New Atrial Fibrillation Guidelines Confront Underlying Illness - Medscape - September 01, 2024.
LONDON — Updated guidelines for the management of atrial fibrillation released by the European Society of Cardiology are revamping the approach to care for this complex, multifactorial disease.
Quote:- Class I Recommendation
In fact, on the basis of overwhelming evidence, a class I recommendation has been issued for a large number of goals in the comorbidity and risk factor management step of atrial fibrillation management, including those for hypertension, components of heart failure, obesity, diabetes, alcohol consumption, and exercise.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors "should be offered to all patients with AF," according to Van Gelder, who identified this as a new class I recommendation.
Patients who are not managed aggressively for the listed comorbidities ultimately face "treatment failure, poor patient outcomes, and a waste of healthcare resources," she said.
Control of sleep apnea is also noted as a key target, although Van Gelder acknowledged that the supporting evidence only allows for a class IIb recommendation.
Control of comorbidities is not a new idea. In the 2023 joint guideline, led by a consortium of professional groups, including the American Heart Association (AHA) and the American College of Cardiology (ACC), the control of comorbidities, including most of those identified in the new ESC guidelines, was second in a list of 10 key take-home messages.
Comments? Thoughts?
I know little of SGLT2 inhibitors but do know that high blood sugar creates havoc with our bodies. I seem to have very stable blood sugar (known from continual monitoring during Zoe programme testing) and do not have either diabetes but I was treated for Sleep Apnea and am overweight (still!)
I am just wondering what do others think? Are your co-morbidities (if you have them) well enough considered in managing your AF? Are SGLT2 inhibitors appropriate for all AF patients? My own experience is that this is where GPs, at their best, can be much better at taking a global view than specialists.
FYI - Sodium-glucose transport protein 2 (SGLT2) inhibitors are a class of medications used to treat type 2 diabetes. They’re also known as gliflozins.
SGLT2 inhibitors prevent the reabsorption of glucose from blood that’s filtered through your kidneys, therefore facilitating glucose excretion in the urine. This helps to lower your blood sugar levels.
I have always thought that AF needed to be viewed through a global, less specialised lens and more emphasis on treating cause rather than symptoms but is prescribing SGLT2 inhibitors for every AF patient not just a step too far? Like every other drug SGLT2 inhibitors come with risks, especially for those with low BP and Osteoporosis. Not sure they would be for me but I can imagine they may help some.
Yesterday we visited EP for husband’s annual check and I was pleased to note that following discussion on bloods, pacemaker reports, results of echocardiogram - all stable - the questions asked were far more about Lifestyle - alcohol consumption, BP control, exercise and sleep. AF stable at 2% burden, valve function - improved, EF - good so we must be doing some things right!
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Very interesting. I need to know more about this before commenting so will do some research. The thing is what about people who are not overweight and have rarely, if ever been overweight, do not have diabetes, exercise regularly and were not diagnosed with sleep apnoea. I have only suffered from disturbed sleep from chronic back and neck pain. Maybe this can be part of the cause in my case, along with being extremely physically active in my work for 37 years as a PTI and PJI in the military, semi professional football player etc. and then the Hormone Treatment for Prostate Cancer - though I only had 9 months where others are on this treatment for at least 2 years and many for longer? I am still not sure if science has found a definite link between between receiving Hormone Therapy and AF, my oncologist and urologist played down the links - even after I was diagnosed with AF whereas the "word on the street" so to speak, was that yes it could. Whatever, I couldn't have avoided it. Without doing further research I don't know how this treatment could have helped in my treatment and the treatment of others like me.
The three year I was on hormone therapy for PC (Zoladex) came after my successful treatment for AF though it is true that my atrial tachycardia came later.
I think that is great news, and sensible, to tackle possible root causes.
The York cardiologist whom I know is often mentioned here has a video (YouTube) on SGLT2. I think the trial was called Emperor?!? It’s targeted for heart failure but it explained how it’s beneficial for hearts.
Sorry to be vague it was a wee while since I watched it.
Great that a more holistic approach appears to be desirable particularly regarding obesity and Type 2 diabetes. That said there are always racing snakes with AF so it doen't always need obesity! I know that having been warned I was close to pre diabetic status, it took me less than a year to lose one and a half stone and drive well clear of that just simply with life style.
