CW: Treating atrial fibrillation in athletes: Tough choices

The number of emails that come from fellow cyclists (and endurance athletes) with heart rhythm issues amazes me. I am more convinced than ever that our “hobby” predisposes us to electrical issues like atrial fibrillation (AF)—that the science is right.

Obviously, my pedaling “habit” creates an exposure bias. I hear from many of you because we cyclists understand each other. Like you, I consider not competing a lousy treatment option.

As a bike racer, I know things: that prancing on an elliptical trainer at a health club doesn’t cut it, and, that spin classes may look hard, but do not come close to simulating real competition. I know the extent of the inflammation required to close that gap, to avoid getting dropped when one of the local Cancellara-types have you in the gutter in a cross-wind, or the worst one of all, to turn yourself inside out to stay with a group of climbers over the crest of a seemingly endless hill—”ten more pedal strokes and I’m out”…Then ten turns to 20, then 40, and maybe you hang, and maybe not. The common denominator of all this: suffering.

It’s little wonder that we get AF.

With that as a backdrop, my goal for this post is to provide a modest amount of insight to the most common question asked by athletes with AF.

“Should I have an ablation, or not.”

Though my two episodes of heart chaos amount to only a mild case of AF, I think it’s fair to say that personal experience with a problem helps a doctor better understand your choice. I’ve thought to myself, on more than one occasion, what would I do if the watt-sucking irregularity persisted? Would I have an ablation; would I live with it; would I stop drinking so much coffee?

Here’s a stab at highlighting some of the real-world issues that come up frequently when talking with AF-patients in the office:

Intro: Before moving on with any AF-therapy, you should do three things:

• Make sure that the diagnosis is correct. I frequently see patients incorrectly diagnosed with AF. They are said to have AF, but actually have a focal atrial tachycardia or common atrial flutter. The distinction is important because the latter two problems can be ablated with a simpler and less risky ablation procedure.
• Stop inflaming your heart with known irritants. I am sorry to tell you this, but alcohol, caffeine, and cold remedies can exacerbate–and in some cases cause–heart rhythm problems. Before taking an AF drug, or having burns made in your left atrium, you should try eliminating mochas, gin and tonics, beer and wine. Got a cold; try my favorite remedy: low-sodium chicken soup. Remember, you are middle-aged now. What was tolerable in your twenties, is no longer such in your fifties.
• Pay attention to your sleep habits. Disordered sleep is strongly associated with AF. Because skinny people can have sleep apnea you might consider getting a sleep study. At minimum, try improving your sleep hygiene. There are few more potent anti-arrhythmic agents than a good night of sleep.

If these “simple” measures fail, and your confirmed case of AF persists, you have three choices for controlling the heart rhythm. (The below discussion assumes that your heart rate is well-controlled and your blood thinned, if appropriate.)

Option A: Live with AF:

Not treating AF is a choice. I strongly believe in patient-centered medicine. That means, I hear about your symptoms, teach you about the disease, lay out the pros and cons of treatment, and you choose what’s best for you.

For an athletic person without underlying health conditions, AF is not life-threatening. You don’t have to take suppressive drugs, or have a procedure; you could just have AF. And for some, say for example, those with infrequent episodes, minimal symptoms, or those who can accept lower power outputs, foregoing a rhythm-controlling strategy is a viable choice.

An important caveat about declining a rhythm-controlling strategy now, is that later-stages of AF are harder to treat. Many–though not all–cases of intermittent AF progress to persistent or permanent AF. You don’t have to decide on AF-treatment tomorrow, but if you change your mind five years later, restoring regular rhythm becomes a much steeper hill.

The final factor that looms large for patients who accept permanent AF is population data that suggests AF increases the risk of health complications down the road.

Option B: You could take medicine:

In general, for athletes, AF-drugs have significant limitations:

• At best, they suppress AF only half the time;
• When they do work, they are often partially effective, decreasing the frequency or duration of episodes;
• Athletes have low resting heart rates, and nearly all AF-drugs lower heart rate;
• AF-drugs reduce exercise performance by decreasing either maximal heart rate or the strength of the heart contraction, or both. This truth is a real problem for athletes.

The thing that many doctors don’t know about competitive athletes is that the difference between first and last place in a bike race is razor thin. Those five beats per minute, or twenty watts off the top end produce huge differences in results, and thus, in many cases, self-esteem.

