Atrial fibrillation
Introduction:
Full aspects of atrial fibrillation treatment and management by a Cardiologist is extremely important to reduce the risk of potential complications such as embolic stroke and heart failure. Certain nutrients or nutrient deficiencies may place patients at risk for atrial fibrillation. Atrial fibrillation may be influenced by the intake of certain foods, electrolytes, and nutrients.
Atrial fibrillation and risk of stroke:
Patients with atrial fibrillation are at a higher risk for stroke between 1-20% per year or 4.5% on average depending on the presence of additional risk factors and medical problems. For detailed information on prevention of stroke with anticoagulation including warfarin (Coumadin), antiplatelet agents (aspirin and clopidogrel) and new recommendations for dabigatran, please see the American Heart Association/American Stroke Association (AHA/ASA) “Guidelines for the Primary Prevention of Stroke” available at http://www.ncbi.nlm.nih.gov/pubmed/22858728 or http://stroke.ahajournals.org/content/43/12/3442.full (4).
Prediction of ischemic stroke:
A CHADS2 score is the most accurate tool for prediction of stroke in patients with atrial fibrillation. Calculating a CHADS2 score uses the following scoring system (6):
- 2 points for previous stroke or TIA (transient ischemic attack)
- 1 point for recent CHF (congestive heart failure)
- 1 point for hypertension
- 1 point for age 75 years or older
- 1 point for diabetes
Rate of stroke by CHADS2 score:
The rate of stroke occurrence without anticoagulation per year depends upon the CHADS2 score as follows (6):
- CHADS2 score of 0: 1.9% per year.
- CHADS2 score of 1: 2.8% per year.
- CHADS2 score of 2: 4.0% per year.
- CHADS2 score of 3: 5.9% per year.
- CHADS2 score of 4: 8.5% per year.
- CHADS2 score of 5: 12.5% per year.
- CHADS2 score of 6: 18.2% per year.
Prevention of ischemic stroke in patients with atrial fibrillation:
- The patient’s cardiologist and primary care provider are responsible for recommending treatment for the prevention of stroke. According to the American Heart Association/American Stroke Association (AHA/ASA) basic treatment guidelines are as follows (5):
- CHADS2 score of 0: No treatment or aspirin is recommended.
- CHADS2 score of 1: Antithrombotic therapy choice by the physician varies.
- CHADS2 score of 2 or higher: Anticoagulation is recommended for atrial fibrillation to prevent stroke.
Warfarin, aspirin, and clopidogrel use in risk of stroke:
Warfarin with dose changes to maintain therapeutic range reduced the risk of stroke in atrial fibrillation from an average of 4.5% to 1.4%. Aspirin reduces the risk of stroke in atrial fibrillation by about 21%. Benefit verses risks of bleeding or adverse effects from anti-thrombotic therapy should be discussed in detail with the physician. The risk of severe bleeding episodes while taking warfarin was about 1.3% per year, and with aspirin, about 1% per year. Therapy with both aspirin and clopidogrel were demonstrated to be about the same severe bleeding risk as warfarin with a small reduction in stroke rates.
Creatine phosphate and atrial fibrillation:
Creatine has been shown to have lower rates of arrhythmias before and after heart surgery, but creatine phosphate has not been studied yet for use in atrial fibrillation, but should be investigated. Three days before surgery, creatine phosphate supplementation showed improved heart function after bypass surgery with less ventricular arrhythmias and reduced use of inotropic drugs (7). Creatine phosphate given during cardiac surgery and the early postoperative period reduced CK and CKMB levels plus resulted in a lower percentage of arrhythmias compared to controls (8).
Low lutein and zeaxanthin levels:
Elderly individuals with specifically low lutein and zeaxanthin levels may face an increased risk of atrial fibrillation according to a study that included 1,847 participants aged 61-82 years. The study calculated hazard ratios after adjusting for systolic bp, diabetes, age, smoking, diabetes, alcohol use, use of bp medication, gender, congestive heart failure, recurring atrial fibrillation, and myocardial infarction. The hazard ratio for low lutein was 1.70 and for low zeaxanthin it was 1.99. Lycopene, β-cryptoxanthin, α-carotene and total carotenoids were not found to be associated with the risk of atrial fibrillation.
