Vagal AF

From my experience, it seems that most cardiologists in the United States dont acknowledge or discuss or treat VAGAL atrial fibrillation. Most articles I see come from consultant cardiologist's in the UK, etc... What has been your experience? I'm curious?

Good Topic.

I have been to 2 Cardiologists, and 4 EP's in the US, none of them ever inquired about trying to figure out if I had Vagal vs Adrenergic AFIB.

15 years ago, I had a treadmill test with cardio #1. I described what I later learned were vagal triggers (episodes came on at 3AM, most converted with exercise). I asked him how common they were, he said I was first person he'd ever seen this. I then found this site and read Hans Larsen's first book <[smile.amazon.com] I learned about vagal vs. adrenergic. I went to see highly recommended cardio #2. I thought he'd be on same page as me. He did not believe in vagal vs. adrenergic triggers, digoxin was his favorite afib med. We'd have hour long discussions about this. He got tired of me and referred me to the EP in the practice. I told my presentation to the EP who said, "You are obviously vagal and there are certain meds we won't prescribe for you." I was pleased we were on the same page and it was all I could do to not suggest he needed to give his partner an in-service education update.

Last week my son-in-law, whose had afib for ~3 years went to the ER for an episode. Doc prescribed chronic beta blocker despite the fact he's obviously vagal. Sent him a lot of info to arm himself with before he meets with a cardio in a few weeks. He has 3-4 episodes/year and magnesium helps a lot. Taking the BB chronically is NOT indicated.

George,

What do you say to doctors who insist on taking a beta-blocker or a calcium channel blocker when on an antiarrhythmic drug?

Being on Flecainide, I fought that topic with my EP for a couple years, since I have vagal afib and reducing my heart rate often triggers it at night. I did try a calcium channel blocker, but it significantly dropped my heart rate even at the lowest dose, so I dropped it. After much nagging from my EP for a year+, I started taking a small dose of Metoprolol (12.5mg) which hasn't seemed to increase my a-fib.

Maybe in a small enough does, the BB can lessen the risk of 1:1 AV conduction without triggering a-fib itself.

Mark

On a side topic, when I was recently getting my 2nd ablation and was awake during the induction, as the EP was chemically increasing my heart rate to induce the afib, I was wondering to myself, "when a person has vagal afib, is this a valid method to identify the electrical source of the afib?"

I did ask my EP about that before my first ablation, and he assured that the procedure works the same regardless of if the person as vagal or adrenergic afib - though I still have some skepticism.

I think your EP is right and people put way too much importance on afib being vagal or adrenergic. It's the same afib either way no matter how it's triggered.

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Carey
I think your EP is right and people put way too much importance on afib being vagal or adrenergic. It's the same afib either way no matter how it's triggered.

You're likely better informed and competent than me, but allow me to say I find this strange, even if it's true.
Of course, afib is afib once it's triggered, but how it's triggered is still a mystery in many cases.
I think MarkF786 is right wondering wether or not increasing heart rate is the best way to trigger afib while in the lab for an ablation.
I experienced the same during my last procedure. I was laying on my back and the nurses were preparing me, lots of electrodes and a couple needles in my arm... I began having runs of ectopics, then afib. I asked the EP if I had been injected something, and he answered "no, not yet".
During the procedure, after some burns in both atria, I went back in NSR and nothing could still induce afib. We wait and wait, other injections, wait once more... nothing.

I'm still vagal. If I don't sit down, if I don't lay down, if I move around... I'm fine.

Maybe our EPs have to find new ways to induce afib while their vagal afibbers are in the lab?
Just wondering...

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MarkF786
George,
What do you say to doctors who insist on taking a beta-blocker or a calcium channel blocker when on an antiarrhythmic drug?

Not something I've faced. I've only looked at it when used prior to a loading dose for on-demand use of flecainide. I've not looked at the proarrhythmic properties when using the med in smaller but chronic doses, and the best way to mitigate those issues.

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Carey
I think your EP is right and people put way too much importance on afib being vagal or adrenergic. It's the same afib either way no matter how it's triggered.

I concur, once you are in afib.

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Pompon
Maybe our EPs have to find new ways to induce afib while their vagal afibbers are in the lab?
Just wondering...

Being unable to provoke afib happens sometimes. It happened to me. But a skilled EP can almost always provoke it with a combination of isoproterenol, rapid pacing of the atria, and making sure all antiarrhythmics are stopped well before the procedure.

