Picking my poison

I was diagnosed with paroxysmal afib in June, put on metoprolol and Xarelto, and given a cardioversion. It restore rhythm for 2 months. It seemed to raise the LVejection fraction from 30% to 42. The cardiologist wanted to add an Ace inhibitor to my med to possibly raise it to 55%. In October an EKG showed me in bradycardia, the Ep gave me a 3day heart rate monitor which showed afib 87% of the time. He wants to put me on Tykosin. My blood pressure has always been on the low side of normal my entire adult life. They want me on 3 meds which typically lower blood pressure and don't necessarily control heart rate. I feel they are making me worse and hastening the need for a pacemaker. Am I basically being asked to pick my poison?

Hi merri, welcome to the forum.

No, I don't think you're being asked to pick your poison. I think your doctors are trying to save your life.

You're in afib a huge amount of time, so clearly you need to be on an anticoagulant. That's why they put you on Xarelto. For the same reason you also need a rate control drug, so they put you on metoprolol, which is pretty standard. That's to prevent strain on your heart and worsening of your heart failure. The heart failure is why they added the ACE inhibitor, which is also standard and highly recommended.

I'm pretty sure what they're thinking now is to put you on Tikosyn to stop the afib because that will help improve your heart failure, which it probably will.

With an ejection fraction of 30-42%, I would strongly urge you to follow their advice. You're already a candidate for a pacemaker so they're trying to pull you back from that step. Sounds to me like you've got some good docs.

Thank you for your reply. All of this has come at me a bit out of left field and I am really spooked. I had a mitral valve repair at age 53 in 2000 at the Cleveland Clinic ( done by the big guy himself - Toby Cosgrove) which was successful with no meds given following. Until 2016 my yearly echocardiograms showed the repair to be intact. My underactive thyroid is under control with Levothyroxin. In 2019 is the first really serious afib episode that I experienced which prompted me to get back to the Cleve Clinic. The funny thing is that from end of Nov to end of Oct my heart rate stayed between 65-75 resting. Then it gradually went up to the 80's and 90's, spiking as high as 128. I was told to take 1/2 a tablet of Metoprolol in addition to the 50mg I take daily, if I have an episode of breakthru fib with a bp of systolic higher than 100 with heart rate greater than 110. My problem is what to do if I have a reading of f90/77 and heart rate of 140?

Merri, sorry to see you having issues.

Carey's assessment of what seems to be going on is spot on. It's important to get and keep your heart in rhythm if possible. Tikosyn (dofetilide) is one of the newer antiarrhythmic drugs EP's are using.

I was actually on it for a time a couple years ago without any apparent issues. It also works better the longer you are on it for most people. Good luck to you.

Wondering if ablation with a top guy like Natale would help the med issue?

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merri
I was told to take 1/2 a tablet of Metoprolol in addition to the 50mg I take daily, if I have an episode of breakthru fib with a bp of systolic higher than 100 with heart rate greater than 110. My problem is what to do if I have a reading of f90/77 and heart rate of 140?

Follow their instructions and don't take additional metoprolol if your systolic BP is under 100. Doing that could drop your BP dangerously low.

With a rate of 140 and a BP of 90/77 your options are to take it easy and wait it out or visit the ER. If it were me in that situation, I'd head to the ER and ask to be cardioverted. Honestly, cardioversions are your friend in this case. As someone who's been cardioverted 15-20 times I can tell you it's a complete breeze, one of the easiest procedures there is (and 15-20 times isn't even a record around here). Considering that you got two months of normal rhythm and a big boost in ejection fraction from your first cardioversion, I would definitely go for it again. And obviously let your cardiologists know you did so.

The whole point of the Tikosyn is to keep you out of afib and eliminate all the hassles above. I would definitely give it a try if I were in your shoes. I've been on it before and found it very effective. And like rocketritch said, it became more effective the longer I took it.

Speaking of cardiologists, is one of the doctors you're seeing for this an electrophysiologist (EP)? If not, you need to get one involved.

Thank you all ever so much for your responses.Carey's explanation of the need and separate issues for a beta blocker as well as an Ace inhibitor makes sense which ,by the way my cardiologist did not bother doing. He simply said if you don't want the Ace inhibitor that's up to you. His manner is somewhat abrupt and impatient. I'm sure he knows his stuff otherwise he would not be at the Cleve Clinic. The electrophysiologist who did my cardioversion is good about explaining things, but all this is a lot to absorb in the short time that they allow in the office. He is the one who put me on the 3day monitor which showed me in afib all over the place. I really appreciate the info and experience with Tykosin . The EP says I have to be in the hospital for 3 days for them to load it and I guess to see if I can tolerate it. I am in Florida for the winter and won't be back in Cleveland until May to do this. I wonder if I should go for another eval at Mayo in Jacksonville before that?

Any cardiologist can get you started on Tikosyn. There's no reason to wait six months until you're back in Cleveland, especially since the afib appears to be contributing to your heart failure. You can't ignore that. So I would just go to Mayo then have your CC doc talk to the Mayo doc and get you started. Your CC doc can forward records to Mayo so they don't have to repeat everything.

Once you've got the afib under control, it would be a good time to consider what George brought up earlier -- an ablation. You need a permanent fix for the afib and antiarrhythmic drugs are all famous for not being permanent solutions. If you go that route, just make sure you do your homework and choose the EP wisely. Just because they're affiliated with places like Mayo or CC doesn't make them good choices. We can help you out on that decision.

Carey is right, a cardio conversion is a breeze. I may share his record. It’s close to 20. You just shouldn’t eat or drink 6 hours before.

Just wondering - When I was scheduled for my cardioversion a week ago (converted before it happened), a TEE was scheduled immediately before. Is that normal?

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Ken
Just wondering - When I was scheduled for my cardioversion a week ago (converted before it happened), a TEE was scheduled immediately before. Is that normal?

It is if you haven't been on anticoagulants for at least 3 weeks prior to the cardioversion, or if the doctor doing the cardioversion is simply very conservative. The purpose is to make sure there are no clots lurking in your left atrium that could be pumped out when you return to NSR.

I was on Eliquis for over 6 months and my ER regularly were eager to cardio convert EXCEPT they won’t without a TEE if one had flown a long international flight in the past 10 days. It’s their policy. Other than that one time, as long as I am on an anticoagulants they just cardio convert.

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Carey
Any cardiologist can get you started on Tikosyn. .

I am just curious on this b/c I have an adult congenital cardiologist.. and an EP cardiologist. and my adult congenital's nurse said that he would not prescribe it and there is extra training involved to be able to prescribe it. I am just curious. I have been on it a year trying to still sort it out a bit (QT interval stuff.). just curious. thanks Amy

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bettylou4488
I am just curious on this b/c I have an adult congenital cardiologist.. and an EP cardiologist. and my adult congenital's nurse said that he would not prescribe it and there is extra training involved to be able to prescribe it. I am just curious. I have been on it a year trying to still sort it out a bit (QT interval stuff.). just curious. thanks Amy

Yes, it does require specific training so I shouldn't have said any cardiologist can get you started on it. But probably almost any EP can. My point was simply that you don't need to wait for months to have CC start you on it. Mayo is perfectly capable of doing that, and so are dozens of other large hospitals in your general area.