New ESC Guidelines on AF

[Cliff_G]

Very disappointed but not surprised. No serious coverage of vagal AF, other than saying disopyramide can help.

[PlanetaryKim]

Do you have a link for the new guidelines?

[CDreamer in reply to PlanetaryKim]

You might be interested in section 13 - considerations for treatments for females and the different reported presentations and need for individualised treatment. Yeah! I call just that progress!

[CDreamer]

academic.oup.com/eurheartj/...

Review of their guidelines with some interesting thoughts

medscape.com/viewarticle/93...

[CDreamer]

Are you disappointed just about the lack of information on Vagal AF or the paper as a whole?

[BobD Volunteer in reply to CDreamer]

Surely AF is AF is AF? The vagus nerve is just another part of the body which can be inflamed and we know that any inflamation can exacerbate AF. I accept that some treatments (beta blockers for example) may be inapropriate if your AF is vagally mediated but it is not a separate condition.

[Cliff_G in reply to BobD]

Absolutely not, Bob, which is why I am so diasappointed. It's the effect of the vagus (inflamed or not) on the heart muscle. The eminent Phillippe Coumel described it back in the 70s and if you are someone who fits the pattern, it is a very important consideration, and I speak as someone who has lived with this since 1995. Simply, it arises from being vagally hypertonic, which can include inflammation or afferent/efferent interplay between the gut and the heart. If I read his work correctly, the neurotransmitters released at the sinus change the properties of the heart muscle, and when consistently in imbalance (sympathetic / parasympathetic) will start to remodel the heart. Coumel was very clear that the neural influences on the heart are absolutely vital but not adequately recognised in the field, and there are a couple of key voices in the US who agree (names I can find if needed). There are even those who believe that AF is NOT one disease. According to these folk, in the older, with comorbidities such as heart disease etc, it is seen as more of a side effect of those comorbidities. Whereas in the younger, with no heart disease (i.e. lone AF) it IS the disease itself. I think Sanjay Gupta covers all of this.

Even after 15 years of AF freedom thanks to Mr Haissaguerre himself, and an aortic dissection plus Post Op AF due to that (then NSR by Amiodarone), I can still see the vagal pattern and be able to damp down what for me are now only ectopics. I just wish more folk who have this would be able to do the same.

Incidentally, other Guidelines (US?) do recognise it as a subtype.

One of my wishes is also that research tries to stratify trial cohorts into adrenergic/vagal/neither since the results in the vagal arm could easily offset those in the adrenergic arm when lumped in, and lead to a no-effect conclusion. One paper that did do nearly this found a clear U-shaped curve of tendency to AF vs resting heart rate. The tendency was highest at both high and at low heart rates. I must find that paper again, for my own interest.

[CDreamer in reply to Cliff_G]

I agree with everything you say about vagal theory, however, ESC does mention some of the points you outline - except vagal. It clearly states that AF is not one single condition and needs many differing, personalised approaches and gives guidelines about people with various co-morbidities.

Autonomic Dysfunction is way under resourced and many people don’t know about it or understand it. The connections with inflammation and ANS and connection with gut and heart is well researched and come on a lot since the 1970’2 - but STILL largely ignored!

I have Autonomic Dysfunction with Autoimmune and Hypermobility = extremely low BP for much of my life - until I started taking Pyridostigomine for the Autoimmune condition - which causes antibodies to eat up neurotransmitter receptors causing extreme muscle weakness - including the heart. Beta blockers and anti-Arrythmic drugs were a disaster for me whilst ablation stopped the AF but exacerbated the Autoimmune leaving me far worse off.

What we need is a much more wholistic approach and less specialisation and with improvements in testing and technology, epigenetics and Lifestyle Medicine.

Polyvagal theory is more evident in Psychology and Psychotherapy - but that doesn’t mean it is psychosomatic! It fully explains the complexities of the ANS and describes the effects, especially the effects of trauma on the ANS and the link to inflammation.

I always felt my various conditions were linked and it is only recently I have now discovered the theories and research which confirms my experiences. I am lucky in that my EP and Neurologist have offices on the same floor of my local hospital so have been known to talk to each other, a rare occurrence which finally resulted in a red alert flag being put on my medical file about Adrenaline, Beta-Blockers and antiarrythmic drugs.

I will go look at the work of Phillippe Coumel.