III. Common Highest Lutein and Zeaxanthin Containing Foods:
| Spinach, frozen, chopped or leaf, cooked, boiled, drained, w/o salt, 1 cup | 29811 mcg |
| Kale, frozen, cooked, boiled, drained, without salt, 1 cup | 25606 mcg |
| Kale, cooked, boiled, drained, without salt, 1 cup | 23720 mcg |
| Spinach, canned, regular pack, drained solids, 1 cup | 22631 mcg |
| Spinach, cooked, boiled, drained, without salt, 1 cup | 20354 mcg |
| Turnip greens, frozen, cooked, boiled, drained, without salt, 1 cup | 19541 mcg |
| Collards, frozen, chopped, cooked, boiled, drained, without salt, 1 cup | 18527 mcg |
| Mustard greens, cooked, boiled, drained, without salt, 1 cup | 14560 mcg |
| Turnip greens, cooked, boiled, drained, without salt, 1 cup | 12154 mcg |
| Collards, cooked, boiled, drained, without salt, 1 cup | 11774 mcg |
| Dandelion greens, cooked, boiled, drained, without salt, 1 cup | 9616 mcg |
| Spinach soufflé, 1 cup | 4419 mcg |
| Squash, summer, all varieties, cooked, boiled, drained, without salt, 1 cup | 4048 mcg |
| Peas, green, frozen, cooked, boiled, drained, without salt, 1 cup | 3840 mcg |
| Spinach, raw, 1 cup | 3659 mcg |
| Noodles, egg, spinach, cooked, enriched, 1 cup | 3571 mcg |
| Squash, winter, all varieties, cooked, baked, without salt, 1 cup | 2901 mcg |
| Beet greens, cooked, boiled, drained, without salt, 1 cup | 2619 mcg |
| Pumpkin, cooked, boiled, drained, without salt, 1 cup | 2484 mcg |
| Corn, sweet, yellow, canned, cream style, regular pack, 1 cup | 2429 mcg |
| Squash, summer, all varieties, raw, 1 cup | 2401 mcg |
| Brussels sprouts, frozen, cooked, boiled, drained, without salt, 1 cup | 2389 mcg |
| Peas, green (includes baby and lesuer types), canned, unprepared, 1 cup | 2295 mcg |
| Cornmeal, degermed, enriched, yellow, 1 cup | 2247 mcg |
| Corn, sweet, yellow, canned, vacuum pack, regular pack, 1 cup | 2195 mcg |
| Broccoli, frozen, chopped, cooked, boiled, drained, without salt, 1 cup | 2015 mcg |
| Brussels sprouts, cooked, boiled, drained, without salt, 1 cup | 2012 mcg |
| Lettuce, butterhead (includes boston and bibb types), raw, 1 head | 1993 mcg |
| Broccoli, cooked, boiled, drained, without salt, 1 cup | 1685 mcg |
| Cornmeal, whole-grain, yellow, 1 cup | 1653 mcg |
| Lettuce, iceberg (includes crisphead types), raw, 1 head | 1493 mcg |
| Peas, edible-podded, frozen, cooked, boiled, drained, without salt, 1 cup | 1429 mcg |
Atrial Fibrillation and Peppermint Intake:
A case of atrial fibrillation has been reported to occur with excessive peppermint intake (3).
Assessment and Plan: Atrial Fibrillation
- Atrial fibrillation: Patients with atrial fibrillation are at a higher risk for stroke between 1-20% per year or 4.5% on average depending on the presence of additional risk factors and medical problems. For detailed information on prevention of stroke with anticoagulation including warfarin (Coumadin), antiplatelet agents (aspirin and clopidogrel) and new recommendations for dabigatran, please see the American Heart Association/American Stroke Association (AHA/ASA) “Guidelines for the Primary Prevention of Stroke” available at http://www.ncbi.nlm.nih.gov/pubmed/22858728 or http://stroke.ahajournals.org/content/43/12/3442.full (4).
- Prediction of ischemic stroke: A CHADS2 score is the most accurate tool known for prediction of stroke in patients with atrial fibrillation. Calculating a CHADS2 score uses the following scoring system (6):
- 2 points for previous stroke or TIA (transient ischemic attack)
- 1 point for recent CHF (congestive heart failure)
- 1 point for hypertension
- 1 point for age 75 years or older
- 1 point for diabetes
- Rate of stroke by CHADS2 score: The rate of stroke occurrence without anticoagulation per year depends upon the CHADS2 score as follows (6):
- CHADS2 score of 0: 1.9% per year.
- CHADS2 score of 1: 2.8% per year.
