Can’t figure out the triggers

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wolfpack
It sounds like vagally-mediated AF due to chronic fitness (something I know something about).

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The Anti-Fib
Did you ever follow up on an Endocrine/Cortisol check-up, as suggested in in your earlier Post? A Saliva Cortisol 4X/day test would tell what is going on with Adrenal output. The fact that you can sense it coming on several hours prior suggests some sort of intermittent Hormonal or Electrolytic imbalance. I had intermittent periods of Adrenal Suppression which triggered AFIB. I felt wiped out and unsually tired for about a day prior to my episodes.

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hwkmn05

Did you ever follow up on an Endocrine/Cortisol check-up, as suggested in in your earlier Post? A Saliva Cortisol 4X/day test would tell what is going on with Adrenal output. The fact that you can sense it coming on several hours prior suggests some sort of intermittent Hormonal or Electrolytic imbalance. I had intermittent periods of Adrenal Suppression which triggered AFIB. I felt wiped out and unsually tired for about a day prior to my episodes.

What is the treatment/med or protocol you use for adrenal fatigue or high cortisol levels at night?

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Pompon
Your doc is right when he wants having you back in NSR as soon as possible. Waiting is usually bad because the longer you're in afib, the more likely afib would worsen.

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The Anti-Fib
Did you ever follow up on an Endocrine/Cortisol check-up, as suggested in in your earlier Post? A Saliva Cortisol 4X/day test would tell what is going on with Adrenal output. The fact that you can sense it coming on several hours prior suggests some sort of intermittent Hormonal or Electrolytic imbalance. I had intermittent periods of Adrenal Suppression which triggered AFIB. I felt wiped out and unsually tired for about a day prior to my episodes.

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bolimasa
Curious I'm trying to get a handle on "vagally-mediated"
Is there a reason the chronically fit people would have vagally mediated afib? (reference?)
Was there something in his description of his symptoms that would indicate it is vagal? I guess I don't really how people tell vagal from non.

Which gets around to another question I've been having... there are all these things that seem to associate with afib... hypertension, obesity etc.
But of course association and causation are two different things.

I can see that that if longstanding hypertension has damaged (enlarged etc) your heart, that may be causative for afib. But say you are hypertensive and your heart is still normal, is it really the hypertension causing afib? Or is it merely associated, but not causative?

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wolfpack
Beardman,

Your EP is really just following standard procedure for paroxysmal AF patients. It's cardioversion within 48 hours of onset, followed by anticoagulation and AAR/rate control meds. He isn't using you as a "guinea pig" by any means. I can certainly understand not wanting to do that on your part, but do bear in mind that you really want to minimize the time in AF or else it will just get worse. 2 days on, 3 days off is actually a fairly high burden. I know you've said the rate isn't terribly high during an episode, but it will still "wear" on the ventricles after some time.

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The Anti-Fib


Did you ever follow up on an Endocrine/Cortisol check-up, as suggested in in your earlier Post? A Saliva Cortisol 4X/day test would tell what is going on with Adrenal output. The fact that you can sense it coming on several hours prior suggests some sort of intermittent Hormonal or Electrolytic imbalance. I had intermittent periods of Adrenal Suppression which triggered AFIB. I felt wiped out and unsually tired for about a day prior to my episodes.

What is the treatment/med or protocol you use for adrenal fatigue or high cortisol levels at night?

I didn't have high levels at night, more on the low side. I was running out of Cortisol especially upon Stressful situations. I have a relatively rare condition of constant Thirst, and I was drinking way too many fluids, and was flushing out the Cortisol in my Urine. As for a treatment, I try to cut down on Water intake, even if I'm thirsty. Also I stopped taking Prednisone and getting Steriod injections for inflammation. I was intermittently taking the potent Drug Prednisone (boosts Cortisol) for Inflammation, and when I stopped taking it, my body did not make enough of its own Cortisol, and I had low Cortisol output for 7-10 days causing the "Adrenal Suppression" which triggered my AFIB. Now if i feel wiped out, I take a low dose of Hydrocortisone (Stress Dosing) to temporarily boost up my Cortisol levels. I have been doing well since I made this change. Almost 10 years into AFIB, never been doing better. No Ablation or Anti-Arrythmics.

