Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Converting atrial fibrillation to a normal rhythm can be accomplished with medications (chemical
cardioversion) or by electrical shocks (electrical cardioversion). Doctors
usually recommend that all patients with chronic sustained atrial fibrillation undergo at least
one attempt at cardioversion, chemical or electrical. Successful cardioversion
can alleviate symptoms, improve exercise tolerance, improve quality of life, and
lower the risk of strokes. Doctors usually try medical cardioversion first, and, if
medications fail, then try electrical cardioversion.
Patients who are more likely to attain and maintain a normal heart rhythm
with either chemical or electrical cardioversion include:
Patients younger than 65 years of age
Patients who have had atrial fibrillation for a short time (less than
12 months)
Patients with normal-sized atria and ventricles
Patients who are having their first episode of atrial fibrillation
Cardioversion with medications. Before prescribing medications for cardioversion, the doctor usually
controls the rate of ventricular contractions and thins the blood, usually with
warfarin.
1) Available Medications. Medications used in
cardioversion usually work by blocking the channels in the walls of cells through which ions
travel (sodium channels, potassium channels, beta adrenergic channels, and calcium
channels). Some examples of these medications include:
These medications are capable of converting atrial fibrillation to normal rhythm in about 50%
of patients. They often are used long-term to maintain a normal rhythm and
prevent recurrences of atrial fibrillation.
2) Disadvantages of using medications. Medications used for
converting atrial fibrillation carry a small risk of causing other abnormal heart rhythms--they
are said to be pro-arrhythmic--especially in patients with diseases of the
heart muscle or coronary arteries. These
abnormal heart rhythms can be more
life-threatening than atrial fibrillation. Therefore, treatment with these medications often is
initiated in the hospital while the patient's rhythm is continuously
monitored for 24-72 hours.
These medications may not be effective in the longer-term. Many patients
eventually develop a recurrence of atrial fibrillation despite the medications.
Medications used in treating atrial fibrillation often have important side effects.
Many patients discontinue them because they cannot tolerate these side
effects. For example, amiodarone is commonly used in treating atrial
fibrillation because it
is less pro-arrhythmic and has been shown to maintain a normal rhythm in up to
75% of patients. However, amiodarone frequently causes side effects and drug
interactions. About 7 out of every 10 patients taking amiodarone experience
some type of side effect, and between 1 in 5 and 1 in 20 experience side
effects that are severe enough that the amiodarone must be stopped. Amiodarone
can interact with other medications such as
tricyclic antidepressants,
for example, amitriptyline (Elavil,
Endep) or phenothiazine antipsychotics, for example,
chlorpromazine (Thorazine) and cause abnormal heart rhythms. Amiodarone interacts with
warfarin and increases the risk of bleeding. This interaction with warfarin can
occur as early as 4-6 days after the start of both drugs or can
be delayed by a few weeks. Thus, doctors prescribing both warfarin and amiodarone will adjust
the dose of warfarin to avoid excessive blood thinning. Amiodarone also can
cause thyroid disturbances in the fetus when administered orally to the
mother during pregnancy. Amiodarone also may affect thyroid function in adults.
The most severe side effect of amiodarone is lung toxicity that potentially
can be fatal. Because of this lung toxicity, patients should report any
symptoms of cough, fever, or painful breathing to their doctors.
Electrical cardioversion.
Electrical cardioversion is a procedure used by doctors
to convert an abnormal heart rhythm (such as atrial fibrillation) to a normal rhythm (sinus
rhythm). Electrical cardioversion requires the administration of an electrical shock over the
chest. This electrical shock stops the abnormal electrical activity of the heart
for a brief moment and allows the normal heart rhythm to take over. Although
electrical cardioversion can be used to treat almost any abnormal fast heartbeat
(such as atrial flutter and ventricular tachycardia), it is used most frequently
to convert atrial fibrillation to a normal rhythm.
Warfarin usually is given for 3 to 4 weeks prior to cardioversion to minimize
the risk of stroke that can occur during or shortly after cardioversion.
Warfarin is continued for four to six weeks after successful cardioversion. For
some patients requiring urgent electrical cardioversion, warfarin may not work
fast enough to thin the blood. Therefore, these patients may be given heparin prior to
electrical cardioversion. Heparin is a faster-acting blood thinner than
warfarin, but it must be administered as a continuous intravenous infusion or as
injections under the skin. After successful cardioversion, these patients can be
switched from heparin to warfarin.
