Atrial fibrillation is characterized by a rapid, irregular heart beat and can be paroxysmal (intermittent) or permanent in nature. It is caused by a dysfunction of the heart tissue or nodes, by a dysfunction of the autonomic nervous system or by a combination of both. Individual heart cells are capable of "beating" on their own outside the control of the autonomic system. Sometimes agglomerations of very active cells form and create a focus for so called ectopic beats (beats originating outside the SA (sino-atrial) node). The junction between the left atrium and the pulmonary vein is a particularly popular spot for these "rogue" cell agglomerations and some arrhythmias can be successfully treated by removing them with radio frequency ablation. If the ectopic beats become very frequent they may run together and create atrial fibrillation. Atrial fibrillation basically involves a chaotic movement of electrical impulses across the atria and leads to a loss of synchrony between the atria and the ventricles. Once an episode has begun the atria may quiver or fibrillate at a rate as high as 300 to 600 times per minute. This causes a very inefficient filling and emptying of the atria; the chaos is transferred to the ventricles causing them to lose their regular rhythm and begin to contract fast and in a totally irregular manner. This is what gives rise to the fast and irregular pulse rate felt during an AF episode (90-160 beats/minute).

Atrial fibrillation in itself is not a disease, but rather a symptom of some other disorder of the body. Atherosclerosis, angina, heart attack, heart surgery, valvular heart disease, hypoglycemia, hypertension, electrolyte imbalances, hyperthyroidism, anemia, pheochromocytoma, strenuous exercise, binge drinking, consumption of tyramine-containing foods, and exposure to mental or physical stress can all trigger atrial fibrillation. Very recent research has found that an inflammation of the heart lining (myocardium) is often involved in atrial fibrillation.If none of the above conditions are causing the atrial fibrillation then it is diagnosed as primary or idiopathic (of no known cause).

Most cases of atrial fibrillation are caused by heart disease or an abnormality of the heart. However, between 12 and 30 per cent of all cases do not involve an underlying heart problem. These cases are classified as lone atrial fibrillation (LAF) or, by some cardiologists, as paroxysmal atrial fibrillation. It should be kept in mind that the validity of the diagnosis is highly dependent on the quality and quantity of the tests done to rule out underlying heart problems. Just recently researchers at the Cleveland Clinic confirmed that inflammation, presumably of the heart lining, is frequently present in patients who have been diagnosed as having LAF. Nevertheless, it is generally accepted that lone atrial fibrillation (LAF) is characterized by the absence of heart abnormalities or heart disease. This means that LAF is not life-threatening and is far less likely to precipitate a stroke than is atrial fibrillation involving heart problems.

Medical intervention in lone atrial fibrillation is aimed at preventing episodes, ameliorating the symptoms of episodes, converting the fibrillation to normal sinus rhythm (NSR), and reducing the risk of stroke. With the exception of surgery (the maze procedure) and catheterization (radio frequency and ultrasound ablation) medical intervention is not meant to eliminate (cure) the disorder, but rather to control (manage) it over the long term.

Lone atrial fibrillation is a chronic disorder like diabetes or arthritis rather than an acute disorder like the flu or a bout of pneumonia. It comes in three "flavours" – paroxysmal, persistent, and permanent. Paroxysmal AF converts to normal sinus rhythm on its own and episodes last less than 7 days (most less than 24 hours); persistent AF episodes last more than 7 days, but cardioversion is effective in conversion to normal sinus rhythm; permanent LAF is permanent and does not respond to cardioversion. It is possible, but probably rare, to have just one episode of LAF. Far more common is the paroxysmal (intermittent) form of LAF. The frequency and duration of episodes vary greatly, but generally increase with age and the number of years the disorder has been present. In some cases LAF becomes permanent, that is, the irregular, rapid heartbeat becomes a constant companion.