Regarding the following excerpt from the article . . . Sodium-glucose cotransporter-2 (SGLT2) inhibitors "should be offered to all patients with AF," according to Van Gelder, who identified this as a new class I recommendation. . . . my sense is that Dr. van Gelder may have been referring to all patients with AF and obesity/diabetes/heart failure in the interview. Regardless, as is, it certainly is misleading and one would hope for a correction/clarification. In Recommendation Table 5 (see also Tables 3 and 17) of the new guidelines the following is listed as a Class I recommendation: "Sodium-glucose cotransporter-2 inhibitors are recommended for patients with HF and AF regardless of left ventricular ejection fraction to reduce the risk of HF hospitalization and cardiovascular death."
Thank you for that clarification, the article was certainly ambiguous and the statement “should be offered to all patients with AF” is what disturbed me. I can see the link between diabetes and heart failure with AF but for someone such as Desanthony???
I looked up the SGLT2 inhibitors and was not impressed by the long list of possible side effects some of them serious. I cannot imagine that this class of drugs would be recommended for patients who have PAF and no other comorbities even those like myself ( obese but normal blood sugar) . Maybe I am being naive. I would not consider taking them anymore than a statin!
This is really interesting, CDreamer, thank you so much! I find it reassuring they are looking at the wider picture, and would welcome more research and understanding.
I’m intrigued by the question of the SGLT2 treatment and would welcome them doing more research. I think personally I’d want more assurance before I launched off on yet another medication. (But then I’m dutifully taking Bisoprolol despite all my reservations, because of being scared into believing it essential for me, so I might be the same with these in another few years!)
I do get slightly alarmed at feeling a bit like guinea pigs with all the heart rhythm related recommendations and developments, though I know that’s the way medical science progresses and knowledge is gained.
I agree with you wholeheartedly about needing the global lens on AF and arrhythmia. No one medical has said anything to me about lifestyle changes or the impact of what I eat & drink. It’s only on here have I picked up on the importance of this. Thank you all! Personally speaking, I’ve cut out all my own triggers (alcohol, sweeteners, dark chocolate, sugars) plus lost a lot of weight over the last 2 years (bmi down to 20) and my AF burden has improved. However, I have lately developed NSVT, so things are not straightforward!
I’m very glad to hear your husband’s annual check was thorough and reassuring- good news! Jx
I was prescribed Dapagliflozin for heart failure a few years’ ago which I understand is an SGLT inhibitor. I had been diagnosed with Diabetes Type 2 before that although there was some doubt about this as it appeared at a time when I was hospitalised for other reasons. I was underweight but am now just about in ‘normal’ range. However, it would appear that the Dapagliflozin is having an effect as my blood sugar levels were only just slightly above ‘normal’ just into the ‘pre-diabetic’ range. I also have AF which is asymptomatic and I am not sure whether it is permanent or paroxysmal. I am due for a pacemaker check up next week but it seems that my heart is now functioning at the lower end of ‘normal’ thanks to the drugs and pacemaker combination.
I am on Dapagliflozin. It was prescribed when I was diagnosed with HF last autumn caused by pacemaker dissynchrony. (With my old dual lead PM, the unpaced ventricle wasn't functioning in sync with the paced ventricle EF 35%! ).
It's been corrected with a biventricular PM - a triple lead PM - and the ejection fraction was near normal at 50% last check and possibly improving. But I was given Dapagliflozin and Spironolactone too.
Dapagliflozin can give me hypos occasionally (tachycardia is the symptom and weakness and hunger) . I don't have diabetes and Dapagliflozin increases massively the amount of sugar you pee out! So I occasionally take a glucose sweet. The effect is immediate.
With the combined effect of Spironolactone I pee more and also get occasional UTIs. The sugar pee is a bit of a breeding ground for bacteria. Tbh I'd come off it tomorrow if the docs thought it was OK. Checkup next month.
PS the effect on AF hasn't been noticeable. I've had a couple of bad episodes since October. But overall the burden is 5%. Not changed much for a while.
