical shock is delivered to your heart to stop AF and restore a normal heart rhythm. The procedure is performed at the hospital under temporary anesthesia. During an ablation procedure, a catheter applies high-frequency energy on the inside of the heart, creating a lesion, or scar. As a result, this tissue is no longer capable of conducting or sustaining the arrhythmia. What are possible complications and risks of the catheter ablation procedure? Because ablation procedures require the insertion of catheters into the body, they do involve some risk. * Some patients can have bleeding, swelling or bruising where the catheters were inserted. CATHETER INSERTED THROUGH A BLODD VESSEL IN THE ARM Implantable devices A device such as an implantable defibrillator or pacemaker can be used to suppress the symptoms of AF with low-dose electrical energy. A special algorithm programmed in the device makes this possible. Curative therapies Catheter ablation For many patients, a procedure called catheter ablation may be recommended. During the procedure, small wires or electrode catheters are placed through a blood vessel into the heart to record electrical activity and help locate the problem areas responsible for AF. After locating these areas a physician uses an ablation catheter to apply high-frequency energy to the inside of the heart, creating a lesion or scar. As a result, the tissue s electrical pathway is isolated from the rest of the heart or made incapable of producing AF. Surgical ablation Surgical ablation may be an option for people who cannot tolerate drugs or for whom these and/or other therapies have been ineffective. During this procedure a physician applies energy to the outside of the heart, creating a lesion or scar that blocks abnormal electrical signals that cause AF. Patients who undergo cardiac surgery, such as a valve replacement or coronary artery bypass graft (CABG), may be advised to undergo AF ablation at the same time. Serious complications do sometimes occur. These include infection, damage to the heart or blood vessels and blood clots. It is also possible that the heart s normal electrical system could be damaged during this procedure. If this occurs, an artificial pacemaker may be necessary. Although all types of anesthesia involve some risk, individual side effects and complications from anesthesia can vary. Specific risks can differ depending on various health factors. Any potential concerns should be discussed with your physician. *Mayo Clinic; CATHETER INSERTED THROUGH A BLODD VESSEL IN THE GROIN Catheter ablation

5 What are the benefits of the catheter ablation procedure? The procedure is minimally invasive. It may permanently interrupt the triggers of the heart arrhythmia; many patients require no further treatment. For some patients, it brings freedom from long-term use of blood-thinning medications. Recovery is relatively fast; most patients leave the hospital after one or two days and resume normal activities a few days after the procedure. This information is intended as a general overview. Your experience may differ. Please talk with your physician for specifics regarding your case. * After the procedure Following the procedure, you will be moved to a recovery area where you will be monitored for complications from the procedure. Depending on your condition, you may be able to go home the same day as your procedure, or you may need to stay in the hospital for one to three days. After you return home, you should limit your activity for several days, avoiding all vigorous physical exertion and strain (such as lifting heavy objects.) Additionally, you should carefully follow any instructions your physician has given you regarding medications. Bruising or a small lump located at the site where the catheters were inserted is not unusual. However, should the site become warm to the touch, tender, painful or swollen, you should contact your physician. In addition, should you develop a fever or experience a recurrence of your rapid heart rhythm, chest pain, dizziness or shortness of breath, you should contact your physician immediately. Although catheter ablation is often successful, some people require repeat procedures. You may also need to take medications, even after you ve had an ablation procedure. Your physician will determine the best option for you. Patient resources To learn more about AF, talk to your physician. Below are other resources you may find useful: American Heart Association Heart Rhythm Society Mayo Clinic Frequently asked questions: What are atria? Atria are the two upper chambers of the heart. What are ventricles? Ventricles are the two lower chambers of the heart. What are heart palpitations? Heart palpitations are described as a pounding, racing or fluttering of the heart. Is atrial fibrillation genetic? AF can occasionally be genetic, meaning transmitted through the genes, and hence recurrent in a given family. Is atrial fibrillation a prelude to a heart attack? No; a heart attack is a sudden event in which a portion of the heart muscle stops working because it no longer receives blood, usually due to a blockage in the coronary artery, whereas AF is primarily an electrical or rhythm problem that causes the heart to beat too fast. Can I die from atrial fibrillation? Most episodes of AF are not life threatening, but AF is a progressive disease and tends to get more severe over time. The biggest danger from AF is the increased risk for heart disease and stroke, both leading causes of death in the United States. What are Warfarin and Coumadin? Both are drugs taken by mouth to prevent blood clotting. What is Heparin? Heparin is a drug given directly into a vein; it thins the blood when there is a danger of clotting. What does an ECG record? An ECG (sometimes called an EKG) records the heart s electrical activity. What is a transesophageal echocardiogram? A transesophogeal echocardiogram (TEE) is a procedure that uses ultrasound waves to obtain images of the heart structure and function. These images are obtained by inserting a small, microphone-like transducer, which is attached to the end of an endoscope, into the esophagus. Can atrial fibrillation go away by itself? On occasion this does happen. In a process called spontaneous remission, the heart adjusts to whatever caused the AF and starts beating normally. This is very rare, however, and you should continue being supervised by your physician. Is atrial fibrillation curable? While today there is no cure for AF, many physicians are achieving improved success in the treatment of this disease. Because AF is easier to treat in its earlier stages, you should not wait to explore your treatment options. *Mayo Clinic; 2009