Violent palpitations, breathlessness, dizziness and frequent urination are common features of LAF episodes. Many LAF patients suffer greatly during their episodes while others have no symptoms at all and are diagnosed only by chance through a routine electrocardiogram.Dr. Philippe Coumel of the Lariboisiere Hospital in Paris proposed in 1989 that a dysfunction of the autonomic nervous system plays a major role in LAF. He found that there are two varieties of paroxysmal LAF, an adrenergic form and vagal form.Adrenergic type LAF is intimately connected with an over-active sympathetic (adrenergic) nervous system and is primarily found in older people. Episodes occur almost exclusively during daytime and is often preceded by exercise or emotional stress. This type of LAF can also be a symptom of hyperthyroidism or pheochromocytoma. Some cardiologists feel that adrenergic type LAF may involve some sort of unrecognized heart abnormality.Vagal type LAF is associated with an overactive parasympathetic (vagal) nervous system and is often observed in athletes and people with digestive problems. It is most common among men aged 40 to 50 years. The commonest feature is that of weekly episodes, lasting from a few minutes to several hours. The essential feature is the occurrence of attacks at night, often ending in the morning. Rest, digestive periods (particularly after dinner), and alcohol consumption are also predisposing factors. Exercise or emotional stress does not trigger the arrhythmia. On the contrary, on feeling the sensation of an oncoming episode (repeated atrial premature beats), many patients have observed that they can prevent an attack by exercising, but the relaxation period that follows an effort or an emotional stress frequently coincides with the onset of vagal LAF. There is no indication that vagal LAF involves any heart abnormality and vagal LAF rarely if ever develops into a permanent condition.Some LAF patients experience both vagal and adrenergic episodes and are classified as having a mixed variety of LAF.Frequent urination (every 20 minutes or so) often occurs during the early phase of an episode and is due to the release of atrial natriuretic peptide from the fibrillating atria.

A comprehensive survey of afibbers (LAF patients) carried out by THE AFIB REPORT revealed that most afibbers have a vivid memory of their first LAF episode. The most common trigger of that first one was emotional or work-related stress (26%) closely followed by physical overexertion at 24%. Caffeine, alcohol, and ice-cold drinks were next at 10%, 6% and 8% respectively. Other less common triggers were severe illness or a viral infection (experienced by 6% of respondents), dehydration (4%), and rest (4%). Digestive periods, coughing and burping, pharmaceutical drugs, surgery, electromagnetic radiation, and toxic chemicals round off the list of initial triggers with 2% (1 respondent) each. The triggers of subsequent episodes follow in the footsteps of the first one. The overwhelming favourite for the title of most important trigger is emotional or work-related stress. A full 50% of all respondents listed stress as a trigger. Physical overexertion was next at 24% closely followed by alcohol (including wine) and rest at 22% each. The digestive period following a heavy meal was a trigger for 18%, caffeine was mentioned by 16%, and an ice-cold drink by 12%. Ten per cent reported that MSG (monosodium glutamate) was a trigger for them and 6% said that lying on the left side would set off an episode. Aspartame (NutraSweet) was mentioned as a trigger by two respondents (4%) as was chocolate, coughing and burping, and flying (at high altitudes). Three men over 30 years of age (6%) felt that their episodes were cyclical in nature and not related to any specific trigger. Other triggers mentioned were aged cheese, sugar, food additives, acid indigestion, a hot bath, NyQuil (a cold remedy), electromagnetic radiation, toxic chemicals, hypoglycemia, high blood pressure, and changes in weather patterns. Please note that the percentages do not add up to 100 because many respondents listed more than one trigger.

It is clear that the triggers for LAF are many and varied and highly specific to each individual except for excessive emotional and physical stress which are pretty well universal.

LAF is a very frustrating disorder for both patient, family physician and cardiologist. Although it is not life-threatening it can really wreck havoc with one's quality of life and basically, short of surgical intervention, there is no consistently effective, safe way of preventing or terminating episodes. Pharmaceutical drugs are prescribed in an attempt to prevent or terminate episodes or to slow the heart rate during an episode.

Prevention of adrenergic type LAF
Beta-blockers like atenolol, propranolol and metoprolol are usually prescribed as the first line of defense against repeated episodes of adrenergic type LAF. The surveys reported in the September 2001 and June 2002 issues of THE AFIB REPORT found no evidence that they are actually useful for this purpose. The second line of defense involves antiarrhythmic drugs like sotalol, propafenone and amiodarone. Again there was no evidence in the survey that they actually do any good. As a matter of fact there was some indication that adrenergic afibbers on drugs have more episodes than those not on drugs. In addition, amiodarone and to a lesser extent sotalol and propafenone have some very serious potential adverse effects. So, in a nutshell, pharmaceutical drugs would seem to be of little use in preventing LAF of the adrenergic variety.