Can anyone tell me any good cardiologists they've found who believes in vagal af and treats accordingly? Thanks! (PM is fine.)



Edited 1 time(s). Last edit at 12/06/2019 12:22PM by cirenepurzalot.

I don't think you'll find any cardiologists who don't believe in vagal afib, but it's not treated differently. The only differences between vagal and adrenergic afib are the things that trigger it. But once triggered, it's just afib and there's no difference between them. It's the same disease with the same causes and the same treatment.

I heard that some of the drugs cardiologists prescribe can actually be bad (or not work as good) for vagal af.

I don't believe that to be true. Besides, most people have both vagal and adrenergic triggers, so what would you do for them if the treatments differ?

Beta blockers may be contraindicated in cases of vagal AF. I know from my own experience that the introduction of betas made my nightly episodes also occur in the middle of the day. They also lowered my resting NSR rate to nearly 40 and gave me tunnel vision. Great fun!

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wolfpack
Beta blockers may be contraindicated in cases of vagal AF.

I hear this over and over on this forum but I have yet to see a single credible source of evidence to support it. Can someone help me out here and show me something more than legend and anecdote?

Totally agree with you Wolfpack. 100% of my episodes occurred around meals or rest/sleep which I believe to be vagally initiated. It also started in my 50s, another Vagal sign. However, Carey isnt wrong to suggest this is anecdotal reporting and questionable on how to manage or prescribe. I would add that tho my episodes respond nicely to Flecainide while Beta blockers cause issues or lack any remedy for episodes where some may convert back with rate control only, never for me.

When I first got AF, the doctor I went to prescribed a Beta Blocker, it made me very tried, then when going into NSR from AF, my heartrate dropped to almost a flat line, a pacemaker was implanted. I was in my EPs office, during that time, and my chart was on the door to the room I was in, I read it, he wrote that he believed the Beta Blocker I was taking was responsible for my 1st degree heart block. I am Vagal, I have always gotten my episodes of AF at night when resting or while sleeping.

If a person has always gotten their episodes in the evening while resting or sleep, seems to be more than legend, the Beta Blocker harmed me.

Liz

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Elizabeth
If a person has always gotten their episodes in the evening while resting or sleep, seems to be more than legend, the Beta Blocker harmed me.

Beta blockers can cause heart block in anyone, not just people with afib, so anecdotal experiences don't tell us anything.

What I'm looking for is evidence (ie, published clinical studies) that vagal afib is harmed by (or benefits from) being treated differently. The bonus question would be what to do with the mixed types, which is probably most people.

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Carey
What I'm looking for is evidence (ie, published clinical studies) that vagal afib is harmed by (or benefits from) being treated differently. The bonus question would be what to do with the mixed types, which is probably most people.

Wonder if you were a treating doc, would you treat a young (34), fit, paroxysmal afibber who gets episodes 3x/year with afib rates in the 150's BPM, a resting HR of 50 and BP of 100/60 with a chronic dose of a beta blocker?

In this paper <[sci-hub.tw] , Dr. Coumel notes on p 1002 that most vagal episodes are preceded by a slowing of the HR (lower right on the page).

From personal experience, when my electrolytes were out of balance with too much Ca++, after orgasm, I could feel my heart rate slowing, leading to PAC's and quickly to afib. That is unless I did something to reverse the situation and increase my heart rate with activity. This was a repeatable experience for me. Same thing with cold drinks during this time. The vagal stimulation of the cold drink would slow my heart rate, leading to PAC's and afib if I didn't reverse the ANS situation.

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GeorgeN
Wonder if you were a treating doc, would you treat a young (34), fit, paroxysmal afibber who gets episodes 3x/year with afib rates in the 150's BPM, a resting HR of 50 and BP of 100/60 with a chronic dose of a beta blocker?

Nope, sure wouldn't, but not because I thought their afib was vagal or not. I wouldn't prescribe daily BBs for anyone unless I thought it had actual preventative value for them, which is rare, or their burden was so high that they needed rate control on a constant basis. Trust me, I'm no fan of beta blockers. Almost everyone I prescribed them for would be told to take them as needed for rate control only.

But I'm still struggling to understand how vagal afib is different from adrenergic afib once it gets started. In what way are these two separate diseases requiring separate treatments?

