Interesting episode conversion experience

Last night my HR was in the 70’s when I went to bed. Normal would be in the 50’s. This is usually a signal I’m sensitive to something I ate. In this case, it would have to be in the spices as the meal was prepared from scratch and everything else were ingredients commonly eaten. This kept me awake, so I went to the basement so as not to disturb my wife. I was starting to do a meditation which will commonly put me to sleep. As I started, I went into afib (who knows what the trigger was – could be vagal from the food interaction???). I went and chewed my normal 300 mg of PIP (on-demand) flecainide along with some extra magnesium and potassium.

An hour and a half later, I still had not converted. Never to pass up an opportunity to experiment, I decided to use my Frolov breathing device (explained in detail later). This is a rebreathing device that increases the CO2 content of your inhaled breath. I used it for a few minutes (didn’t have the presence of mind to time it) and my rhythm went out of afib to a rhythm at 134 BPM. I wasn’t thrilled about the high rate and was concerned it might be flutter, though the Kardia ECG strips looked like they had p waves. I’ve not looked at a lot of flutter strips (I’ve never had it, to my knowledge), so wasn’t confident in my strip analysis. So I quit using Frolov and in a few more minutes, the rhythm was back to afib. I waited a while longer and tried again with the Frolov and got the same 134 BPM result. Waited some more and tried again. This time the rate was 104. My normal flec conversion rate is ~90, so a bit high. Again, I thought their were p waves in the pattern. This time I continued with the Frolov and the rate dropped in to the mid 90’s. The rate dropping made me confortable enough to try and get some sleep, about 2:30 AM now. I slept for few hours and at 5:30, the rate was 75 and at 6:30 65.

So not sure what the CO2 (or lower serum pH) did to the rhythm, but this was an interesting experience. If you think this is interesting, I would suggest learning about the technique and practicing before an afib episode. I don’t think there is a big downside to trying this, but what do I know?

More info:

Frolov devices are based on the work of a Russian doctor, Konstantin Buteyko. Dr. Buteyko had malignant hypertension as a young man in 1952. He had an insight that overbreathing might be a cause and cured himself using reduced breathing to increase serum CO2. He went on to have a lab to study breathing for the Soviet space program. Frolov was a Russian engineer who developed his device (photos on p 9 here <[www.avivahealth.com] ) as a way to increase CO2 in a more comfortable way than Buteyko’s approach (I have actually put my device inside a 2 liter bottle - cut in half and resealed with tape - to increase the CO2 storage).

The idea is from the Bohr effect <[en.wikipedia.org] – hemoglobin has a great affinity for oxygen and if you increase CO2, you will actually allow the cells to get more oxygen as the CO weakens the affinity. You can see this in the hemoglobin/oxygen disassociation curve <[en.wikipedia.org]

Frolov devices can be had off Amazon or eBay for under $30 US. They are shipped from Russia. Here is a sample of a book that talks about the device <[www.normalbreathing.com]
You can tell how well you are doing with a test called the control pause (CP) or BOLT score (same thing). Patrick McKeown describes this test here <[oxygenadvantage.com]

More info is available from <[www.normalbreathing.com] <[oxygenadvantage.com] and <[patrickmckeown.net] < [buteykoclinic.com] Both of the authors have a number of YouTube videos as well as podcast interviews.

I’ve not pushed my training with this hard (my morning CP/BOLT score is in the mid-20's), but I now ski hard off piste’ at 12-13,000’ always breathing through my nose and never breathing hard.

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GeorgeN
I used it for a few minutes (didn’t have the presence of mind to time it) and my rhythm went out of afib to a rhythm at 134 BPM. I wasn’t thrilled about the high rate and was concerned it might be flutter, though the Kardia ECG strips looked like they had p waves. I’ve not looked at a lot of flutter strips (I’ve never had it, to my knowledge), so wasn’t confident in my strip analysis.

P waves will be present in flutter. In fact, the hallmark of flutter is one or more extra P waves between each QRS.

Nothing to see, but your story reminds me of one of my early afib attacks. I was such panicky I tried to breathe avidly, swallowing a lot of oxygen while my EF was very low. I thought I was about to die. I couldn't stand up, speak clearly or move my fingers normally...
Later, my sister told me I'd have been better breathing slowly in a paper bag. I felt so stupid...

Sounds like it could be Flutter. It is a Common Effect from the Flecainide. Many people who previously just had NSR/AFIB, now have alternating NSR/Flutter/AFIB. Its why some of us don't take it, once we establish NSR.

The 134bpm may correspond to a 2:1 Conduction rate the 1st time around. Then in your second bout, the 104bmp may have been a 3:1 Conduction Ratio. In a 2:1 Flutter, there would be 2 P-Waves before each QRS Complex. In 3:1 Conduction, there would be 3 P-waves prior to each QRS Complex.

Ok, here is a file with 8 Kardia strips. <[drive.google.com]

(1-7 have flec in my system)
1. First afib 131 BPM
2. Non-afib 138 BPM
3. Afib 126 BPM
4. Non-afib 105 BPM
5. Non-afib 96 BPM
6. "Normal" 87 BPM
7. "Normal" 71 BPM
8. Normal - no flec 60 BPM

2, 4 & 5 came out as "unclassified"

All the strips where flec is in the system have a different character than the one with no flec.
My eye says that 5, 6 & 7 waveforms all have the same character.
4 looks a little different than 5 in amplitude of the T wave.

After doing some study, I don't conclude that 2 (or 4 are flutter), but I understand that this is very hard to diagnose with a single lead ecg.