6 What is the heart s healthy rhythm like? In a normal heart, blood flows into the right side of the heart and then is pumped out to the lungs to receive oxygen. The oxygen-rich blood then returns to the left atrium and ventricle, where it is pumped through the aorta out into the body. The blood delivers oxygen to all organs of the body, then flows back to the right side of the heart to begin the cycle again. The heart s electrical system is what regulates the rhythm and keeps the heart pumping. A normal heart rhythm is called sinus rhythm and begins in the sinoatrial (SA) node, which is the heart s natural pacemaker. The SA node initiates an electrical impulse that travels through the right atrium to the atrioventricular (AV) node. The AV node is the gatekeeper to the ventricles and regulates with electrical impulses that are passed to the ventricles. Once an electrical impulse reaches the ventricles it causes the lower chambers to contract and pump blood out to the body. SUPERIOR VENA CAVA What is Atrial Fibrillation? Atrial fibrillation is the result of abnormal electrical impulses that originate in the left atrium and pulmonary veins. These impulses travel chaotically throughout the atria, causing them to contract so quickly that they appear to quiver rather than beat. The AV node protects the ventricles from many of the impulses, but some make it past the gatekeeper and force the heart to beat very rapidly, irregularly and ineffectively. SUPERIOR VENA CAVA SINOATRIAL (SA) NODE ATRIOVENTRICULAR (AV) NODE PULMONARY VEINS Atrial Flutter Atrial flutter is a re-entrant tachycardia that moves round and round in racetrack fashion, usually in the right atrium. The resulting rhythm is organized, but so rapid that the atria are not able to fully empty their contents into the ventricles. Symptoms may be pounding of the heart or heart palpitations. Wolff-Parkinson-White syndrome Also known as pre-excitation syndrome, Wolf- Parkinson-White (WPW) syndrome is a fast heart rhythm in which the normal electrical signals in the heart travel along an extra, abnormal electrical pathway that bypasses the AV node. WPW syndrome is associated with an increased risk of dangerous ventricular arrhythmias and sudden death. INFERIOR VENA CAVA SINOATRIAL (SA) NODE PULMONARY VEINS Atrial fibrillation Atrial flutter WPW ATRIOVENTRICULAR (AV) NODE INFERIOR VENA CAVA Heart healthy rhythm Other arrhythmias treatable with catheter ablation Focal tachycardias In focal tachycardias, also called ectopic arrhythmias, a site other than the SA node is starting the heartbeat, which may cause the heart to beat faster. Atrioventricular Nodal Re-entrant Tachycardia Atrioventricular nodal re-entrant tachycardia (AVNRT) is a fast heart rhythm where an extra electrical pathway is found in or near the AV node. When an electrical impulse travels along this extra pathway, it is repeated in a circular fashion, resulting in a fast heartbeat. Many patients with AVNRT will have a rapid heart rate (160 to 220 beats per minute) and feel a sensation of chest pressure, i.e. pain or shortness of breath. Some patients may feel light headed or may even faint. In patients with coronary artery disease, AVNRT may cause angina (chest pain) or myocardial infarction (heart attack). AVNRT

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