Yours in sinus rhythm – some of the time,
Hans

ABSTRACTS

BOSTON, MASSACHUSETTS. The proven cardiovascular benefits of fish oil consumption are many and varied. Among the more important – reduction of the risk of sudden cardiac death, ventricular arrhythmias, stroke and heart attack as well as lowering of blood pressure and reduction of inflammation. On a more esoteric level, fish oils also reduce vasoconstrictive responses to angiotensin II and improve left ventricular diastolic filling and arteriolar wall compliance. Researchers at Harvard Medical School now report that regular intake of fatty fish is associated with a reduced risk of developing atrial fibrillation.

Their study involved 4815 adults aged 65 years or better whose dietary intake of fish was assessed in 1989 or 1990. During 12 years of follow-up 980 cases of AF were diagnosed corresponding to a total incidence rate of 20%. AF was diagnosed either during an annual ECG or from hospital discharge records. The researchers found that the incidence of AF was inversely associated with the consumption of tuna or other broiled or baked fish. Study participants who consumed this type of fish 1 to 4 times per week experienced a 28% lower risk of developing AF than did those who consumed it less than once a month. Participants who consumed fried fish or fish sandwiches (fish burgers) on a regular basis (once or more per week), on the other hand, had a slightly higher risk of developing AF than did those consuming this type of fish less than once per month.

The researchers also observed that study participants who had a greater intake of tuna or other broiled or baked fish had a higher blood plasma content of the two main components of fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). No increases in EPA and DHA levels were noted with an increased intake of fried fish and fish burgers. The researchers point out that fish used for frying is generally quite lean and has a low content of EPA and DHA. Furthermore, frying increases the meal's content of detrimental omega-6 fatty acids, trans-fatty acids, and oxidation products, particularly when frying oils are reused.
Mozaffarian, D, et al. Fish intake and risk of incident atrial fibrillation. Circulation, Vol. 110, July 27, 2004, pp. 368- 73

Editor's comment: It is encouraging that the consumption of broiled and baked fish, especially tuna, materially reduces the risk of developing AF. However, there are two sides to this story. Tuna is highly contaminated with mercury, so frequent consumption can certainly not be recommended. It is much preferable to obtain adequate amounts of EPA and DHA from wild salmon or from a molecular distilled fish oil supplement. It is also interesting that the study confirms that fish burgers and fried fish are not a viable alternative source of beneficial fish oils, quite the contrary.

BONN, GERMANY. Blood clots (thrombi) often form in the left atrial appendage (small sac attached to the left atrium) of patients with permanent atrial fibrillation. The thrombi can escape into the blood stream and cause a stroke (cerebral infarction). German researchers now report that anticoagulants are not very effective in eliminating left atrial appendage (LAA) thrombi or in preventing stroke. Their study involved 43 patients who had been admitted to hospital with permanent AF and who had been found to have thrombi in the LAA. Twenty- three (53%) of the patients were effectively anticoagulated before admission to hospital (they still had atrial thrombi) and the remaining 47% were put on phenprocoumon (a cousin of warfarin) before being released from hospital. The patients were re-examined at 1, 3, 6 and 12 months after discharge using transesophageal echocardiography (TEE) to check for LAA thrombi and magnetic resonance imaging (MRI) to check for embolisms (blood clots) in the brain.

The researchers found that 16% of the LAA thrombi disappeared after 1 month, 42% after 3 months, 49% after 6 months, and 56% after 12 months. Patients whose thrombi disappeared had smaller initial thrombi and smaller left atrial size. Six patients (14%) developed clinically apparent neurologic deficits and cerebral infarctions (stroke) as documented by cranial MRI. The researchers conclude that, "continued effective anticoagulation does not prevent thromboembolic events in patients with permanent AF and prevalent LA thrombi".
Bernhardt, P, et al. Fate of left atrial thrombi in patients with atrial fibrillation determined by transesophageal echocardiography and cerebral magnetic resonance imaging. American Journal of Cardiology, Vol. 94, September 15, 2004, pp. 801-04

Editor's comment: It is clear from this study that coumarin derivatives (warfarin and phenprocoumon) are not very effective in preventing strokes caused by blood clots in the left atrial appendage, nor are they very effective in eliminating (dissolving) existing blood clots. That this is so should not come as a surprise. Coumarins work by destroying vitamin K and thus reducing the production of vitamin K-dependent clotting factors. In other words, they work to prevent the formation of blood clots. There is, as far as I know, absolutely no evidence that they have any effect whatsoever on fibrinolysis (the digestion and removal of existing blood clots). The body does produce fibrinolytic enzymes that, over time, remove blood clots, so it is likely that any reduction in the number and size of thrombi observed during the study was due to the body's own natural blood clot removing capabilities rather than to anticoagulation.