Many likely know more than I do and I welcome your comments.

Keeping in mind that it's virtually impossible to positively identify flutter without a V1 lead, here's my take on it:

1-AF
2-Mixed AF/AFL
3-AF
4-Probable AFL
5-Probable AFL
6-Probable AFL
7-NSR
8-NSR

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The Anti-Fib
Sounds like it could be Flutter. It is a Common Effect from the Flecainide. Many people who previously just had NSR/AFIB, now have alternating NSR/Flutter/AFIB. Its why some of us don't take it, once we establish NSR.

Wow! Thanks for the heads-up on flec. I'm just approaching flec for the first time (for PIP only) and wasn't aware of this perverse effect--seems kinda obvious now that I know about it though

My cardiologist tells me he doesn't think I'll have any side effects. He said to take 300 mg. when an episode hits. He did not mention flec's proarrhythmic effects as a possibility though

What is the likelihood of pill-in-pocket leading to atrial flutter??

New at this and have never taken any heart drugs. Would rather not but it would be nice to cut the episodes short!

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DavidK

Sounds like it could be Flutter. It is a Common Effect from the Flecainide. Many people who previously just had NSR/AFIB, now have alternating NSR/Flutter/AFIB. Its why some of us don't take it, once we establish NSR.

Wow! Thanks for the heads-up on flec. I'm just approaching flec for the first time (for PIP only) and wasn't aware of this perverse effect--seems kinda obvious now that I know about it though

My cardiologist tells me he doesn't think I'll have any side effects. He said to take 300 mg. when an episode hits. He did not mention flec's proarrhythmic effects as a possibility though

What is the likelihood of pill-in-pocket leading to atrial flutter??

New at this and have never taken any heart drugs. Would rather not but it would be nice to cut the episodes short!

David,

I've successfully used flec PIP for 14 years without anything negative. I don't take anything with it. I do generally get prone after I take it and before I convert to minimize the probability of flutter. A more conservative approach would be to take a beta blocker first (say 25 mg Toprol XL) followed 30 minutes later by the flec.

Our moderator, Shannon, can tell you horror stories of converting from afib to 1:1 conduction flutter, however. I'm sure it is individual, the risk is there.

George

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Carey
Keeping in mind that it's virtually impossible to positively identify flutter without a V1 lead, here's my take on it:

1-AF
2-Mixed AF/AFL
3-AF
4-Probable AFL
5-Probable AFL
6-Probable AFL
7-NSR
8-NSR

Carey, my understanding was that flutter tended to stay at whatever rate it is at until it converted, not slide down in rate as what happened over time in 4-7. I could be wrong about this.

Back when it was common for people to use r to r recording heart rate monitors, people would send me readings when they were in flutter. These could be for 30 minutes, an hour or more. My recollection is the rate tended to be rock steady at what ever it was.

My flec conversions are historically almost always are to rates in the high 80's to low 90's. This rate then slows over time, I presume as the flec leaves the system.

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GeorgeN
Carey, my understanding was that flutter tended to stay at whatever rate it is at until it converted, not slide down in rate as what happened over time in 4-7. I could be wrong about this.

Flutter is something I know far better than I wish I did, and I think you are wrong about that. Although what you say is usually true, it appears you have a mix of afib and flutter going on (clearly visible in #2), and you probably also have some flutter with a variable rate due to varying AV nodal blocking. Both of those things can combine to produce rates all over the chart that don't seem to match typical afib or flutter. Variable rate flutter can mimic afib to the point that even cardiologists mistake them. That was a new phenomenon for me until early 2017 when I began to experience it myself. I have 12-lead ECGs of mixed afib/flutter and variable-rate flutter that I thought were afib until my EP pointed out the subtle differences.

Hmm, interesting. So according to your hypothesis, I converted to lower rate AFL then to NSR over time.

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GeorgeN
Hmm, interesting. So according to your hypothesis, I converted to lower rate AFL then to NSR over time.

Looks that way to me. You went from pure afib to an afib/flutter mix then to flutter at a diminishing rate and finally to NSR.

George,

I’m sure I’ve posted before about my AF alternating with a different regular arrhythmia (that whilst less unpleasant than AF still feels bounding and just not right) which I do have on a 12 lead ECG from 2009 (100mg BID Flecainide then as now). This runs From 80 to 90 BPM with the ECG machine in 2009 ‘deciding’ that it was an accelerated junctional rhythm. I never go into it from NSR - only from AF. Sabine Ernst looked at this 2009 ECG recently and whilst certain it wasn’t/isn’t AFlutter she was somewhat mystified by the lack of P waves and what looks like AF between the perfectly regularly spaced QRS complexes. A previous EP thought it might be a side effect of the Flacainde - well.....for me at least. That said, she (along with the aforementioned previous EP) seemed comfortable enough that it was of no more concern than AF. I wonder if it’s still AF but the AV node isn’t having it and has decided to regulate the impulses to the ventricles itself - maybe something to do with the Flecainide slowing down the conduction through the AV node. But what do I know. This happens increasingly more as time goes by - as in AF when I’m prone and then switching to the other arrhythmia when I get up and walk around and then back to AF (but after a few mins) when I lie down again and so on - so definitely a postural (perhaps vagal?) component. I can convert to NSR from either AF or the regular arrhythmia. For me NSR on conversion from either is always around 60 BPM.

Mike



Edited 2 time(s). Last edit at 04/22/2018 11:40AM by mwcf.