It’s not surprising that research is finally looking at the root cause of AF with the rapidly increasing number of people being diagnosed and the toll it must take on health providers. It is encouraging, but owing to the “complexity and multifactural” nature of AF., l think this is a very difficult and lengthy project. SGLT2 inhibitors for all AF patients filled me with horror, especially for the elderly. I cannot clearly see the link in managing comorbidities because perfectly healthy people can have AF. Until a cause for AF is found there could never be a complete cure, l would think. . It has baffled the medical profession for decades hence they are only in a position to treat the symptoms. The GP is better placed for the global view of any research because he has a wider knowledge, as you say CD. At least this is a start to combat AF., rather than sitting on the shelf and a holistic approach is always much better welcomed.
Pleased to hear your husband’s good results and your discussion was regarding getting on with life!!! That’s a real tonic. xx
interesting, from my experiences not a lot look at the interaction between body’s systems 🙄 I’ve found out that I’ve Haemochromatisis Compound variant,Can cause iron overload in the organs (genetic liver disorder). Have PAF gained T2 diabetes 😵💫 Drs are reluctant to look at the whole picture 🤯
Try as I might to get medics to try and put the pieces together
My Triage team has no Heart Specialist amongst it.
Not good when Surgeon is setting me up for a Radio Active Iodine Scan. Because of possible return of Thyroid cancer.
Not experienced in thyroid and heart I protested that if I stopped thyroxin for 21 days my TSH would be sky high and my rapid heart rate tamed by CCB Diltiazem may not hold with low iodine diet also for 21 days could be fatal.
So he wrote and talked to Auckland where R.A. Iodine Scan was taking place, and rung me to start taking thyroxine as I was off closer to Whangarei and changed to a PET Scan.
Phew I thought.
The result of that was no other imaging to compare and this 3 calcifications showed in CT Scan but not in PET SCAN as intake goes red. A face to face with my surgeon after 4 years from Thyroidectomy revealed he thought the back thing was my Thymus and I said the infusion killed off the 7mm & 8mm lymphs. Reason because my thyroglubin serum level had dropped from 1.7 to 1.1.
The thyroglubin serum is an indicator for cancer. Between 1.0-2.0 cancer may have returned.
Do you think that a holistic approach could be done by a TRIAGE TEAM.
I don't want the Endocrinologist in my Triage Team but rather a heart cardiologist. She prescribed me Metopolol when I said No Way. She prescribed it anyway. It was proved with a 24hr Heart Monitor that a 186bpm Day, breathless and pauses at night plus awful fatigue was made it BANNED. I had it in 2008-9 & when doubled from 47.75 x 2 I almost ended up in hospital my breathing! This new Dr didn't write it down my allergy.
My first mini schnauzer was named lacey with her prominent white marks in black. Such a lovely dog.
Hey I'm always asking questions but mostly I ask the computer but i've joined a lot of Research Companies. So they pop up answering my ?s.
You can ask them here in this forum.
A 1st year general nurse, a carer of handicapped children and my ongoing enquiring mind make me question things about myself. I want to know.
You would be amazed at the ?s I asked my surgeon after 4 years .. going back. Put delicately we got through them all.
About my cancer returning.
1. I am on the AF forum. some with thyroid cancer had 15, 20 or man had 46 lymph nodes removed with the thyroid. Why 12 for me? Explained sort of.
2. 2 lymphs were affected what measure were they? 1mm and 3mm
3. Should I have stopped thyroxine earlier before my PET scan?
4. Do you think the 2 lymphs were killed by the RA Iodine infusion owing to reduction of Thyrogl. serum? Yes he said could be.
5. Why isn't there any imaging to compare the 3 areas in ? ..
6. I emphasized that I wanted the most qualified and high powered Ultra-Sound there is. Please agree.
7. Why not much information on treatment including tests. Risks etc. He was not aware that the dye can give me leukaemia. So very important to have lots water before and after with CT Scans and Pet Scans.
8. Why does it take 6 weeks to organise a scan neck yearly? He told me he was retiring in December and would set up 6 mthly CT Scans until this area was resolved.
9. Promised to operate if required before he left if necessary.
10. Why can't I have a Cardio-specialist on my Triage Team.
Just some of the ?s I asked.
And farewelled him to have a rest from Thyroidectomies, Colon Cancers and Breast Cancers.
He said he would make it so I stay under a Surgeon for clinical purposes. I was diagnosed within a stay on hospital for Stroke and on 4 I was given a Carotid Scan which incidentally showed a shadow on my thyroid.
I'm sure you can ask for a specialist who is interested and happy to answer any questions.