The study also underscores the relative futility of placing prospective ablation candidates on warfarin for 1 or 2 months prior to the procedure. More than half the patients admitted to the study had LAA thrombi even though they had been effectively anticoagulated prior to admission – only a small percentage of the clots disappeared during 1 month of anticoagulation. Fortunately, there are highly effective alternatives. Nattokinase has proven ability to prevent the formation of blood clots and is also effective in dissolving existing clots. Vitamin C inhibits plasminogen activator inhibitor PAI-1 and thereby allows the beneficial plasminogen activators to accelerate fibrinolysis. It should also be noted that, while blood clot formation in the LAA is a real and serious problem in patients with permanent AF and underlying heart problems, there is no evidence that it is a problem in otherwise healthy lone paroxysmal afibbers.

FLORENCE, ITALY. Researchers at the University of Florence report that high homocysteine levels and low blood levels of vitamin B6 are associated with the presence of AF (nonvalvular, ie. not caused by rheumatic fever or a problem with heart valves). Their study involved 310 AF patients and 310 healthy controls. About 55% of the patients had hypertension, 35% elevated cholesterol levels, about 18% diabetes and 54% had experienced a previous heart attack or stroke – not a very healthy group!

After adjusting for all other known risk factors, the researchers found that study participants with a homocysteine level at or above 15.8 micromol/L had a 6.4-fold greater prevalence of AF than did participants with a level at or below 11.9 micromol/L. Participants with a vitamin B6 level below 3.1 micromol/L were 3 times more likely to have been diagnosed with AF than were those with higher levels. No association was observed between blood levels of folic acid and AF presence or between levels of vitamin B12 and AF presence. The researchers observed that homocysteine levels were significantly higher in the 54% of patients who had experienced a previous stroke or heart attack. They also found a correlation between high homocysteine levels and an enlarged left atrium.

Treatment with medications such as statins, beta-blockers and ACE inhibitors did not appear to affect homocysteine or vitamin levels. The researchers point out that low levels of vitamin B6 have been associated with increased levels of C-reactive protein, a marker of inflammation. They suggest that vitamin supplementation should be investigated as a means of preventing stroke and heart attack in AF patients.
Marcucci, R, et al. Hyperhomocysteinemia and vitamin B6 deficiency: new risk markers for nonvalvular atrial fibrillation? American Heart Journal, Vol. 48, September 2004, pp. 456-61

Editor's comment: There is already ample evidence that high blood levels of vitamin B6 can decrease stroke risk by as much as 90%[1]. Other research has shown that oral supplementation with 40 mg/day is enough to achieve this 90% reduction[2]. Thus, it is clear that an adequate intake of vitamin B6 or its main metabolite, pyridoxal-5'-phosphate, is essential for all afibbers.
[1] Kelly, PJ, et al. Low vitamin B6 but not homocysteine is associated with increased risk of stroke and transient ischemic attack in the era of folic acid grain fortification. Stroke, Vol. 34, June 2003, pp. e51-e54
[2] Zempleni, J. Pharmacokinetics of vitamin B6 supplements in humans. Journal of the American College of Nutrition, Vol. 14, 1995, pp. 579-86

PITTSBURGH, PENNSYLVANIA. Researchers at the University of Pittsburgh have analyzed data on hospital admissions for atrial fibrillation compiled by the National Center for Health Statistics. Here are some highlights of their findings:

• A review of the details of 212 million hospital discharge records for the period 1996 to 2001 identified 2,003 million admissions with a primary diagnosis of AF in patients aged 15 years or older.

• The number of hospitalizations for AF increased from 286,300 in 1996 to 383,924 in 2001 corresponding to an increase of 34%.

• The average age of men admitted for AF was 66.8 years – substantially lower than the age for women of 74.6 years.

