Other questions on paroxymal a-fib

Hi Dr. McWilliams:
Many thanks for your reply to my questions of June 24, 2008.  Your reply has prompted me to ask you several other questions.  First of all I was probably remiss in not stating on my question to you yesterday that after my CABG and during my hospital stay after the stroke, EKG monitoring and other rhythm tests, have not indicated any evidence evidence of paroxsymal a-fib.  The only thing indicated on such tests have been some PVC's  Accordingly, other than the MRI results of the  location of the infarction my neurologist's conjecture of paroxsymal a-fib being a cause of my stroke is not substantiated by any substantive rhythm test results.  That being the case I would really appreciate your answer to the following questions:
(1) Since the paroxsymal a-fib at this juncture has not been substantiated on any type of any recent heart rhythm monitoring, do you think it is still prudent to immediately consider taking coumadin rather than plavix prior to any further testing, and if so do I need to be weaned off of plavix in the transition period?
(2) What tests would your recommend to ascertain whether paroxsymal a-fib could have been the precipiating cause of my stroke?
(3) Since I eat a lot of food that contains Vitamin K, is there any chance that my body could be producing excess coagulation enzymes that could cause an emboli?
(4) If I do have paroxsymal a-fib, what is the typical treatment protocol, and can the condition be cured?
(5) What, if any lifestyle changes, does a person with paroxymal a-fib need to make?
(6) How may I arrange a consultation with you and do you believe a long-term doctor-patient relationship would be workable considering that I live in Kansas and your practice is in North Carolina?  
(7) If after testing paroxsymal a-fib is confirmed, would the Cox-Maze procedure I had two years ago be considered unsuccessful and if so, would such failure preclude successful ablations in the future?
Thanks for your help!

[Michael J. McWilliams, M.D.]

1.  That is a tough question to answer.  If your doctors think that the stroke is consistent that a cardiac source, I am not sure what option you have besides coumadin.  Plavix and aspirin only slightly decrease your risk of stroke.  Plavix does not need to be weaned.

If you have a history of paroxysmal atrial fibrillation, it is very possible to not capture it on short term monitor.  You need to talk to your doctor about the risks, benefits and alternatives to coumadin and your risk of recurrent stroke, and then make an informed decision about whether you want to take it.  

2. If your MRI is consistent with cardio emboli, I would assume that it is and what to see over time if the atrial fibrillation returns.  I would do a 30 day monitor to look for asymptomatic atrial fib, but if it was negative I probably would not stop it.

3. No, you body regulates that closely.

4. It can be cured but there is no evidence that curing atrial fibrillation reduces the risk of stroke.  This is something that some physicians assume, but has never been proven.  If you have stroke from atrial fibrillation, I would not stop the coumadin.  If you have no symptoms with atrial fib, rate control is sufficient.  If you have symptoms not improved with rate control, the medical and procedural management depends on many factors.

5. Avoid triggers for atrial fib if any are known.

6. To be completely honest, there is nothing that I can offer you here in NC (beside beach) that you cannot find in Kansas.  On my colleagues from the Cleveland Clinic, Dhanunjaya Lakkireddy, works at the Mid America Cardiology at the University of Kansas.  He is very bright, procedurally excellent, and a good clinician.  I am always happy to see new patients but I think given the distance it is probably better to see someone closer to home with good training.  DJ Lakkireddy is on the cutting edge of atrial fib treatments.

7. I am not sure that I would say that it failed but it didn't last.  This would not preclude you from catheter based ablation.

I am not sure that you can be 100% sure that your stroke was from atrial fib.  You need to work with your team of doctors to figure that out and coumadin may be indicated while they are working that up.  If you want a second opinion, I would recommend the University of Kansas.

I hope this helps and good luck.