Carey, If Vagal patients can diminish the frequency of episodes by modifying dietary and sleep habits, it would only make sense to treat them differently than adrenal afib patients. The triggers are mostly irrelevant once we are in an episode, however there are certain meds that actually aggravate vagally induced episodes such as digitalis due to its vagotonic action, failing to convert and causing more harm. My episodes are mostly well under 100 bpm, more like 75-85 with my normal resting at 58-62. BB's alone do nothing for me except a slow, yet irregular HR. Some with Vagal can and do convert with treatment to the digestive system, possibly why Magnesium works for Vagal patients. Studies are vague, but my own studies are all that matter to me, not just the guy with a stethoscope and a white coat.

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hwkmn05
The triggers are mostly irrelevant once we are in an episode, however there are certain meds that actually aggravate vagally induced episodes such as digitalis due to its vagotonic action, failing to convert and causing more harm.

That's been my point all along. Vagal vs adrenergic only refers to what tends to trigger episodes. Once triggered, the two are utterly identical diseases, so the distinction just isn't as important as people make it out to be.

As for digitalis, anybody taking that for afib needs to find a cardiologist who has kept up with their medical education during the last 30 years. Utterly inappropriate drug for afib no matter what "kind" of afib you have.

Digitalis, the same Doctors that are still prescribing dangerous Amiodarone? It was one example of a med, yes ancient I know, that worked for adrenal initiated and not Vagal. We disagree and you didnt respond to my point. If we arent treating triggers and only the effect of them, we could be mistakenly treating the heart with meds that wont work. If someone fails a sleep study, we dont prescribe meds, we treat that trigger with CPAP. If its a thyroid issue, we dont prescribe CPAP instead of Synthroid. Yes, identical diseases, yet one could be a runaway HR of 250, while my vagal initiated is 85. I would hope the treatment is different.

I don't know where you heard that amio doesn't work for vagal afib but I don't believe that to be true at all. If it were true it wouldn't work for a huge number of afib patients, probably the majority, but in fact it works for almost all afib patients. Is it a drug with nasty side effects when used long-term? You betcha. Should it be used long-term for afib? No, almost never, but there are rare exceptions where it's the only option. Good EPs don't do that without compelling reasons. I've never had an EP even consider it with me despite some pretty intractable afib and flutter that didn't respond to anything else.

I'm not sure what you think I didn't respond to, but good EPs do treat triggers. They check thyroid levels, they recommend testing for sleep apnea, they recommend weight loss, quitting smoking, BP control, reducing alcohol intake, and so forth. The trouble with treating triggers beyond those tangible things is they're extremely individual and patients are highly prone to imagine them. I can't count how many times I've heard things like "I had X and 5 minutes later I went into afib, so I'm never touching X again." That's it, a single correlation and they declare it a trigger. So how would you propose EPs go about treating triggers beyond what they do now? And how would you suggest they treat people with mixed vagal/adrenergic, which is probably the majority of them?

As for your 85 vs 250 example, those are treated differently. A HR of 85 doesn't need rate control meds or much of anything, really, other than an anticoagulant. But a HR of 250 needs immediate rate control meds and/or cardioversion. You seem to be arguing that there's some fundamental difference that EPs aren't addressing, but I've seen no evidence whatsoever to support the notion that vagal and adrenergic afib are different in any way other than what triggers them. I'd love to see it if you've got some.

Carey, understood. I guess I was referring to treating the triggers and the protocol for standing meds for Vagal or Adrenal, not only the conversion methods. I dont do well on BB's, but always seem to be scripted for them. I was referencing Amio as a med that could be dated, not that it doesnt work, it does. However, the past med Digitalis was reported to work for adrenal and not vagal, thats all. Thanks

Yeah, I despise BBs. They make me feel like someone tied lead weights to my arms and legs. And they're kind of a reflex prescription for most EPs. Walk into any cardiologist's office with afib and you'll be walking out with a prescription for metoprolol with directions to take it daily no matter how infrequent your afib episodes. I usually tell people if they're not on flecainide to screw that and just take them after an episode begins.

I've never taken digitalis and I hope I never will. I certainly wouldn't for afib. Never heard it doesn't work for adrenergic afib but it's a lousy choice of drugs for afib in general. I'd tell anyone who's been prescribed digitalis for afib to find a new doctor.