• The incidence of hospital admissions for AF in men between the ages of 15 and 44 years was 0.02% a year; that in men over the age of 85 years was 1.0% a year. Corresponding numbers for women were 0.006% a year and 1.2% a year respectively. Thus younger women (premenopausal) are very likely to develop AF.

• Most AF patients had one or more accompanying disease conditions such as hypertension (37%), heart failure (22.5%), coronary artery disease (17.8%) or diabetes (15.2%).

• Ten percent of AF patients admitted underwent electrical cardioversion, 8.2% had an echocardiogram, 3.8% underwent cardiac catheterization, and 3.4% had a permanent pacemaker implanted. Patients in larger hospitals were almost twice as likely to undergo one of these procedures than were those in smaller hospitals (6- 99 beds).

The researchers conclude that atrial fibrillation places an enormous burden on the healthcare system – a burden that is rapidly growing.
Khairallah, F, et al. Epidemiology and determinants of outcome of admissions for atrial fibrillation in the United States from 1996 to 2001. American Journal of Cardiology, Vol. 94, August 15, 2004, pp. 500-04

CLEVELAND, OHIO. C-reactive protein (CRP) or, more specifically, high sensitivity CRP has emerged as an important indicator of systemic inflammation. A recent study of 5000 healthy individuals found that values varied between 0.01 mg/dL (0.1 mg/L) and 0.38 mg/dL (3.8 mg/L) with a median of 0.16 mg/dL (1.6 mg/L). CRP values tend to increase with age and are generally higher in men than in women. Typical normal values are 0.06 mg/dL for men between the ages of 20-29 years and 0.17 mg/dL for men aged 70-79 years. Corresponding values for women are 0.032 mg/dL and 0.13 mg/dL respectively.

A value higher than 0.38 mg/dL (3.8 mg/L) is generally considered an indication of a systemic inflammation. (For a thorough discussion of CRP please see www.yourhealthbase.com/database/rheart_CR P.htm).

British researchers recently reported an association between the presence of blood clots (thrombi) in the left atrium and high CRP levels in AF patients. Researchers at the Cleveland Clinic now confirm these observations and add the important finding that high CRP levels are generally associated with an increased risk of ischemic stroke. The Cleveland study involved 104 afibbers who underwent transesophageal echocardiography (TEE) and had their CRP levels measured within 1 week of the TEE. The researchers observed significantly higher CRP levels in men (median 0.59 mg/dL), patients with hypertension (median 0.48 mg/dL), patients with coronary artery disease (median 0.78 mg/dL), and in patients with severe mitral regurgitation (median 0.67 mg/dL). Afibbers with significant TEE risk factors (presence of thrombi in left atrium, severe spontaneous echo contract or inadequate blood flow from left atrial appendage [emptying velocity of 20 cm/sec or less]) were found to have an average (median) CRP value of 1.0 mg/dL, while those without TEE risk factors had a median value of 0.30 mg/dL. The researchers also found a strong correlation between CRP levels and overall stroke risk (according to SPAF criteria). Patients with an average CRP level of 0.21 mg/dL (0.08 to 0.68) had a low stroke risk, those with an average level of 0.47 mg/dL an intermediate risk, and those with a level of 1.21 mg/dL had a high risk.

The researchers conclude that high CRP levels (greater extent of systemic inflammation) are associated with a greater risk of ischemic stroke and a greater chance of finding thromboembolic abnormalities on a TEE. They speculate that, apart from being an indicator of systemic inflammation, high levels of CRP in themselves can increase the synthesis of tissue factor, an important initiator of blood coagulation.
Thambidorai, SK, et al. Relation of C-reactive protein correlated with risk of thromboembolism in patients with atrial fibrillation. American Journal of Cardiology, Vol. 94, September 15, 2004, pp. 805-07

Editor's comment: The finding that afibbers with a CRP level of 0.2 mg/dL or lower have a low risk of ischemic stroke and a low risk of thrombus formation in the left atrium is of significant importance. My own CRP level is 0.03 mg/dL, thus supporting my decision to forego warfarin therapy. Maintaining a CRP level at or below 0.2 mg/dL is clearly important for afibbers. Fortunately, there are many effective, natural approaches for accomplishing this.