Prevention of vagal type LAF
Flecainide and disopyramide can be quite effective in preventing vagal LAF episodes. They are both powerful drugs and can have very serious adverse effects so they should only be used by afibbers with structurally sound hearts. Beta-blockers and sotalol have strong beta-blocking properties and are contra-indicated for vagal afibbers as they are likely to worsen their condition by further increasing vagal dominance of the autonomic nervous system. Propafenone also has beta-blocking properties, but is likely to be OK for most vagal afibbers unless they have a genetic predisposition to metabolizing the drug slowly. Some afibbers have found the time-release version of propafenone (Rythmol SR) to be significantly more effective than the standard version taken two or three times a day.

Prevention of mixed LAF
Our survey found no evidence that any drugs were effective in preventing LAF of the mixed variety. As a matter of fact, it seems that mixed afibbers on drugs had substantially more and longer episodes than those not taking any drugs at all.

Termination of episodes
LAF episodes can be successfully terminated in a hospital setting by injection of flecainide, dofetilide or ibutilide provided the injection is carried out very soon after the start of an episode. It is also possible to terminate an episode at home by using the on-demand (pill-in-the-pocket) approach. Several afibbers have found this approach very effective in keeping the duration of their episodes to two hours or less. This approach involves swallowing propafenone or flecainide tablets with warm water as soon as possible after the start of an episode. The recommended dosage is 200 mg of flecainide or 450 mg of propafenone (for people weighing 70 kg (155 lbs)or less) or 300 mg of flecainide or 600 mg of propafenone for people weighing more than 70 kg. I have found that lying down on my back (supine position) after swallowing the pills results in quicker conversion, perhaps because being in this position would give the heart rate-slowing parasymphatetic arm of the ANS a bit of a boost.

Slowing of heart rate
Heart rates of 100 bpm or higher can be very uncomfortable and, if continued for long periods, can also damage the heart and circulatory system. The calcium channel blockers verapamil and diltiazem are quite effective in slowing the heart rate although they are of no help in speeding up the conversion to sinus rhythm. Diltiazem in particular would seem to be the drug of choice for permanent afibbers.

Special note on digoxin
Digoxin (Lanoxin) is frequently prescribed for patients with lone atrial fibrillation. This is indeed unfortunate as there is ample clinical evidence that digoxin not only increases the number of episodes, especially in the case of vagal LAF, but also is very likely to turn intermittent (paroxysmal) LAF into permanent LAF. There is no justification for someone with LAF to be given digoxin on an ongoing basis (it can be used on an intermittent, short-term basis to slow down the heart rate) and many afibbers report a substantial improvement in their condition after discontinuing this drug.

About half of all lone afibbers have been able to reduce or eliminate their afib episodes for extended periods of time through diet changes, supplementation or other alternative protocols. A survey (LAFS-14) of 248 afibbers (89% paroxysmal) was carried out in 2007 to determine the most successful strategies for managing LAF. A summary of the findings is presented below.

• It is clear that vagal afib is more likely to be manageable through diet changes and supplementation than is mixed afib. Only 27% of mixed afibbers had found natural approaches to be useful as compared to 56% among vagal afibbers.
• The most popular intervention program was trigger avoidance engaged in by 88% of all respondents. This was followed by supplementation (84%), dietary changes (55%), and other therapies (55%).
• Avoidance of caffeine had been found useful by 67% of respondents, alcohol avoidance by 56%, and avoidance of aspartame and MSG by 38% and 34% respectively. Altogether, respondents had identified 17 important triggers.
• The most important dietary changes were elimination of wheat, gluten and dairy products, and a switch to the Paleo diet. These changes were significantly more successful among females and vagal afibbers.
• Eighty-five percent of responders had tried supplementation. The most effective supplement was magnesium glycinate, which had been found beneficial by 48% of those who had tried it. Potassium supplementation (including low-sodium V8 juice) had been tried by 79% of all respondents and found beneficial by 43%. Taurine had been tried by 43% and found beneficial by 32%. About half of those supplementing with magnesium also took potassium and taurine.
• Breathing exercises and relaxation therapy were the most commonly tried stress reduction measures and had been found successful by 39% and 34% respectively. Yoga had been tried by 19% and found beneficial by 52%.
• Dealing with GERD, digestive problems, and food allergies had benefited 26-30% of those who dealt with these conditions. This clearly indicates that digestive problems are an important component of afib.