I'm hoping I get a surgeon as good as if not better than my favourite now surgeon. He got a colourful mug saying "Best ... in the world... The scanner young Jade got one too. I saw her the other day.
I’ve recently been put on dapagliflozin for heart failure after an ECHO that showed HF with preserved EF. It was a considerable shock to me. I haven’t had any side effects, touch wood, and am hoping it will improve my HF. If by doing that it improves my AF so much the better, although to be fair mine is very well controlled. Dapagliflozin seems to be prescribed straightaway for HF nowadays and I could imagine a situation in which it might be prescribed in the future for AF, rather like the ubiquitous statins.
One of the side effects is UTIs. Having had 2 new hips I am supposed to have antibiotics for UTI. Before my ops I treated the only one I have had for decades myself as I did not want antibiotics. The thought of frequent courses of antibiotics destroying my microbiome fills me with horror. Even if diagnosed with HF I would be asking to see what alternatives there were. I suspect my stepson who is diabetic is taking one as he is having problems with urgency.
That's what my Loctum said I should be on. But in NZ only those with Diabetes can have it. Although I thought hers was Empagliflozin - it certainly. ended with the last few letters.
Did you have any side effects? Have you diabetes? Are you overweight?
Radcliffe Research are researching AF as well. Getting it right from the diagnosis is of course the way to go. High Heart Rate was my first symptoms to control. Over 200bpm.
But they gave me a BB Beta Blocker - hopeless in taming it. Changed at 1 year 5 months after 24hr monitor to another BB Bisprolol didn't control it either.
Introduce CCB that did it. On low dose as well. AM only.
The reality mistakes were made in the first instance.
I think it’s only in the last year or so that dapagliflozin has been prescribed for HF in the UK. I haven’t had any side effects luckily. It was all a shock to me because I don’t have diabetes, I’m not overweight, I feel fit and I don’t get out of breath. I’m thinking of dipping into my paltry savings to get a private appointment with a cardiologist, so I can ask lots of questions!
Yes it's only recently that Research has delivered this new med regime.
Don't be obsessed by Heart Failure word. I was told it covers everything a heart defect displays. The words heart failure should not really be used because most of us have our meds to help with our hearts.
I asked had I heart failure and he said you are controlled with meds Diltiazem and Bisoprolol.
Wasting money just so that you can get answers is not right. Ring up and have a session with your heart specialist's nurse. Or ask for another appointment or put it up here under your post to get answers.
I just had a face to face with my surgeon who did my thyroidectomy in Feb 2020. I was recalled after my 4th Yearly Check and have undergone further tests CT scan without and with contrast, alined uo for a R.A.Iodine Scan in Auckland but I questioned the 21 days of no thyroxine and low iodine diet. Each time after a test he wrote. He phoned me before the latter scan and after discussion with Auckland he cancelled it and it was made a PET Scan/ CT Scan without & with contrast. Report of that I received from Radiologist in my Lab Tests. The Pituitary Gland was warm so MRI of that which proved normal. The 3 areas in ? have not been imaged previously so with my Triage team and others in thyroid came to a conclusion that I should have a CT Scan repeated in November.
My thyroglubin serum - an indication of return of cancer is often used as an indicator.
I was delighted to see a reduction of my level - before PET scan 1.7 now 1.1. I reckon the 2 small lymphs hav been killed off by the iodine infusion from Australia.
I kept asking for a face to face as little information on these tests and I finally got one.
He tells me during the 15mins talk that he is retiring from his job. Boo whoo. It was the 2nd sighting of him from 2020. usually clinical letters or he phoned me.
Assurance is power. Power is top in the journey of your health.
I haven't read this too closely as I no longer have AF after my ablation. I wonder if the 70% who have successful ablations have no co-morbidities. This was true for me.
I also feel that the extra electrical signals produced in the heart are the result of the brain trying to aid the heart to beat faster when under pressure.
I may have pushed myself too hard, just on occasions, and got an extra signal which caused my PACs. Nearly 30 years ago I was seen at the hospital and the heart surgeon said 'everything is tip top apart from these missing beats - which are no problem at all'. He then drew me a picture showing that they were caused by an extra signal which was coming from a different part of the heart.