ROCHESTER, MINNESOTA. Obstructive sleep apnea (OSA) has been linked to an increased risk of recurrent atrial fibrillation after electrocardioversion. Now researchers at the Mayo Clinic report that afibbers are more likely to have OSA than are patients with cardiovascular disease. Their study involved 151 patients with AF or flutter referred for electrocardioversion and 373 patients with cardiovascular disease. Administration of the Berlin questionnaire (designed to ascertain the presence of OSA) and formal sleep studies in 44 patients showed that 49% of the patients in the afib group also had OSA as compared to only 32% in the general cardiovascular disease group. Other strong predictors for OSA were obesity (body mass index over 30 kg/m2) and a greater neck circumference.

The researchers suggest that the increased sympathetic nervous system activity engendered by OSA, especially at night, may explain why OSA patients are more likely to develop AF. However, the possibility that AF precipitates OSA cannot be ruled out. The researchers also speculate that obesity could be a causal factor in AF, particularly in view of the fact that the current obesity and AF epidemics seem to run in parallel. They conclude that some afib patients may benefit from bringing their OSA under control through such measures as continuous positive airway pressure therapy.
Gami, AS, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation, Vol. 110, July 27, 2004, pp. 364- 67

Editor's comment: There is no indication from our LAF surveys that obesity is more prevalent among lone afibbers than in the general population.

SAO PAULO, BRAZIL. Radiofrequency ablation involves the creation of a scar through the application of heat to tissue. In pulmonary vein isolation (PVI) the scars ("burns") are created around the pulmonary veins (usually four) so as to prevent rogue electrical impulses originating from the veins from entering the atrium and causing fibrillation.

There are several variables in radiofrequency ablation. Catheter size, power (wattage) applied, temperature of tissue achieved during burn, and amount of time the catheter is activated during each burn. Higher temperatures and longer contact times lead to more effective scar tissue creation, but carry the risk of subsequent stenosis and the burning of a hole in the atrium wall so that blood escapes into the pericardium (the liquid filled sac surrounding the heart). A fairly standard approach employs heating of the tissue to 50-52o C, a maximum power (wattage applied) of about 30-35 W, and a contact time of 20-40 seconds.

Cardiologists at the University of Sao Paulo Medical School report a case where a 72-year-old man died after a PVI because a fistula (abnormal connection between two hollow organs) had been created between the left atrium and the esophagus. The cardiologists used an 8 mm tip catheter, a power of 60 W, a contact time of 15 seconds, and achieved a tissue temperature of 55o C; in other words, a fairly aggressive approach. The patient had a seemingly successful ablation, but it was clear that the atrium wall had been penetrated during the procedure as evidenced by a sharp drop in blood pressure and the need to drain blood from the pericardium. The patient later developed breathing difficulties and had problems swallowing solid food. Twenty-two days after the procedure, he experienced seizures and 3 days later died from blood poisoning (septicemia) and the failure of several organs.

There have been a few earlier cases reported where a fistula between the left atrium and the esophagus was created through the application of high power RF pulses to a thin left atrium posterior wall. The Brazilian cardiologists suggest that decreasing RF power when ablating the posterior wall and inserting a gastro- esophageal tube or an esophageal lead could help to recognize the position of the esophagus and thus prevent injury. They also point out that breathing difficulties and problems in swallowing solid food should be taken as an early warning that a fistula may have been created.
Scanavacca, MI, et al. Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology, Vol. 15, August 2004, pp. 960-62

ANN ARBOR, MICHIGAN. Comparatively little is known about the long-term efficacy of pulmonary vein isolation (PVI) through radiofrequency catheter ablation. Electrophysiologists at the University of Michigan have just released the results of a study that followed 165 PVI "graduates" for about 2 years after a successful PVI procedure. The average age of the study participants was 53 years and none had reported any symptoms of afib for at least 6 months following the successful procedure. Fifteen per cent of the group underwent a "touch- up" procedure before achieving the afib-free condition. The 165 successful ablatees were part of a larger group of 244 patients who underwent PVI, thus yielding an overall success rate of 68%.

The researchers focused on those afibbers, in the group of 165, who had experienced at least one afib episode per week prior to their ablation (average number of episodes per month was 19). From this group, 60 afibbers were chosen at random for further follow-up (the study group). At about 2 years after the successful PVI members of the study group were provided with a patient-activated, trans-telephonic, continuous loop recorder for 30 days and were asked to provide a 3-minute rhythm recording at least once a day at a randomly chosen time. They were also asked to activate the recorder if they felt any palpitations or symptoms of AF. Among the highlights of the study findings are:

• The majority (85%) remained in sinus rhythm throughout the 30-day study period.