The percentages of responders who believed that the various therapies had been beneficial on their own, or in combination with other measures, are given below:

Therapy: Trigger Avoidance
Sole Therapy: 36%
Combined: 50%

Therapy: Dietary Change
Sole Therapy: 30%
Combined: 55%

Therapy: Supplementation
Sole Therapy: 25%
Combined: 53%

Therapy: Stress Reduction Therapy
Sole Therapy: 19%
Combined: 53%

Therapy: Treatment of underlying disease
Sole Therapy: 35%
Combined: 44%

About 50% of respondents had found a way of shortening their episodes. On-demand (pill-in-pocket) flecainide had been found effective by 25%, light exercise by 24%, and resting by 21%. The most effective therapies for women were hydrotherapy, meditation, tranquilizers and resting, while the most effective therapy for men was vigorous exercise. This is not surprising since vigorous exercise will increase adrenergic tone and 80% of respondents who had found vigorous exercise beneficial were male, vagal afibbers.

• A third of respondents had found ways of preventing ectopics with supplementation with the magnesium/potassium/taurine combination being the most popular followed by the consumption of low-sodium V8 juice.

For detailed supplement suggestions please see The Strategy

For details of LAF Survey 14 please see the November 2007 issue of The AFIB Report (by subscription).

Overview of ProceduresThe procedures used to cure atrial fibrillation can be divided into two groups: – catheterization procedures and surgical procedures. Both types involve the creation of lesions on the heart wall (right and/or left atrium) in order to stop the propagation of impulses not involved in conducting the heart beat "signal" from the sino-atrial (SA) node to the atrio-ventricular (AV) node.

Catheterization procedures create the lesions from the inside via an ablation catheter threaded through the femoral vein and are performed by electrophysiologists (EPs). Surgical procedures create the lesions from the outside and access is either through incisions between the ribs or may involve open-heart surgery and the use of a heart/lung machine. Surgical procedures are carried out by cardiothoracic surgeons.

The overwhelming majority of catheterization procedures use radiofrequency (RF) energy to create the lesions, but some EPs prefer the use of nitrogen-cooled catheters (cryoablation) rather than RF-powered ones due to their reduced risk of creating pulmonary vein stenosis.

In some cases, cardiologists recommend that their patients undergo an ablation of the atrio-ventricular (AV) node accompanied by the implantation of a pacemaker. This procdure does not eliminate atrial fibrillation, but makes it substantially less noticeable. Patients who undergo AV node ablation and pacemaker implantation are entirely dependent on the pacemaker and are usually on warfarin for life. Thus this procedure is generally considered the procedure of last resort.

The original surgical procedure, the full maze or Cox procedure, used a cut-and-sew protocol for creating lesions forming a "maze" that conducted the electrical impulse from the SA to the AV node, while at the same time interrupting any "rogue" circuits. The cut-and-sew method has now largely been replaced by the use of RF-powered devices, but cryosurgery, microwave application, and high-intensity focused ultrasound (HIFU) have all been tried as well and are preferred by some surgeons.

The so-called mini-maze procedure also involves lesions on the outside of the heart wall, but access to the heart is through incisions between the ribs rather than via open-heart surgery. The mini-maze may involve the creation of the full maze set of lesions, but usually focuses on pulmonary vein isolation. The procedure does not involve the use of a heart/lung machine.

Most of the rogue electrical impulses that create afib originate in the area where the pulmonary veins join the left atrium. Thus, all catheterization procedures aimed at curing afib involve electrical isolation of the pulmonary veins from the left atrium wall. Depending on the origin of the afib, catheterization procedures may also involve ablations of the superior vena cava and coronary sinus (thoracic veins), linear ablation of the left atrial roof, and a standard cavotricuspid isthmus (right atrial flutter) ablation.

Surgical procedures, except for the full maze, also focus on isolating the pulmonary veins, but in addition may involve lesion creation at specific spots located by mapping, removal of the left atrial appendage, and disconnection of the ligaments of Marshall – a potent source of vagal input.