I am guessing that they got added to over the next seventeen years when I was first diagnosed with atrial fibrillation. It then took another six years before I got my Apple watch and realised I was in atrial fibrillation for a third of the time. A year later I got my ablation.
I don't think I would have benefited from sodium-glucose inhibitors and it might have caused other problems.
Dealing with comorbidities is in my book more important than dealing with AF direct....the earlier the better !! I try and do this by not being complacent that they will bypass me and accepting habits take a long time to change but need to.
My Locum Dr (left under Dr guidelines 15min each patient) said the med given to Diabetes patients is best for Af patients.
I'm trying to recall. see Crystalbowl's post it is given to Diabetics. We are not allowed them. Here the Maori folk can get it too as so much diabetes in their heritage
But I read side effects.
For me I should have been put on CCb Calcium Channel Blocker as the Rapid AF symptom was principle in my treatment. The cause thyroid cancer had to wait whilst the Dr on the stroke ward was an Endocrinologist who voiced that I had to wait 6 months. When Surgeon and Anaesthetist came onboard, they said a.s.a.p. The Anaesthetist had had thyroid cancer and he showed us his scar but his had spread down further.
I was done in 4 months.
The fact that I was put on Metoprolol a Beta-Blocker was wrong. I had said No to it but she over road me. Proven 1 year 5 months when I asked for a Heart Specialist that H/Rate 186, fatigued and breathless but I had pauses at night. Low Night Rate 47avg bpm. My normal.
Changed to Bisoprolol and monitored at 156bpm wasn't reducing me under 100. Now left.
10 months and I opted to be referred by this Locum. A Chinese guy who was interested. He introduced CCB Diltiazem but 1/2 dose too much. Twinked down to 120mg so my regime for the past 2.1/2 years..
AM 120mg Diltiazem for rapid Heart Beat... Now 60s Day
PM 2.5mg Bisoprolol for control BP Systolic was high at 150-160
PRADAXA 110mg twice daily
A Thyroidectomy would not have helped immediately and Stroke came with the AF so treating the cause not right in my case.
Reading about Apnoea re AF treat the obesity by pills.
I have T2 diabetes, managed with insulin, not overweight, but constant battle to avoid hypos from undereating , or the other way, excessive blood glucose from overindulging carbs, both no doubt put pressure on heart, along with getting up several times during night to pee, never sleep more than 2 hours a go. Nevertheless, so far (ten days to go before the end of 3 month blanking period) this doesn't seem to have stopped my ablation being "successful ".It would be a minor miracle if I ever came across a doctor who was able to manage me and my comorbidities with a holistic view. It's only ever dealing with one topic at a time for the allotted ten minutes. I sincerely hope the NHS is not being deliberately allowed to go down the dentist route, where time and attention is only available to those who can afford to pay privately. I fear we are heading to a two tier health system . It would suit the snakes who run the economy.
Ooh, thanks for sharing. My initial response is mixed: thank the lord they are talking about addressing underlying co morbidities as well as lifestyle. But a global decision to dish out these blood sugar inhibitors? What about those of us who have really looked into our blood sugar and manage it well? Like you, I did the Zoe programme and discovered a glucose sensitivity and changed my diet accordingly. I will say it helped me realise that many morning spikes of.higher HR I'd been having - though not necessarilyAF - were due to a glucose response. From advice on this forum, I realised my organic rice milk with my bircher muesli was the issue. Rice and oat milk (for anyone needing to know) have a high GI. Understanding the importance of moving our bodies- including awareness of modifications people.may need according to age and ability is also a must in my opinion.
Overall - to answer the 2nd part of your post - looking into the whole medical history through a bio psychology social lens is the way forward.
As an example for anyone reading this. Prior to diagnosis of AF I was subclinical hypothyroid for at least 5 years. No-one explained the dangers to me. I'd managed to lose weight by eating only.fresh fruit in the morning- blood sugar alert. I'd worked for 8 years doing a PhD whilst co running a small.home business - stress and exercise alert. Finally, aged 19 I had abdominal surgery in which they removed the digestive end of my vagus. I suspect a sliding hiatus hernia and know that I have substantial internal scar tissue - likely making my stomach smaller. Still waiting for a scan on this!
So, my job has been to inform myself about all aspects of my well being and to nudge the medical teams to help me address all these factors. And I've had to accept, with the digestive issue and a malfunctioning vagus, I may never be entirely free of AF. But I CAN learn.to manage it well. I certainly wouldn't be open to the suggestion of taking this medication recommended in the report without a compelling reason.
