My Doctor Online The Permanente Medical Group

Symptoms

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Atrial fibrillation is a common heart rhythm abnormality that can happen at any age. However, the incidence increases as we age. Some patients do not detect any symptoms. Others experience symptoms including:

• Racing, uneven heartbeat
• Flopping, fluttering, or pounding feeling in your chest
• Heart palpitations
• Dizziness or lightheadedness 
• Sweating
• Chest pain (angina) or pressure
• Difficulty catching your breath
• Feeling weak and tired
• Fainting or near fainting
  

Diagnosis

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Since atrial fibrillation may not cause any symptoms, it is often detected when a rapid, irregular heartbeat is noted during a physical exam.
 
Atrial fibrillation can be confirmed with an electrocardiogram (EKG/ECG), a test that checks the heart's electrical activity.

Once a diagnosis is made, other tests will usually be done that help identify causes and guide treatment. These tests may include:

• Lab tests to show the levels of thyroid hormones and certain electrolytes (minerals) in your blood.
• Chest X-ray.
• Echocardiogram, which is an ultrasound picture of the heart that gives information about the chamber size and function and valve function.

Causes

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There are many conditions that can lead to the development of atrial fibrillation. However, in many patients we do not find the specific abnormality that causes it. Some of the more common conditions that can potentially lead to atrial fibrillation include:

• High blood pressure
• Coronary artery disease (CAD)
• Heart valve disorders
• Heart disease or damage
• Obstruction sleep apnea
• Other medical conditions such as lung disease, pneumonia, and hyperthyroidism

Treatments

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Getting treatment for atrial fibrillation is important in order to lessen the risk of heart failure or stroke. There are several ways to treat your condition. We will determine the best option for you based on the cause, your symptoms, and your risk for stroke.

Our goals for treatment usually are to:

• Control your heart rate.
• Try to restore a normal rhythm.
• Prevent blood clots from forming in the heart.
• Lower your risk of having a stroke caused by atrial fibrillation.
  

Hospitalization

Hospitalization is occassionally needed for atrial fibillation when the rapid heart beat is sustained and cannot be controlled with oral medications. There may be other symptoms such as chest pain and difficulty breathing that will require intravenous medications and close monitoring.

Cardioversion

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We might recommend a procedure called cardioversion to help your heartbeat return to a normal rhythm. There are 2 common forms of cardioversion:

• Chemical cardioversion. This involves taking a medication to convert your heart rhythm to normal.
• Electrical cardioversion. This involves receiving a low-voltage electrical shock through paddles or patches on your chest. During this process, the shock converts your irregular heart rhythm back to normal. We may recommend electrical cardioversion if chemical cardioversion does not work well for you.

Medications

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Medications are used to either slow your heart rate or to try to keep your heart in a normal rhythm. In most cases, we first treat atrial fibrillation by controlling your heart rate with medication. Sometimes a cardioversion is needed to return your heart into a normal rhythm. Atrial fibrillation can sometimes resume after cardioversion treatment. In these cases, medications called antiarrhythmics are given to keep your heart in a normal rhythm. In general, medications used to treat atrial fibrillation include the following:

Rate-control medicines. These medications keep the heart from beating too fast during atrial fibrillation.

Some common rate-control medications include:

• Metoprolol (Lopressor), Atenolol (Tenormin)
• Verapamil (Calan, Isoptin)
• Diltiazem (Cardizem, Tiazac)
• Digitalis (Digoxin, Lanoxin, Digitoxin)

Rhythm-control medicines (antiarrhythmics). These medications help return the heart to its normal rhythm and keep it there.

Some common antiarrhythmic medications include:

• Amiodarone (Cordarone, Pacerone)
• Flecainide (Tambecor) 
• Propafenone (Rythmol)
• Sotalol (Betapace)
• Dofetilide (Tikosyn)

These medications can help keep a normal heart rhythm, but they sometimes cause side effects, including:

• Nausea
• Dizziness
• Fatigue
• Headache
• Congestive heart failure 
• Slow or abnormal heartbeat

In many cases, we will also recommend that people with atrial fibrillation take a blood-thinning medicine to help prevent strokes, like the anticoagulant warfarin (Coumadin). Alternative medications include Dabigatran (Pradaxa). Taking aspirin and/or clopidogrel (Plavix) might also be an alternative for those patients who cannot tolerate warfarin. 

Procedures

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In some cases, cardioversion and medicines do not help improve the atrial fibrillation symptoms. When this occurs, we may suggest one of the following procedures:

• Ablation. This procedure disables the small area of the heart's electrical system that causes or maintains the irregular heart rhythm. In this process, tiny wires are threaded into a vein that leads to the heart. An X-ray monitors the wires as they reach the heart. The wires are then heated at the end, which destroys (ablates) the tissue or the node in the heart that is causing atrial fibrillation. Patients are often awake during the ablation procedure, but the area where the wire enters the body will be numbed. It usually takes 2 to 4 hours, and patients are closely monitored after the procedure.
• Heart surgery. We might consider surgery to stop atrial fibrillation. A common surgery for atrial fibrillation is called the maze procedure. The surgeon may use one of several methods to create scar tissue, which blocks the electrical signals that cause atrial fibrillation. Surgery is performed to treat atrial fibrillation only when it cannot be corrected with any other treatment and at the same time as another surgical intervention, such as valve replacement or bypass. Open heart surgery will require staying in the hospital and being monitored for several days following the surgery.
  