• One patient was documented to have experienced 2 asymptomatic afib episodes during the observation period and another recorded atrial flutter on two occasions.

• Seven (12%) of the patients developed symptoms of afib after being asymptomatic for an average of 18 months. The average ventricular (pulse) rate during an episode was 130 beats per minute, significantly higher than the 90 bpm recorded for the patient with the two asymptomatic episodes.

The researchers point out that the occurrence of asymptomatic episodes in afibbers who have undergone a successful PVI are rare indeed, even 2 years after the procedure. Symptomatic episodes are more frequent and may occur in as many as 12% of successful PVI alumni and as late as 2 years after the procedure. It is possible that a psychological effect is at work here based on the observation that the 7 patients who recorded symptomatic episodes during the 30-day study had been totally afib-free for at least 6 months before they received the event recorder.

The researchers conclude that, "Because the first recurrence of AF may occur more than two years after pulmonary vein isolation, a long period follow-up is necessary to define the long-term efficacy of ablation procedures for AF".
Oral, H, et al. Prevalence of asymptomatic recurrences of atrial fibrillation after successful radiofrequency catheter ablation. Journal of Cardiovascular Electrophysiology, Vol. 15, August 2004, pp. 920-24

Results of LAF Survey VII – Part II

The second part of our survey summary covers the methods used by afibbers who have been able to eliminate or control their episodes by the use of means other than antiarrhythmic drugs.

A. ALTERNATIVE METHODS

Forty-one of the 116 survey respondents (35%) had relied solely on the use of means other than antiarrhythmic drugs (including beta- and calcium channel blockers) to manage their afib. The majority (83%) were men with the average (mean) age of 56 years (median 57 years, range 36-73). The mean age at diagnosis was 47 years (median 51 years, range 18-71). The number of years the respondents had experienced afib varied between 1 and 41 years with a mean of 9 years and a median of 6 years. Four respondents (10%) had been diagnosed with underlying heart disease, while one (3%) had been diagnosed with mitral valve prolapse. The majority (88%) had received a medical diagnosis of paroxysmal, persistent or permanent atrial fibrillation. The distribution of the various types of afib follows:

Six respondents (15%) had experienced minor "side effects" such as:

• missing a glass of wine or beer;
• limited food choices;
• bowel problems (detoxification);
• cutback on strenuous exercise;
• high cost of supplements.

The 15% who experienced side effects from the non-drug protocols compares to 56% who experienced far more serious side effects from the drug protocols. This is clearly a very significant difference.

Thirty respondents (73%) reported additional benefits from their regimen. This is a substantial difference from the 33% who reported additional benefits from their drug regimen. Among the benefits reported were:

It is clear that the protocols used by this group had very substantial overall benefits above and beyond the control of afib severity.

Only 4 out of 41 respondents (10%) no longer needed to avoid their previous episode triggers such as exercise, alcohol, caffeine, MSG, cold drinks, large meals, etc. This percentage is clearly significantly lower than the 40% reported by the antiarrhythmics group. Thus, it is clear that the alternative approach to afib management requires continued vigilance to a greater extent than does a pure drug protocol. Ten respondents (25%) still needed to avoid some triggers, but not as many as before. Twenty-two (53%) had observed no improvement as far as trigger avoidance is concerned, while the remaining 5 (12%) were not sure whether they still had to avoid triggers.

The majority of respondents (90%) would recommend their program to other afibbers and only 5% were contemplating an ablation as compared to 30% in the drug group (see Part 1). Twelve respondents (29%) were not sure whether they would have an ablation (41% in the drug group), and the remaining 27 (66%) were quite certain that they would not undergo an ablation. The desire to have an ablation is probably largely related to how serious an impact afib has on one's life. Thus, it would seem that the impact of afib is less pronounced among afibbers using alternative means than among those using antiarrhythmics – or perhaps users of pharmaceutical drugs are more comfortable with surgical interventions.

The sources of information used in arriving at the successful regimen were as follows:

It is clear that afibbers who relied on alternative methods for managing their afib were much less likely to have obtained their information from a cardiologist or electrophysiologist than were those relying on antiarrhythmics. The main information sources for afibbers using alternative management were the book Lone Atrial Fibrillation: Towards A Cure, personal research on the Internet, the affibers.org bulletin board, and The AFIB Report.