Catheterization Procedures (RF Ablation)A survey of over 600 afibbers who had undergone a total of 950 radio frequency ablation procedures (LAFS-12) was carried out in October 2008. The conclusions reached from that survey are presented below:

• The overall objectively-rated complete success rate (no afib without the use of antiarrhythmics) for 461 afibbers after an average of 1.5 procedures per patient was 56%, partial success was achieved in 10% of cases, and 34% of all afibbers who underwent one or more RF ablations continued to experience AF episodes.
• The subjective judgment of success by ablatees was somewhat more favourable with 64% feeling that the end result was total success, 20% claiming partial success, and 16% judging their procedures as a failure.
• The objectively rated complete success rate for a single RF ablation procedure was 34%, that of partial success 5%, and that of failure 61% when averaged over the years 1998-2008. For the more recent period 2007-2008, the complete success rate for a single RF ablation procedure averaged 48%. This remarkable improvement in single procedure success is reflected in an overall average increase in final (complete) success rate from 47% in the period 1998-2004 to 66% in the period 2007-2008.
• • The average complete success rate for the 15 top-ranked RF ablation centers was 65% with a failure rate of 27% for the period 1998-2008. This compares to a complete success rate of 32%, and a failure rate of 61% at other than top-ranked institutions. This clearly indicates that the all-important factor in determining the outcome of an RF ablation is the skill and experience of the EP performing it. Techniques and outcomes have improved markedly from the period 1998-2004 to the period 2007-2008. For example, the final success rate for the three top-rated RF ablation centers (Cleveland Clinic (Ohio), Hopital Cardiologique du Haut Leveque (Bordeaux), and California Pacific Medical center (San Francisco)) has increased almost 10% to average 82% for the period 2007-2008. A very encouraging trend indeed! The average repeat rate was 30% at top-ranked institutions versus 44% at other institutions.
  • Forty-one percent of 358 RF ablation procedures were accompanied by an adverse event, the most common (17%) being temporary hematoma in the thigh area. Left atrial tachycardia was also a fairly common adverse effect (12%), but resolved by itself in about 50% of cases. Stroke and TIA were rare at 0.6% and 0.8% respectively. About two-thirds of all adverse events were fully resolved at the time the survey was completed. Successful ablations were much less likely to be accompanied by an adverse event than were unsuccessful ones. NOTE: This data is from the 2006 ablation/maze survey.
  • There were no significant differences in success and adverse event rates between a first and subsequent RF ablations, perhaps indicating that the technical difficulty in performing them is pretty much the same.
  • The majority (79%) of respondents experienced AF episodes at least weekly prior to their ablation. [From 2007 survey]
  • There was no evidence that age at diagnosis and ablation, gender, years of afib, or type of paroxysmal afib affected the outcome to a significant degree. However, more frequent episodes were associated with a lower success rate. [From 2007 survey]
  • The most successful procedure for the period 2005-2008 was the pulmonary vein antrum isolation procedure (Natale method) with a single procedure complete success rate of 62% (paroxysmal, persistent and permanent combined). The segmental PVI (Haissaguerre method) was the second-most successful procedure with an average complete success rate of 42%.
  • A significant majority (69%) of afibbers who had a completely successful ablation experienced no AF episodes at all after the procedure. Only 8% of those "doomed to failure" experienced no episodes at all after their procedure. Only 2% of completely successful ablatees experienced episodes for more than 3 months after the procedure, while 56% of unsuccessful ablatees did so. Thus, if AF episodes continue beyond 3 months the procedure is almost certainly a failure. On the other hand, if no AF episodes occur during the first month then the procedure is likely to be a success. [From 2007 survey]
  • Almost 60% of ablatees recovered fully in less than 2 months, but 24% took longer than 3 months to return to their pre-ablation level of stamina. NOTE: This data is from the 2006 ablation/maze survey.
  • Most (96%) of afibbers who had a completely successful ablation did not continue with warfarin, but 13% of them continued to use natural stroke prevention remedies such as fish oil, nattokinase, vitamin E and ginkgo biloba. Seventeen percent took a daily aspirin for stroke prevention. In contrast, 36% of ablatees with a failed procedure continued on warfarin. [From 2007 survey]
  • While 79% of successful ablatees no longer needed to avoid previous triggers, only 23% of those having undergone an unsuccessful ablation were so lucky. Nevertheless, it would seem that any ablation, whether successful or not, does help to reduce trigger sensitivity.
  • The incidence of post-procedure ectopics (PACs and PVCs) even 6 months or more following the procedure was high at 50% for completely successful ablations and 71% for failed procedures, a difference that is statistically significant. There was no indication that having undergone a right atrial flutter ablation prior to or during the left atrium ablation reduced the incidence of ectopics.
  • The incidence of post-procedure tachycardia (SVT and inappropriate sinus tachycardia) was 12% for completely successful and 44% for failed ablations. Having undergone a right atrial flutter ablation as part of or prior to the left atrium ablation did not affect the incidence of post-procedure tachycardia.
  • The incidence of post-procedure flutter was 7% for a completely successful ablation and 41% for an unsuccessful one. Having undergone a prior right atrial flutter ablation made no difference to the post-procedure incidence of flutter perhaps indicating that most of the post-procedure flutter was left atrial flutter.
  • Even an unsuccessful ablation resulted in a significant reduction in episode frequency in 74% of cases and in 75% of cases was associated with a significant decrease in episode duration. Overall, 70% of unsuccessfully ablated patients experienced a 50% or better decrease in their afib burden. [From 2007 survey]
  • Considering a 50% or greater reduction in afib burden (frequency x duration) as an indicator of improvement, it is estimated that close to 90% of RF ablations were ultimately successful in improving quality of life. [From 2007 survey]
  • A post-ablation increase in heart rate was a common occurrence. This phenomenon was more prevalent among successful ablatees (67%) than among those whose ablation had failed (41%). This may indicate that a more aggressive approach (increased destruction of vagal nerve endings) is associated with a better outcome. [From 2007 survey]
    