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Jackie
Joel/Beardman - The Adrenotone may be too stimulating... esp. in combo with L-arginine. The Adrenotone product data sheet has this notation:
Advise patient to discontinue use and consult you if they experience sleeplessness, headache or
heart palpitations when using Adrenotone™.

You should consider cutting back on the arginine as well as that can be too stimulatory for some individuals .... (or just stop completely for a while).

Also - what's your source of magnesium ? Most people can't get enough from food and supplements are needed. Have you assessed your daily intake of potassium from food sources? Those who do endurance athletics and also are plagued by arrhythmia and/or ectopy need to be sure they have the right balance of electrolytes that affect heart cell function.

Jackie

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beardman

Your doc is right when he wants having you back in NSR as soon as possible. Waiting is usually bad because the longer you're in afib, the more likely afib would worsen.

I understand this, but with the ability to convert on my own, I just didn't feel it was necessary. I am usually in NSR for 3-4 days at a clip and then out for 1-2 days.

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wolfpack
Beardman,

Your EP is really just following standard procedure for paroxysmal AF patients. It's cardioversion within 48 hours of onset, followed by anticoagulation and AAR/rate control meds. He isn't using you as a "guinea pig" by any means. I can certainly understand not wanting to do that on your part, but do bear in mind that you really want to minimize the time in AF or else it will just get worse. 2 days on, 3 days off is actually a fairly high burden. I know you've said the rate isn't terribly high during an episode, but it will still "wear" on the ventricles after some time.

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bolimasa

It sounds like vagally-mediated AF due to chronic fitness (something I know something about).

Curious I'm trying to get a handle on "vagally-mediated"
Is there a reason the chronically fit people would have vagally mediated afib? (reference?)
Was there something in his description of his symptoms that would indicate it is vagal? I guess I don't really how people tell vagal from non.

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bolimasa
Which gets around to another question I've been having... there are all these things that seem to associate with afib... hypertension, obesity etc.
But of course association and causation are two different things.

I can see that that if longstanding hypertension has damaged (enlarged etc) your heart, that may be causative for afib. But say you are hypertensive and your heart is still normal, is it really the hypertension causing afib? Or is it merely associated, but not causative?

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GeorgeN


Your doc is right when he wants having you back in NSR as soon as possible. Waiting is usually bad because the longer you're in afib, the more likely afib would worsen.

I understand this, but with the ability to convert on my own, I just didn't feel it was necessary. I am usually in NSR for 3-4 days at a clip and then out for 1-2 days.

I would say that an electro cardioversion would be pointless, it would shorten that event but won't likely prevent the next one. You need a plan to stay in rhythm after you convert.

You don't want meds, but perhaps flecainide on demand might do a quick conversion. Not a forever solution, but at least would minimize the AF burden while you try to figure out triggers.

Even though exercise will convert you, it is also likely part of the problem. It certainly was for me <[www.afibbers.org]

George

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beardman
I consume 1,000-1,500 MG of calcium a day, maybe that’s too much and I could try cutting down. I eat a Keto/vegetarian diet though, so I am sourcing most of my fat content from dairy.

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GeorgeN

I consume 1,000-1,500 MG of calcium a day, maybe that’s too much and I could try cutting down. I eat a Keto/vegetarian diet though, so I am sourcing most of my fat content from dairy.


From my experience, I'd stop the Ca++ completely. Now. When I was overeating Ca++ , I had many more triggers. I'm much more robust without it.

How much is too much exercise is too much is likely very individual.

In your shoes, I'd cut the Ca++ and also go to no material exercise and see what happens. If all is good, then I'd gradually add in exercise and see what level is triggering. I'm an "endpoint" guy. I like to start from known "good" and then work from there. Hence I'ld try ditching the Ca and the exercise and see what happens. If it is all good, then you can add back. If that doesn't do it, then you have to think what your next step is.

George

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beardman
I’ll try dropping my cheese/dairy intake and see what that does for a week or so.

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Jackie
Beardman - your intake of calcium... I consume 1,000-1,500 MG of calcium a day is very high.

You need to cut back to under 500 mg or less... on a permanent basis.

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wolfpack

Curious I'm trying to get a handle on "vagally-mediated"
Is there a reason the chronically fit people would have vagally mediated afib? (reference?)
Was there something in his description of his symptoms that would indicate it is vagal? I guess I don't really how people tell vagal from non.