Thanks, very interesting. In my view any steps towards treating AF and other heart conditions in a holistic way deserve support. The NHS is very bad at this. In none of my consultations with my heart consultant were wider issues ever mentioned. Let's see whether there is any spark of interest from UK based cardiologists given that the conference was held in London.
I have to wonder how often the genetic aspect of the condition is discussed and treatment of the faulty genes considered. Myself, my late father and four sisters all have PAF, all diagnosed when in our seventies, save for my youngest sister who was only sixty when diagnosed (maybe the rest of us had it then, who knows.). I was being treated for elevated BP, but my sisters, to my knowlege, had no co-morbidities, except for one sister, whose PAF was diagnosed when she was discovered to have an overactive thyroid. This was successfully treated and she takes bisoprolol and an anti-coagulant, however, at 85 she has been diagnosed as diabetic. She is not overweight, none of us are !
As has been mentioned, the report refers to SGLT2 for those with AF and HF, not to those without HF:
"For treatment of HFpEF and AF, pre-specified subgroup data on AF from multiple large trials show that the SGLT2 inhibitors dapagliflozin, empaglifozin, and sotagliflozin are effective in improving prognosis."
The section on rate control (Section 7) was interesting and suggests that, for permanent AF, keeping heart rate below 110 bpm is just as effective as keeping it below 80 bpm. Given the number of forum members who feel that Bisoprolol is keeping their heart rate too low and causing lack of energy, perhaps a discussion with their doctor on heart rate target would be useful.
The entire report can be read here, if you have a few hours to spend!
Well said and useful - thanks for posting. I have written about similar in many of my posts here. AF is, in and of itself, a symptom from another cause, not even a "co-morbidity" as such, but I can understand the use of the term in this context. The cause is some kind of deterioration in the cardio-vascular system. Even hypertension is, like AF, similarly, a result of another cause.
We should be sure we bring up our children as healthily as we can, following sensible guidelines regarding weight and exercise. Only by starting from early years can these later cardiovascular illnesses be avoided, and even then, only if genetics allows.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors it manages type 2 diabetes I am searching for a solution for me because I have the opposite problem. when I eat sugar or too many carbs I produce too much insulin and my blood sugar crashes. I have gone so low and to dangerous levels where it takes all my energy to just breathe, until I can get that sugar level back up. Imagine what that does to the heart. I can't get doctors to understand this situation and this has been going on for years, my mother and her sisters had this problem. No help back then and still no help. So to give me something like this most likely would be a huge problem. BTW, a 3 hour glucose test will not discover hypoglycemaia it has to be a 5 hour test. Years ago a holistic dr did the test on me that is the only reason I know. Regular doctors don't have a clue.
Again we are all individuals and we have different needs, until we find a dr that knows and understands that we won't get the help we need. Most doctors are too busy and don't ask any questions regarding any of this.
Protocols given to doctors without the total picture is dangerous IMO.
Thanks for posting the article. It's a positive direction showing how important to treat seriously the other health problems alongside AF rather than focusing only on the irregular heartbeat itself. I've always considered AF a symptom of something else in the body and to take a more comprehensive and team-based approach to it's treatment, considering the whole person rather than just the symptoms of AF.
I can’t say that I’m surprised at this because right at the beginning with my new EP when I moved to Texas, I was scheduled for a test for sleep apnea. Evidently it could be one of the leading problems causing a fib. although it has not been proven to my knowledge. It is the stress that is put on our heart when we stop breathing so many times during the night. It makes sense think about the different things that stress our heart if you were to have asthma or other breathing difficulties and so many other different things they just don’t know that’s why there’s no cure besides the fact that I suspect it’s quite a moneymaker for big pharma. I also think there is no cure because it is so different for each and every one of us. It is not cookie cutter as you read people on here you can see where some people just need meds or an ablation. Then there are the others of us where it gets very complicated. Obesity, obviously please a big role in sleep apnea besides straining our hearts and other ways. I have dropped about 40 pounds since I got my pacemaker. I know I can feel the difference although I’m having some issues now and I suspect a recent medication change may be at fault because I honestly swear I should be about 100 pounds, oh the body is so complicated
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