The final point to make about the use of AF-drugs in competitive athletes is one of risk. People talk about the high-risk of AF-ablation, but what is not often mentioned is that studies demonstrating the safety of AF drugs did not include large numbers of “extreme” people like you. We know that smartly-administered AF-drugs in regular people with normal hearts is safe. But is that data generalizable to those of us who close gaps, battle headwinds, and push ourselves to Ironman-like feats? I don’t know for sure, but I wonder whether racing (aka, red-lining) around on drugs that affect the electrical properties of the heart could be called “safer” than ablation?

Option C: You could have an AF-ablation:

The treasure of AF-ablation is eliminating episodes without taking drugs that impair our athleticism. For the afflicted, that’s a big pot of gold.

In people with intermittent AF and normal hearts, AF-ablation equals Pulmonary Vein Isolation. The triggers (or “drivers”) of most cases of early-stage AF arise from the muscle sleeves that wrap the pulmonary (lung) veins. AF-ablation, through point-to point burns, seeks to electrically isolate (“build an electric fence”) around the orifices of these veins. Though an oversimplification, the notion holds that this electric fence keeps the AF from getting to the atrium. The “success” rate of AF-ablation in endurance-athletes is probably the same as the general population–around 70-90%.

AF-ablation in 2011 is much different than it was just a couple of years ago. Approaching AF with a catheter now represents a majority of my procedures. What was once a four hour procedure that sapped you for the day, can now be done in two hours. It is routine to do two ablations in a day. What took sixty minutes of X-ray exposure now rarely exceeds twenty-five minutes.

Here are three reasons for this renaissance in AF-ablation: (there are more)

• Like many AF-centers, both my own, and our lab’s experience have reached a threshold. AF-ablation has become routine. We have a great team of players. Though it’s not always politically correct to say this: AF-ablation, like much of modern, tech-intensive medicine, is best done by dedicated, specialized personnel.
• The neural pathways required to perform point-to-point navigation of a catheter in the left atrium have become etched in my brain. The largely human task of feeling the tactile sensations of an ablation catheter in a three dimensional heart chamber took years, and hundreds of cases to learn.
• GPS technology built into catheter mapping systems—made by medical companies like J&J, and St Jude Medical—succeeded in the rare feat of delivering more than promised. Could I do AF-ablation without expensive mapping systems? Sure I could, but these systems clearly increase the effectiveness and safety of the procedure.

Though AF-ablation has improved greatly, it still could not be called a mickey-mouse procedure. It requires general anesthesia, thousands of dollars of equipment, and a half-dozen specially-trained personnel. It is a shining example of the fury of modern medicine. And there is risk. Major complications include, death, stroke, pulmonary vein blockage, esophageal damage, heart perforation, and blood vessel damage to the legs. The published complication rates are in the range of 2-10%. There’s little doubt that complication rates vary with experience, and that many ablators minimize the risks.

Even when AF-ablation goes well, it’s hard on you. A past AF-ablation patient who happened to be a gifted writer sent me a note describing that his groin areas felt as though they had been stomped on by a guy wearing golf cleats.

The most nagging problem with AF ablation is that AF can come back. Recurrence after a “successful” ablation occurs because the electric fence around the veins isn’t as durable as we would like. More than one in three patients require a second ablation to “spot-weld” leaks in the electric fence—to re-isolate the pulmonary veins. You should hear this fact loud and clear from your AF doctor. We all hope that technology can help us make more lasting lines of electrical block. We need more fury.

Finally, there are many unknowns about the long-term effects and real outcomes of AF-ablation. For the relief of AF-symptoms, we know that ablation crushes medicines. But does it reduce hard outcomes like hospitalizations, stroke rates, and mortality? These are the big questions that ongoing clinical trials (like CABANA) will surely shed light on. In this regard, some early and preliminary data show promise. This look-back (retrospective) study presented at last month’s ACC meeting showed that AF-ablation may reduce the risk of stroke.

Here’s a hunch from years of following AF patients that I have ablated: AF-ablation is going to look better than current-day AF-drugs.

Summary:

Athletes with AF face a tough choice. The disease tugs at what we hold so precious: our beloved vigor. Each treatment has limitations, risks and benefits. No magic potion exists. No hike to the treasure easy.

I wished you didn’t have to decide.

But…I hope this helps.

JMM