Which gets around to another question I've been having... there are all these things that seem to associate with afib... hypertension, obesity etc.
But of course association and causation are two different things.

I can see that that if longstanding hypertension has damaged (enlarged etc) your heart, that may be causative for afib. But say you are hypertensive and your heart is still normal, is it really the hypertension causing afib? Or is it merely associated, but not causative?

[www.ncbi.nlm.nih.gov]

Vagally-mediated AF is characterized by episodes beginning at rest, often nighttimes, or post-prandially. It is likely an imbalance in autonomic nervous system within the atria in which the parasympathetic (vagal) nerves overwhelm the sympathetic nerves. It is a common side-effect of exercise (AF is something like 5x more prevalent in the athletic community versus the general population).

Think of it like this - when you condition the heart to pump blood very efficiently, my guess is that it needs to retain the ability to "go slow" more than it needs the ability to "go fast" because everyone spends more time at rest than they do at activity. Even if a runner, swimmer, or cyclist spends 1 or 2 hours a day with an elevated pulse due to activity, that still leaves 22-23 hours a day where the heart output needs to meet the lower oxygen demands of being at rest. So to keep the blood pressure low enough, the body will create more parasympathetic tone in the heart to signal the atrial cells to be more refractory (slow down).

In a nutshell, if you're going into AF when you're exerting yourself, you're not vagal. You're adrenergic, or possibly mixed.

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wolfpack
A healthy, adult male between the ages of 18 and 60 could probably exist just fine on 0mg of dietary calcium per day. You really don't need it

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Jackie
Beardman - your intake of calcium... I consume 1,000-1,500 MG of calcium a day is very high.

You need to cut back to under 500 mg or less... on a permanent basis. ... because calcium is excitatory to cells... that includes heart cells. And it will dominate over magnesium... (which is calming or relaxing)..... If your magnesium intake is consistently low, then that explains the problems you are experiencing. Most afibbers need to supplement with magnesium continually... especially those who are heavy exercisers.... and it needs to be the form of magnesium that reaches the interior of the cell without interference.

There is a book written by a cardiologist... Thomas E. Levy, MD, JD... titled Death by Calcium.... and he goes into all the details as to why calcium intake is so detrimental to the body on many levels. We need some calcium but not nearly the amount that many people take in daily.

Jackie

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Jackie

Myth #1 "Calcium supplementation and increased dietary calcium are good for you"
Myth #2 "You cannot get enough calcium in your diet without dairy products."
Myth #3 "Everyone with osteoporosis has a calcium deficiency"
(3 out of 8 elaborations)

Dr. Levy is not alone in presenting the risks of excess calcium in the body. Fortunately, there are many medical professionals giving similar advice and precautions based on the science. The problem is basically, that it's easy to get a lot of calcium from common dietary intake.

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bolimasa
Thanks for the info.
And thanks for the new to me word - "prandially" I'd never heard that one before, and always enjoy an opportunity to learn a new word.

Your description makes me wonder if I am 'mixed'.
Certainly my medical test indicated Afib under exertion, Kinda makes me wonder if this relates to me being a "bad uphill girl" something I've struggled with my whole life. Has my heart always gone a little wacky when I hit that certain exertion point? I wish there was a way to know.

It would be easier to figure all this out if I could really tell when I am in afib... I also wonder about the vagal issue. One odd thing I've been trying to figure out is if there is a link between my pulsitile tinnitus and my afib... I started getting the pulsitile tinnitus ~ 2 years prior to my afib diagnosis. I don't have it all the time, or at least don't notice it all the time, but when I do hear it is when I rest on my couch in the evening and when I go to bed. Now I'm wondering if I am more afibby at this time. I have also noticed that of the few times I could really tell I am in afib, those events happened at night in bed.

Maybe none of this **really** matters... but maybe it would be good for me to understand my patterns (if they exist) so I can best assess my ablation recovery.

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wolfpack
From what you've described - going into AF during the stress echo test - I'd say you're at least adrenergic and possibly "mixed".

It isn't really going to matter much to the EP ablationist. It doesn't change his strategy. My experience post-ablation is that if bad things are going to happen, they're going to happen differently than before anyway. It makes sense to me that if you've altered the electrical substrate of the atria with burns then it's going to behave differently afterwards. If you had an ablation and found yourself as symptomatic as before and with the same trigger patterns, I'd take that as a pretty strong indication that the ablation was a) PVI-only and b) not anwhere near transmural. In other words, a failure probably done by a less experienced operator. (Your EP, Dr. Marrouche, does not fit into this category so no worries there).

