/ 4 July 2011

Stroke can be a heartbeat away

In 1997, 54-year-old Tim van Staden had his first heart attack and he was not aware of it. He experienced chest pains for six hours, but when they disappeared he continued his day-to-day life. Last year he had an atrial fibrillation-related stroke while taking a nap. “It felt as if my heart was trying to leap out of my chest,” he says.

One in four South Africans between the ages of 40 and 80 is likely to have an atrial fibrillation (AF) incident that could lead to a stroke. It is estimated that 15% of people over the age of 80 already have AF and 50% of those who have suffered an AF-related stroke are likely to die within the year. But with proper treatment many strokes can be prevented.

AF is a heart rhythm abnormality that causes the heart to beat irregularly, making it beat too slowly or too fast. This happens when the electrical signals in the heart misfire, causing the upper chambers, the atriums, of the heart to fibrillate.

When blood pools in these chambers rather than flowing to the heart’s lower chambers, the ventricles, it forms clots that may travel through the bloodstream to the brain and can block the flow of blood to the brain, causing a stroke.

AF is common in people with heart disease. Van Staden admits to having a long family history of heart-related conditions but he leads a normal lifestyle. “I don’t drink, smoke, eat junk; I’m not overweight and my blood pressure is perfect.”

According to Prevent Arrhythmic Cardiac Events (Pace), some cases of AF have no causes, but conditions associated with it are high blood pressure, diabetes mellitus, an overactive thyroid gland, vascular disease and drinking too much alcohol.

Although many who have AF experience no symptoms, people are warned to look out for palpitations, dizziness, chest pains and breathlessness. People can suffer from AF on a regular basis without experiencing any symptoms — until they have a stroke.

One of the burdens of having AF is the possibility of being incapacitated after having a stroke. Van Staden, who is a self-employed financial adviser, says he was fortunate enough to be able to handle the financial burdens of living with AF even though he was affected both physically and emotionally. Since his stroke he has been relying on his family for support. “I haven’t earned any money because I haven’t been working.”

Franciska Rossouw, the chief executive of Pace, says some AF patients may suffer from depression and anger after being deprived of a normal life. Patients often have to make frequent visits to the doctor, which may interrupt their daily routine and put a strain on their families. They are also constantly aware of the risk of stroke, which remains a threat.

Dr Ronnie Jardine, the president of the Cardiac Arrhythmia Society of Southern Africa, says that, during the first year of diagnosis for AF, medical bills for a patient can reach up to R100 000.

People living in poor communities who do not have access to medical aid cannot afford the treatment for AF and are “slipping through the net”. But electrocardiogram scanning and anticoagulation treatment is provided for in state hospitals.

Rossouw says Pace has begun an initiative that offers screening at schools, to communities in the rural areas and to those living in poor communities.

It is possible to live with AF for many years and prevent a stroke. John Marquis (77) has been living with AF for 16 years. He is a patient of Jardine’s and there is no recorded incident that triggered the AF. “It came on very suddenly. I was walking and then suddenly had an attack of fibrillation.” He describes it as an irregular heartbeat with no pain. He believes that his medication prevented him from having a stroke.

According to Jardine, AF can be managed by reducing the risks of having a stroke through medication that can thin the blood or restore a normal heart rhythm. Antithrombotic treatment is medication that reduces the chances of blood clots from forming. It is anticoagulant medication that is taken by patients who are particularly at risk of having a stroke. In South Africa, the most commonly used medication is warfarin.

But some patients cannot tolerate anticoagulants and are given antiplatelet agent aspirin, although it is not considered to be as effective for stroke prevention, says Pace.

Pace also identifies other methods of treatment, for example, AF patients with a fast heart rate are often given medication to bring their heart rate back to normal through a treatment called “rate control”. This treatment can improve the symptoms of dizziness and palpitations.

Other forms of treatment for AF patients include electrical cardioversions, a treatment by which the heart is given an electric shock to bring the rhythm back to normal. Other treatments include ablations and pharmacological methods of cardioversions followed by medication to maintain the normal heart rhythm.

Dr Pro Obel, an electrophysiologist, says, because AF is silent and many patients who have it may not sense it, it is important to know your pulse, learn how to take it, identify whether it is irregular and “know the difference between what is normal and not normal”.

Myths and questions
I work too hard and I don’t get enough exercise — can this increase my chances of getting an atrial fibrillation-related stroke?
Exercise can actually trigger an AF-related stroke. When you get fit you stimulate your gall bladder. If you have a bilious attack, you stimulate your vagus nerve, which has a direct link to producing an episode of atrial fibrillation. Therefore, exercise such as jogging and running could increase the chances of having an AF incident.

If I have AF, can I still have a glass of red wine occasionally because it’s good for my heart?
Red wine in moderation has long been thought to be good for the heart. It contains antioxidants, including resveratrol, which may prevent heart disease by increasing the level of “good” cholesterol that could protect the heart against artery damage. It is still debated whether resveratrol could prevent blood clots. Although there is no direct link between AF and alcohol, weekend binge-drinking is associated with Monday-morning AF.

In 2003 former British prime minister Tony Blair had an operation for AF and was cured. Why are doctors wary about this operation?
Blair was suffering from a condition considered to be the cousin of AF — atrial flutter. Fifty percent of people who have had flutter ablation will develop fibrillation over the next three years. For people who have episodes of AF, the procedure works well. But if you’ve had chronic AF for more than five years, the procedure is not for you.