    Cryoablation, AV Node Ablation, and Surgical ProceduresA survey of 87 afibbers who had undergone a total of 94 procedures other than RF ablation procedures (LAFS-12) was carried out in October 2008. The conclusions reached from that survey are presented below.
    
    
    • The outcome (at least 6 months after procedure) was known for 12 cryoablation procedures. Four (33%) were fully successful and one (9%) was partly successful. The average single procedure complete success rate of cryoablation is thus 33%, not significantly different from the average single procedure complete success rate of PVI procedures at 34%. There is insufficient data to say what the final success rate would be after repeated cryoablations.
    • It is not possible, based on a small sample, to evaluate the success rate of an AV node + pacemaker implantation since it, at best, provides symptomatic relief only. Eighty percent of respondents felt (subjectively) that their procedure had been a success, while the remaining 20% felt that it has been partially successful. Thus, based on a small sample of 14 respondents it would appear that AV node ablation + pacemaker implantation is usually a successful procedure and provides significant symptomatic relief even though it does not eliminate the fibrillation of the atria. Nevertheless, it is still the procedure of last resort.
    • The full maze procedure performed by a top-ranked cardiac surgeon provides the best chance of being cured of afib with one single procedure (complete success rate of 88%). However, full maze procedures performed by less skilled surgeons tend to be considerably less successful. This, combined with the potential for significant adverse events (especially associated with the use of the heart/lung machine), would lead one to the conclusion that it may be "overkill" for a paroxysmal afibbers, with no underlying heart disease, to select the full maze over a conventional RF ablation or mini-maze procedure.
    • A mini-maze procedure performed by a top-ranked cardiac surgeon provides the second-best chance of being cured of afib with one single procedure. It is also likely that even a mini-maze performed by a less than top-ranked surgeon will have a substantially better outcome than a single standard RF ablation performed by a less than top-ranked EP. However, the risk of adverse effects accompanying the mini-maze procedure is somewhat higher than for RF ablations.
    For details of RF ablation procedures please see the December 2008 issue of The AFIB Report (by subscription).
    
    For details of cryoablation, AV node ablation and surgical procedures please see the upcoming February 2009 issue of The AFIB Report (by subscription).
    

Amalgam (silver) fillings have been associated with heart palpitations, irregular pulse and rapid heart beat. The LAF Survey clearly showed that afibbers with amalgam fillings had many more LAF episodes than afibbers without amalgam fillings. There is also emerging evidence that strictly controlled replacement of amalgam fillings and dissimilar metals in the mouth can reduce the number of afib episodes or eliminate them completely. Safe removal of amalgam fillings should be done by a holistic or "mercury-free" dentist. The procedure must be followed by effective detoxification as outlined in the July 2001 issue of THE AFIB REPORT.

The following links will assist you in locating a dentist and holistic physician or naturopath in your area who can help you with safe amalgam replacement.

• Hugnet
• International Academy of Oral Medicine and Toxicology
• American College for Advancement of Medicine
• The American Association of Naturopathic Physicians