Lifestyle Management

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Atrial fibrillation is often a result of heart disease or damage. Making choices that improve the health of your heart may also improve symptoms of atrial fibrillation and lower your risk for heart attack and stroke. Heart-healthy choices include the following:

• If you use tobacco, stop. Quitting smoking can quickly reduce your risk of stroke and heart attack.
• Eat a heart-healthy diet including plenty of fish, fruits, vegetables, beans, high-fiber whole grains, and monounsaturated fats. Avoid saturated and trans fats.
• Get regular exercise on most or all days of the week.
• Control your cholesterol and blood pressure levels. If you have diabetes, keep your blood sugar in your target range.
• Find ways to manage your stress. Stress can put extra demands on your heart, damaging it over time.
• Limit your intake of caffeine, alcohol, and other stimulants.
• Avoid the flu. Be sure to get a flu vaccination each year.

Your Care with Me

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If you think you may be having a heart attack, or if you have chest pain or pressure that lasts more than 5 minutes, call 911 or seek other emergency services immediately.

If you have emergency symptoms as described above, do not use this website to e-mail your doctor, but instead call us immediately.

If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If cardiologist’s care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

If you have been seen before by a cardiologist outside of Kaiser Permanente, please bring those medical records with you. Also, please bring with you all your containers with any prescription medications and any over-the-counter medications you are taking.

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If you have been seen before by a cardiologist outside of Kaiser Permanente, please bring those medical records with you. Also, please bring with you all your containers with any prescription medications and any over-the-counter medications you are taking.

At some facilities, we have an atrial fibrillation class that will explain about atrial fibrillation and go over your options for treatment. If you have a weakened heart muscle, I may refer you to our Heart Failure Care Management Program. The nurse or pharmacist care manager will adjust your medications to help improve the function of your heart. We also have a series of classes to learn about heart failure.

Many people with atrial fibrillation are started on a blood-thinning (anticoagulant) medicine. If that is the case, I will refer you to a pharmacist who will monitor and adjust your dose based on regular lab tests to get the best effects and prevent complications.

If we have prescribed blood thinners for you, be sure to:

• Take the medicine at the same time each day.
• If you plan to make changes to your diet or start a weight loss program, talk to us first. Sometimes the foods you eat can affect how well blood thinners work for you.
• Tell your dentist, pharmacist, and other health professionals that you take blood thinners.
• Notify us if you have unusual bruising or bleeding, such as blood in your urine, maroon or black stools, or bleeding from your nose or gums.
• Get regular blood tests to check how fast your blood clots, if you are taking warfarin.
• Wear medical alert jewelry that says you take blood thinners. You can buy this at most drugstores.
• Do not take any vitamins, over-the-counter medicines, or herbal products without talking to us first.

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Contacting Me

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Seek immediate medical care if:

• You are having chest pain more often than usual.
• You feel lightheaded or dizzy, or feel you might faint.

If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

For example, while you are on anticoagulants, call if:

• You cough up blood.
• You vomit blood or what looks like coffee grounds.
• You pass maroon or very bloody stools.

Call me now or seek immediate medical care if:

• You have new severe bruises or blood spots under your skin.

Take your medication exactly as prescribed. If you are having problems with or have any questions about any of the medications I have prescribed for you, let me know. Do not stop taking them without notifying me.

If I prescribed nitroglycerin for you, keep it with you at all times. If you have chest pain, sit down and rest, and take the nitroglycerin as directed. If your chest pain does not get better in 5 minutes, call 911.

If you had surgery or a procedure, please call me if you notice any swelling, redness, pain or discharge at the incision site.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

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If you are considering surgery, a procedure or want more information about your heart problem, please review our health tool called “Preparing for Your Procedure” (Emmi). Emmi programs are available for the following cardiology topics related to your problem:

• Atrial Fibrillation Overview
• Taking Warfarin (Coumadin®)

Emmi programs are also available for the following cardiology topics:

• Anesthesia for an Adult
• Angiogram with Possible Angioplasty
• Aortic Valve Replacement
• Cardiac Catheter Ablation (SVT)
• Cardiac Catheter Ablation (VT) 
• Cardiac Pacemaker
• Coronary Artery Bypass Surgery (CABG)
• Defib (Cardiac Resynchronization Therapy Defibrillator)
• Defib (Implantable Cardioverter Defibrillator) 
• Mitral Valve Repair or Replacement

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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