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The Anti-Fib
Beardman:

'My EP suggested that I take flecainide, but cautioned me that I absolutely couldn’t take it before the cardioversion as it could put me into NSR which could throw a clot. I know they are going by the book and I don’t want a stroke, but I just wish I could find the balance a little better."

Are you misunderstanding what your EP said? The whole point of taking a AAM like Flecainide is to convert to NSR, and avoid ECV's. Throw a Clot? the chances of that are much higher with an ECV, as the massive jolt from the Shock might dislodge a a Clot attached to the Wall of the Heart. Also, you are already Self-Converting 1-2 times a week anyway, why would your Dr. be extra concerned about Self-Conversion prior to a scheduled ECV? Iv'e had several times where I had an ECV scheduled while taking Flecainide, then in final hours before the ECV was to happen, I Self-Converted back to NSR. My EP and everyone was jubilant that I didn't need to follow through with the ECV. Maybe your Dr. wanted to have an TEE Echo done before the ECV, to check the Atria for Clots, but he could have ordered this without an ECV.

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Carey
I suspect he's being required to take anticoagulants for three weeks prior to the cardioversion to give any existing clots time to dissolve. That's standard procedure. So what his EP is saying is don't take flecainide until that time period has passed. You definitely don't want to convert to NSR by any means when you've got a clot lurking in your left atrium.

Another option would be to do a TEE to see if there is a clot, and if not going ahead with the cardioversion right away. That's what I would ask them to do.

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Jackie
Beardman - your intake of calcium... I consume 1,000-1,500 MG of calcium a day is very high.

You need to cut back to under 500 mg or less... on a permanent basis. ... because calcium is excitatory to cells... that includes heart cells. And it will dominate over magnesium... (which is calming or relaxing)..... If your magnesium intake is consistently low, then that explains the problems you are experiencing. Most afibbers need to supplement with magnesium continually... especially those who are heavy exercisers.... and it needs to be the form of magnesium that reaches the interior of the cell without interference.

There is a book written by a cardiologist... Thomas E. Levy, MD, JD... titled Death by Calcium.... and he goes into all the details as to why calcium intake is so detrimental to the body on many levels. We need some calcium but not nearly the amount that many people take in daily.

Jackie

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beardman

The plan was for a TEE and then a ECV, since my chads vasc score is zero it seemed than my stroke chances were actually higher while taking the meds the EP and other cardiologist wanted me on. The stroke chances also appeared to be higher having an ECV done as aposed to just waiting for me to naturally convert. The EP said that my stroke chances where the same no matter how the conversion occurred. He said it didn’t matter if it was an EVC, drug induced or naturally occurring. That statement just didn’t make sense to me and the statistics that I read after the fact didn’t seem to match up either. Again, I am not looking for a stroke, but it just seems like the advice being given is all based on liability.

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beardman
The EP said that my stroke chances where the same no matter how the conversion occurred. He said it didn’t matter if it was an EVC, drug induced or naturally occurring.

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beardman

Beardman - your intake of calcium... I consume 1,000-1,500 MG of calcium a day is very high.

You need to cut back to under 500 mg or less... on a permanent basis. ... because calcium is excitatory to cells... that includes heart cells. And it will dominate over magnesium... (which is calming or relaxing)..... If your magnesium intake is consistently low, then that explains the problems you are experiencing. Most afibbers need to supplement with magnesium continually... especially those who are heavy exercisers.... and it needs to be the form of magnesium that reaches the interior of the cell without interference.

There is a book written by a cardiologist... Thomas E. Levy, MD, JD... titled Death by Calcium.... and he goes into all the details as to why calcium intake is so detrimental to the body on many levels. We need some calcium but not nearly the amount that many people take in daily.

Jackie

It just dawned upon me that when I was originally diagnosed I was eating a completely vegan diet so I can only figure that my calcium intake was almost if not zero. I will definitely be trying a drastic reduction in ca since it is an easy test. Thank you for the advice.