[Cliff_G in reply to CDreamer]

Thanks. Still not read it yet (it's the weekend and sunny!) but you make some interesting points. Prof Coumel's work is fascinating. He contrasts the sympathetic/noradrenaline effect with parasympathetic/acetylcholine activity, at the SA node. The latter has a much faster effect on the heart, and iirc it's the reason why the type of heart rate varibility (HRV) (high frequency or low frequency) can be used to detect vagal vs adrenergic drive, I forget which is which. He does make the point that it's the whole neurogenic influence that matters, and it's not simple. I discovered this myself in 2001. I had been plagued with worsening AF since 1994 and found my digestive status had a lot to do with it, triggering my AF. In 2001 I finally found I was wheat intolerant and over a couple of months my gut pain, wind etc subsided. By then, and knowing a bit about vagal AF, I thought my gastric problems could even have precipitated my AF (I still think that, or at least it aggravated the onset, due to persistent vagal stimulation), but I expected my AF to improve. It didn't, it got worse and nearly permanent just prior to my 2002 PVI.

I read recently, Coumel was asked at one point to withdraw part of a paper on neural influences and he declined, asking instead of his critics that they show him one case of AF where neural influences were not important.

[Cliff_G in reply to CDreamer]

Not read the whole thing yet! But did immediately search for vagal!

[CDreamer]

Interestingly, I was speaking with my step-grandson recently who is an elite athlete and they are now training and working with what is the ideal state of arousal for most effective performance. We often ignore the research the research being done in sport - bit like car racing - the big advances in car design came from Rally and Formula One.

[Cliff_G in reply to CDreamer]

Now you mention it, it was a paper on neural influences in the context of elite athletes which I think he was challenged on (see my other post). I'll try and dig it out.

[CDreamer in reply to Cliff_G]

The work my step grandson is doing is on how to balance between SANS & PSANS to achieve maximum arousal without arousing too much cortisol and noradrenaline which would stress the system. Breathing techniques are a big part of competition now as they attempt to not gasp for breath through the mouth so training to breath long, slow and deep through the nose to the bottom of the lungs where gas exchange is maximised also limits the energy used by intercostal muscles to expand the lungs fast and sideways meaning more energy into the limbs. Tiny percentages are gained but at that level it is the tiny percentage that yields results. Not easy to do when at maximum capacity but exactly what we have been saying on this forum about taking long, slow, deep breaths to mitigate tachycardia and ectopics - which all fits with Prof Coumel’s observations.

[secondtry in reply to CDreamer]

Hi CDreamer, I think your grandson may be interested in James Nestor's new book 'Breath' or perhaps he has already seen it. It mentions carbon dioxide in the body not oxygen is the key to better performance. The research he did for the book could be very relevant to us AFers; I am currently trialling 6 breaths a minute on my daily brisk walks and breathing through the left nostril to relax, the right to get keyed up.

[belindalore in reply to CDreamer]

Doesn't Dr Gupta talk about taking long slow breaths for palpitations? Isn't that the same as what you call ectopics? The USA and UK use different terms for some things. I know if I think my heart is beating a little fast, I massage under the right ear behind the ear lobe and it slows down. The vagal nerve is supposed to run through that area. Also Dr Wolfson (the high priced but very knowledgeable holistic cardio Dr here in Arizona) says it's important to keep the autonomic system in tune and one way to do that is by chiropractic care. When the body is out of alignment the vagal nerve can become irritated. Which makes sense. And putting the body back in alignment can stop the irritation. The gut also. Years ago I had a Dr ( an osteopath) who would give me a treatment. I complained about a pain in my "stomach" all the time and he talked about a nerve running through the body that could cause that pain. When he gave me a treatment the pain stopped. Now I realize it was probably the vagal nerve he was talking about. After he was no longer my Dr I didn't keep up with chiropractic treatment. Never found anyone who could do it as well. My primary's assistant gave me a couple names for chiropractors they suggest. I may give it a try. Having trouble gaining weight so need someone gentle. Don't need any broken bones😒

[CDreamer in reply to belindalore]

Palpitations is just a general, descriptive word for feeling your heart beat - when it is fast or out of rhythm you will feel it whereas when in normal sinus rhythm & not fast you are much less likely to feel or hear your heart beat.

Ectopics = a heart beat that is out of place. They can feel like a skipped beat or similar to Atrial Flutter or Tachycardia or sometimes AF, the only way of knowing is by ECG (EKG). They are considered benign by doctors however when they become multiple they can make you feel dreadful.

[belindalore in reply to CDreamer]

Huh..My Drs refer to palpitations as feeling like a skipped beat. I was diagnosed with benign tachycardia after going through menopause. Dr said back then it was quite common. The hormones are out of balance and it can cause it. Dr referred to them as palpitations. Skipped heartbeat. I don't think I'd ever heard of ectopics til this forum. Whatever we call them you are right. They can make you feel crummy. Thanks for the info.

[Cliff_G]

Interesting. I'd personally say that ectopics are single beats out of sequence, whereas palpitations are a short period of irregular rhythm which then goes back to normal, but palpitations is probably a more imprecise term, ectopics are premature contractions, either atrial or ventricular