METHODS USED IN MANAGEMENT

The protocols used by this group of 41 afibbers to control their afib fall into 5 broad categories:

• Supplementation – used by 73% of respondents
• Dietary changes – used by 41% of respondents
• Trigger avoidance – used by 39% of respondents
• Stress reduction and other methods – used by 41% of respondents
• Elimination of GERD – used by 7% of respondents

Among supplement users, magnesium was by far the most popular and was used by 54% of respondents, fish oils were used by 34%, vitamin E by 27%, coenzyme Q10 by 24%, vitamin C by 20%, potassium, including low- sodium V8 juice by 17%, and a daily multivitamin by 20%.

The Paleo diet was used by 12% of respondents and the Zone diet and the Mediterranean diet by one respondent each. Other dietary changes included elimination of dairy products (22%) and grains (20%), and an increase in the consumption of fruits and vegetables (20%).

Eliminating caffeine had been found beneficial by 20% of respondents, eliminating alcohol by 17%, eating smaller meals by 12%, and eliminating MSG, aspartame and glutamate from their diet had benefited 12% of respondents. Three respondents had reduced their afib severity very significantly by taking steps to eliminate their GERD (gastroesophageal reflux disease).

The stress reduction methods used by the group were many and varied and included breathing exercises (used by 15%), cognitive thinking, meditation, and smelling or ingesting valerian root. Two afibbers had found relief by having an ICD (implantable cardioverter defibrillator) installed or reprogrammed, and one had reduced episode frequency by 98% by having jaw bone cavitations removed.

EFFECTIVENESS OF PROTOCOLS

A total of 23 afibbers in the group had sufficient data for detailed analysis and fulfilled the criteria of having spent at least 50% less time in afib (number of episodes x average duration) in the 3 months after their program became effective as compared to the 3 months prior to embarking on their program.

The 23 afibbers had been on their program for an average of 18 months (4-62 months) and the time before it became effective varied from 1 day to 12 months with a median of 2 months. Afib severity parameters for a 3- month period before and for a 3-month period after the program became effective are presented below:

The average (mean) reduction in time spent in afib by the group of 23 was an impressive 98%.

A comparison between the above data and the corresponding data for the 19 afibbers using antiarrhythmics shows that the average number of episodes and total time spent in afib over a 3-month period prior to beginning the program were very similar. The average number of episodes and total time spent in afib in a 3-month period after the program became effective were also very similar indicating that an alternative program can be just as effective as a drug-based program. The alternative program, of course, has the added advantage of many other beneficial effects and no serious side effects. Nevertheless, a sample of 23 is small indeed and there is obviously no guarantee that a program based on alternative protocols would work as well in the general afib population.

The protocols used by the select group of 23 afibbers paralleled those used by the entire group of 41 afibbers, except that the 3 respondents who had found improvement by controlling their GERD were all in the select group. The percentage of afibbers using the various supplements did not differ between the select and total group. The percentage of afibbers having found improvement through dietary changes was somewhat higher in the select group (56%) than among the remaining 18 afibbers (33%). There were no differences between the select group and the remaining group as far as the use of stress reduction and other methods are concerned nor in the percentage having found trigger elimination beneficial.

Ten afibbers (24%) in the group of 41 had completely eliminated their afib episodes for at least a 3-month period and two had seen a 99.9% improvement. Their profiles are presented below:

It is clear that a well-designed non-drug program can be just as effective as a program based on antiarrhythmics and beta- or calcium channel blockers. The big challenge is to find the protocol that is just right. This clearly can involve a great deal of experimentation and can be costly as well, particularly if supplements and fresh, organic food are part of the program.

A successful program can be as simple as eliminating triggers such as alcohol or caffeine, wheat and dairy or just increasing the intake of magnesium and potassium. However, in many cases fundamental dietary changes, a vast arsenal of supplements, and faithful adherence to stress reduction protocols are required to achieve the afib-free nirvana.

The alternative programs adopted by the respondents to this survey clearly have no serious side effects and many highly desirable benefits over and above the elimination of afib or, at least, a substantial reduction in episode severity. Will they work for everyone? Probably not – we are all an experiment of one it seems, but certainly the afibbers whose programs have been covered here have shown the way and provided many ideas for the rest of us to try.