1) Method of cardioversion. Electrical cardioversions (urgent and
elective) usually are performed in a hospital. For elective (non-urgent)
electrical cardioversion, patients usually arrive at the hospital without
eating in the morning. Necessary medications can be taken with small sips of
water. Patients are given supplemental oxygen via nasal catheters, and an
intravenous infusion of fluids is started. Electrodes (pads) are placed on the
skin over the chest to continuously monitor the heart rhythm. Paddles then are
placed over the chest and the upper back. Patients are sedated (anesthetized)
intravenously with medications. This is followed by a strong electric shock
through the paddles. The shock converts the atrial fibrillation to a normal rhythm. After
cardioversion, patients are observed for several hours or overnight to make
sure that their normal heart rhythm is stable.
2) Effectiveness of electrical cardioversion. Electrical
cardioversion is more effective than medications alone in terminating atrial
fibrillation and
restoring a normal heart rhythm. Electrical cardioversion successfully
restores a normal heart rhythm in over 95% of patients.
3) Limitations of electrical cardioversion. While electrical
cardioversion is effective in converting atrial fibrillation to a normal heart rhythm, the
normal rhythm may not continue for long. Approximately 75% of patients
successfully treated with electrical cardioversion experience a recurrence of
atrial fibrillation within 12-24 months. Older patients with enlarged atria and ventricles who
have had atrial fibrillation for a long time are especially prone to recurrences. Thus, most
patients who undergo successful cardioversion are placed on oral medications
to prevent recurrences of atrial fibrillation.
4) Risks of electrical cardioversion. The risks of electrical
cardioversion include stroke, heart attack,
burns of the skin, and in rare
instances, death.
5) Candidates for electrical cardioversion. Doctors usually
recommend that all patients with chronic, sustained atrial fibrillation undergo at least one
attempt at cardioversion. Cardioversion usually is attempted with medications
first. If medications fail, electrical cardioversion can be considered.
Sometimes a doctor may choose to use electrical cardioversion first if atrial
fibrillation is
of short duration (onset within 48 hours) and the transesophageal
echocardiography shows no blood clots in the atria.
Electrical cardioversion is performed urgently (on an emergency basis) on
patients with severe and potentially life-threatening symptoms caused by
atrial fibrillation.
For example, some patients with rapid atrial fibrillation can develop chest pain, shortness of
breath, and dizziness or fainting. (Chest pain in these patients is due to an
insufficient supply of blood to the heart muscles. Shortness of breath
indicates ineffective pumping of blood by the ventricles. Fainting or
dizziness usually is due to dangerously low blood pressure.)
Rate control therapy. Recent
studies have shown that an acceptable alternative
to cardioversion (chemical or electrical) is rate-control therapy. In
rate-control therapy, the doctor will leave the patients in atrial fibrillation provided their rate
of ventricular contractions is under good control, the output of blood from the
heart is adequate, and their blood is adequately thinned by warfarin to prevent
strokes. Heart rate in these patients can be controlled using medications
such as beta-blockers, calcium channel blockers, or digoxin or AV node
ablation with pacemaker implantation. Rate-control therapy is used to simplify
therapy and avoid the side effects of anti-arrhythmic medications (medications
used to treat and prevent atrial fibrillation).
Over long periods of observation, patients treated with rate-control therapy
have similar survival and quality of life as compared to patients who undergo
repeated electrical or chemical cardioversions.
Suitable candidates for rate-control therapy include:
Patients who have had atrial fibrillation for more than one year
Patients with significant disease of the heart valves
Patients with enlarged hearts as a result of heart
failure or cardiomyopathy (heart muscle weakness)
Patients with significant or intolerable side effects with medications for
atrial fibrillation
Low blood pressure, also referred to as hypotension, is blood pressure that is so low that it causes symptoms or signs due to the low flow of blood through the arteries and veins. Some of the symptoms of low blood pressure include light-headedness, dizziness, or even fainting if not enough blood is getting to the brain. Diseases and medications can also cause low blood pressure. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidneys; the organs do not function normally and may be permanently damaged.