- CHADS2 score of 2: 4.0% per year.
- CHADS2 score of 3: 5.9% per year.
- CHADS2 score of 4: 8.5% per year.
- CHADS2 score of 5: 12.5% per year.
- CHADS2 score of 6: 18.2% per year.
- Treatment for prevention of ischemic stroke in patients with atrial fibrillation: The patient’s cardiologist and primary care provider are responsible for recommending treatment for the prevention of stroke. According to the American Heart Association/American Stroke Association (AHA/ASA) basic treatment guidelines are as follows (5):
- CHADS2 score of 0: No treatment or aspirin is recommended.
- CHADS2 score of 1: Antithrombotic therapy choice by the physician varies.
- CHADS2 score of 2 or higher: Anticoagulation is recommended for atrial fibrillation to prevent stroke.
- Warfarin with dose changes to maintain therapeutic range reduced the risk of stroke in atrial fibrillation from an average of 4.5% to 1.4%.
- Aspirin reduced the risk of stroke in atrial fibrillation by 21%.
- Benefit verses risks of bleeding or adverse effects from anti-thrombotic therapy should be discussed in detail with the physician. The risk of severe bleeding episodes while taking warfarin was about 1.3% per year, and with aspirin, about 1% per year. Therapy with both aspirin and clopidogrel were demonstrated to be about the same bleeding risk as warfarin with a small reduction in stroke rates.
- Creatine phosphate and atrial fibrillation: Creatine has been shown to have lower rates of arrhythmias before and after heart surgery, but creatine phosphate has not been studied yet for use in atrial fibrillation, but should be investigated. Three days before surgery, creatine phosphate supplementation showed improved heart function after bypass surgery with less ventricular arrhythmias and reduced use of inotropic drugs (7). Creatine phosphate given during cardiac surgery and the early postoperative period reduced CK and CKMB levels plus resulted in a lower percentage of arrhythmias compared to controls (8).
- Elderly individuals with specifically low lutein and zeaxanthin levels may face an increased risk of atrial fibrillation.
- See Lutein and Zeaxanthin containing foods as noted above to enhance intake of these nutrients.
- Patients should be counseled to avoid excessive consumption of peppermint until further research is available to clarify risks.
References:
1.Karppi J, Kurl S, Mäkikallio TH, Ronkainen K, Laukkanen JA. Low levels of plasma carotenoids are associated with an increased risk of atrial fibrillation. Eur J Epidemiol. 2013 Jan;28(1):45-53. http://www.ncbi.nlm.nih.gov/pubmed/23238698
2.Adapted from: Nutritive Value of Foods, United States Department of Agriculture, Agricultural Research Service, Home and Garden Bulletin Number 72. May be accessed at: https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR25/nutrlist/sr25w338.pdf
3.Nurick S. Atrial fibrillation and peppermint eating. Report of a case. Guys Hosp Rep. 1963;112:171-4. http://www.ncbi.nlm.nih.gov/pubmed/13939246
4.Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JV, Pearson TA; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council for High Blood Pressure Research,; Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Feb;42(2):517-84. http://www.ncbi.nlm.nih.gov/pubmed/21127304
5.Furie KL, Goldstein LB, Albers GW, Khatri P, Neyens R, Turakhia MP, Turan TN, Wood KA; American Heart Association Stroke Council; Council on Quality of Care and Outcomes Research; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Council on Peripheral Vascular Disease. Oral antithrombotic agents for the prevention of stroke in nonvalvular atrial fibrillation: a science advisory for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012 Dec;43(12):3442-53. http://www.ncbi.nlm.nih.gov/pubmed/22858728
6.Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001 Jun 13;285(22):2864-70. http://www.ncbi.nlm.nih.gov/pubmed/11401607
7.Cisowski M, Bochenek A, Kucewicz E, Wnuk-Wojnar AM, Morawski W, Skalski J, Grzybek H. The use of exogenous creatine phosphate for myocardial protection in patients undergoing coronary artery bypass surgery. J Cardiovasc Surg (Torino). 1996 Dec;37(6 Suppl 1):75-80. http://www.ncbi.nlm.nih.gov/pubmed/10064355
8.Cerný J, N?mec P, Bucek J, Cerný E, Papousek F, Lojek A. The effect of creatine phosphate in patients after surgery in ischemic heart disease. Czech. Vnitr Lek. 1993 Feb;39(2):153-9. http://www.ncbi.nlm.nih.gov/pubmed/8506662