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beardman
Carey said:
I suspect he's being required to take anticoagulants for three weeks prior to the cardioversion to give any existing clots time to dissolve. That's standard procedure. So what his EP is saying is don't take flecainide until that time period has passed. You definitely don't want to convert to NSR by any means when you've got a clot lurking in your left atrium.

Another option would be to do a TEE to see if there is a clot, and if not going ahead with the cardioversion right away. That's what I would ask them to do.
_______________________________________________________________________________________________

The plan was for a TEE and then a ECV, since my chads vasc score is zero it seemed than my stroke chances were actually higher while taking the meds the EP and other cardiologist wanted me on. The stroke chances also appeared to be higher having an ECV done as aposed to just waiting for me to naturally convert. The EP said that my stroke chances where the same no matter how the conversion occurred. He said it didn’t matter if it was an EVC, drug induced or naturally occurring. That statement just didn’t make sense to me and the statistics that I read after the fact didn’t seem to match up either. Again, I am not looking for a stroke, but it just seems like the advice being given is all based on liability.

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beardman

Beardman:

'My EP suggested that I take flecainide, but cautioned me that I absolutely couldn’t take it before the cardioversion as it could put me into NSR which could throw a clot. I know they are going by the book and I don’t want a stroke, but I just wish I could find the balance a little better."
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Anti-FIB:

Are you misunderstanding what your EP said? The whole point of taking a AAM like Flecainide is to convert to NSR, and avoid ECV's. Throw a Clot? the chances of that are much higher with an ECV, as the massive jolt from the Shock might dislodge a a Clot attached to the Wall of the Heart. Also, you are already Self-Converting 1-2 times a week anyway, why would your Dr. be extra concerned about Self-Conversion prior to a scheduled ECV? Iv'e had several times where I had an ECV scheduled while taking Flecainide, then in final hours before the ECV was to happen, I Self-Converted back to NSR. My EP and everyone was jubilant that I didn't need to follow through with the ECV. Maybe your Dr. wanted to have an TEE Echo done before the ECV, to check the Atria for Clots, but he could have ordered this without an ECV.
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Beardman:

I confirmed with the EP multiple times to make sure I understood. As I understand it though it is a by the book play as I had been out of NSR for longer than 48 hours.

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The Anti-Fib


Beardman:

'My EP suggested that I take flecainide, but cautioned me that I absolutely couldn’t take it before the cardioversion as it could put me into NSR which could throw a clot. I know they are going by the book and I don’t want a stroke, but I just wish I could find the balance a little better."
_______________________________________________________________________________________________
Anti-FIB:

Are you misunderstanding what your EP said? The whole point of taking a AAM like Flecainide is to convert to NSR, and avoid ECV's. Throw a Clot? the chances of that are much higher with an ECV, as the massive jolt from the Shock might dislodge a a Clot attached to the Wall of the Heart. Also, you are already Self-Converting 1-2 times a week anyway, why would your Dr. be extra concerned about Self-Conversion prior to a scheduled ECV? Iv'e had several times where I had an ECV scheduled while taking Flecainide, then in final hours before the ECV was to happen, I Self-Converted back to NSR. My EP and everyone was jubilant that I didn't need to follow through with the ECV. Maybe your Dr. wanted to have an TEE Echo done before the ECV, to check the Atria for Clots, but he could have ordered this without an ECV.
______________________________________________________________________________________________
Beardman:

I confirmed with the EP multiple times to make sure I understood. As I understand it though it is a by the book play as I had been out of NSR for longer than 48 hours.

So your EP is saying that if a patient has been in AFIB>48 hours, that they must discontinue Anti-Arrthmics, as it it might convert them back to NSR, thus causing Stroke. An then the Patient undergoes TEE/ECV to get back to NSR.
If such a treatment protocol exists, someone please direct me to it. I've been in these scenarios many times, having 30 ECV's. Sure getting out of AFIB<48 hours is the Goal, but to suggest that we should avoid spontaneous self-conversions by withholding AAM's is new to me. At some point you have to try and get out of AFIB, it's not risk free.
In your case, it sounds like you've Already had 50+ self-conversions over the last year. This is why minimizing Stroke risk is important, and Dr's emphasize anti-coagulation especially for someone in out out of AFIB as much as you are.

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wolfpack
The caveat being to insist on heavy sedation for the TEE as opposed to the “spray”. From what I’ve heard, it’s like swallowing a telephone receiver.