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. A poor blood supply resulting from congestive heart failure may cause the body's organ systems to fail, leading to a weakened heart muscle and fluid accumulation in the lungs and body tissue. There are many diseases that can impair pumping efficiency and symptoms of congestive heart failure including fatigue, diminished exercise capacity, shortness of breath, and swelling. Treatments include lifestyle modifications, medications, heart transplant, and therapy.
High blood pressure, also known as hypertension, is a repeatedly
elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above
140 with a diastolic pressure above 90. There are two causes of high blood pressure, primary and secondary. Primary high blood pressure is much more common that secondary and its basic causes or underlying defects are not always known. It is known that a diet high in salt increases the risk for high blood pressure, as well as high cholesterol. Genetic factors are also a primary cause. Secondary high blood pressure is generally caused by another condition such as renal hypertension, tumors, and other conditions. Treatment for high blood pressure is generally lifestyle changes and if necessary, diet.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
An arrhythmia is an abnormal heart rhythm. With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too early. When a single heartbeat occurs earlier than normal, it is called a prmature contraction.
Hyperthyroidism is an excess of thyroid hormone resulting from an overactive thyroid gland. Symptoms can include increased heart rate, weight
loss, depression, and cognitive slowing. Treatment is by medication, the use of
radioactive iodine, thyroid surgery, or reducing the dose of thyroid hormone.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
COPD (chronic obstructive pulmonary disease) is a disorder that persistently obstructs bronchial airflow. COPD mainly involves three related conditions, chronic bronchitis, chronic asthma, and emphysema. Symptoms of COPD include chronic cough, shortness of breath, frequent respiratory infections, wheezing, morning headaches, and pulmonary hypertension. Treatment of COPD is focused on the related condition(s).
Mitral valve prolapse (MVP) is also also known as "click murmur syndrome" and "Barlow's syndrome." Mitral valve prolapse is the most common heart valve abnormality. Signs and symptoms of mitral valve prolapse include: fatigue, palpitations, chest pain, anxiety, and migraine headaches. Echocardiography is the most useful test for mitral valve prolapse. Most patients do not need any treatment, however, patients with severe prolapse may need treatment.
Heart rhythm disorders vary from minor palpitations, premature atrial contractions (PACs), premature ventricular contractions (PVCs), sinus tachycardia, and sinus brachycardia, to abnormal heart rhythms such as tachycardia, ventricular fibrillation, ventricular flutter, atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), Wolf-White-Parkinson syndrome, brachycardia, or heart blocks. Treatment is dependant upon the type of heart rhythm disorder.
Pulmonary edema (swelling or fluid in the lungs) can either be caused by cardiogenic causes (congestive heart failure, heart attacks, abnormal heart valves) or noncardiogenic causes such as ARDS, kidney failure, high altitude, pneumothorax, pleural effusion, aspirin overdose, pulmonary embolism, and infections. The treatment of pulmonary edema depends on the cause of the condition.
Pericarditis is the inflammation of the pericardial sac that surrounds the heart. The causes of pericarditis include injury from heart attack, heart surgery, trauma; viral or fungal infection, HIV, tumors, mixed connective tissue disease, metabolic disease, medication reactions, or idiopathic. Treatment for pericarditis is generally medication, however, sometimes surgery is necessary.
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Rheumatic fever is a disease that sometimes occurs after a group A streptococcal infection of the throat. Symptoms and signs include carditis, polyarthritis, Aschoff bodies, rash, Sydenham's chorea, and fever. Treatment for rheumatic fever involves eliminating the bacteria with penicillin, erythromycin, or azithromycin. Further treatment focuses on alleviating the symptoms brought on by the body's immunologic response to the bacteria.
Heart attacks are the major causes of unexpected, sudden death among men and women. A heart attack is also a significant cause of heart failure. Learn the risk factors for heart attack such as high blood pressure, diabetes, and other heart conditions. Lowering your risk factor, lifestyle changes, and in some cases medication are the most effective way of preventing a heart attack.
Stroke is the third leading killer in the United States. Some of the warning signs of stroke include sudden confusion, trouble seeing with one or both eyes, dizziness, loss of balance, and more. Stroke prevention and reatable risk factors for stroke include lowering high blood pressure, quit smoking, heart disease, diabetes control and prevention.
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