Increased Afib "Burden"

I used to get episodes 1-2 times a month, but the frequency recently increased to 4 a month. I take 100 mg Flec (plus 12.5 metoprolol) at the start and convert in about 1.5 hours. I often get the black-out type "pause" upon conversion. Since this increase is recent, I set up an appointment with my EP to discuss options. I was mainly concerned about stroke risk, but my doctor seems more concerned about the pauses. He also thinks I should consider ablation and a pace maker. I'm due to have a phone consult soon, but now that I'm doing a bit of online research, I'm having second thoughts about making changes. Any action I take outside of meds will involve increased doctor visits, which I should probably avoid due to Covid-19.

Background. I'm 71, female, have Sjogren's autoimmune disease, CHA₂DS₂-VASc Score of 2, only risk factors are age and female gender. I have multiple vision issues due to dry eyes, high myopia, retinal pathology, and strabismus, and may be considering cataract and/or strabismus surgery soon. Anti-coagulants may increase my risk of a retina bleed.

Eliquis. My doctor's recommendation is 5 mg BID, the amount for 132 lb/60 kg. But I weigh 55 kg. I've read some of the negative side effects on this med, and am reluctant to start. I currently take 100 mg nattokinase daily as a precaution.

Continue flecainide. It has been working for me since 2011. My EP has me taking 12.5 mg metoprolol at the same time as the PIP flec dose to prevent 1:1. My resting heart rate is about 44 (slow, and related to Sjogren's I've been told), and the metop slows it down a bit. This has been a reliable solution for me, but the meds make me sluggish- but only for part of the day. I'm have mostly vagal triggers, and usually get Afib during the night. I'm careful to sit down and anticipate the "pause" so that I don't black out and hit the floor. I don't drive if have an episode.

Ablation. My EP favors it. I'm not against it, but I know nothing about his skills and reputation. He's pretty much a youngish, by-the-book doc and I get along with him. He's in Bloomington, Indiana, 25 miles away. Three years ago at our first appointment, he seemed to have never heard of Nattokinase, but now says several of his patients take it.

Continue mitigation strategies. I manage by avoiding my triggers: full stomach/late night, lying on my back, electrolyte imbalance, sitting too much. I take magnesium 400 mg daily, Co Q10, Vit D, some extra potassium (low-salt V8), potass powder. I've tried other supplements and have started ginger powder recently, but haven't stuck with Taurine, L-Carnitine, or fish oil. I've been happy using this approach and used feel that I had some control over the frequency. I don't know yet if the increase is a trend or not, because I've had periods of increased activity that resolved to less activity.

Thanks for reading; sorry it's so long.

AFAIK, "female gender" is not considered a risk factor any more.

CC66:
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You say that you get blackouts upon converting from AF to NSR. I had that happen to me as well, it was quite a few years ago--when going from AF to NSR I would almost black out, this was caught once when I was in my doctor's office, he said I had 1st. degree heart block and I immediately had a pace maker installed, I never had that happen to me again, I am glad for my pacer, it has never caused any problems for me. One time when I was in my EPs office, my chart was hanging on the door and my EP wasn't in to see me yet, i looked at my chart and my EP had written that he believed my 1st degree heart block was caused by the beta blocker that I had been taking. Since that time I avoid any beta blockers.

Liz

Once my ep mentioned he wanted to rule out a need for a pacemaker by having me wear a 14 day holter monitor. It showed my heart was fine and there was no need for a pacemaker because I showed him a single Ekg with a few pauses. I mentioned pre ablation to my np about occasional pauses and I think she said that perhaps my heart was trying to convert from af to nsr and wasn’t concerned. it’s worth a try wearing a holter to clock the length of your pauses.

I agree that you should consider an ablation, but conversion pauses don't necessarily warrant a pacemaker. That should be looked at as a separate issue. One thing he really should have done is tried switching you to diltiazem instead of metoprolol. It's possible the metoprolol is responsible for or a contributor to the syncopal episodes. If it is, there should be no discussion of a pacemaker. And I'm sure you'll feel better if you get that heart rate back into a normal range; 44 is borderline dangerous.

However, I would probably not consider an ablation with the EP you described:

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I'm not against it, but I know nothing about his skills and reputation. He's pretty much a youngish, by-the-book doc and I get along with him. He's in Bloomington, Indiana

With AF ablations what you absolutely, positively want is the EP with the most AF ablation experience you can find. And by that I mean many hundreds of AF ablations, preferably thousands, spanning a number of years, and more than a few dozen per year on an ongoing basis. (Other types of ablations don't count because AF ablations are the most difficult of all.) I would also recommend against an EP in Bloomington, IN. I'm an IU grad so I know what to expect in Bloomington, and what you won't find there is a large center doing thousands of AF ablations per year, which should be another minimum requirement. AF ablations aren't something that should be performed in small and mid-sized hospitals, and not by doctors who do a handful per month. It's a specialty that should only be performed by highly experienced EPs in high-volume centers.

It's perfectly fine to keep seeing this guy for management of your AF, but if you choose to pursue an ablation, we need to talk about where and with whom. Bloomington is not the place and an EP practicing there is not the doc. That's not to diss Bloomington by any means. I love that town, but it's not the place to get an ablation. Indianapolis perhaps, but there are better choices still.

I often get the black-out type "pause" upon conversion.

CC66 has said these are not just pauses, they are black out pauses which is different than just pauses.

I understand that, but they're happening only on conversion, which makes them a different thing from pauses that happen at random. (If they were happening at random, a pacemaker would absolutely be required.) But if the AF is eliminated, there won't be conversions, so therefore no pauses either.

Carey:

I had the same thing which happened to me, i only got this when going from AF to NSR , I didn't get any pauses otherwise. When my EP saw the tracing that my doctor sent to him, he called me and said I had to go to the hospital and get a pacer implanted. Now who is right you or an EP, I doubt a person could continue this way, so you probably are right about an ablation, either an ablation or a pacemaker that would be the choice. This happened to me 22 years ago so so I was in my sixties, an ablation wasn't mentioned to me, I also at that time I didn't get that many episodes of AF.

Liz, what I said was the pauses need to be evaluated separately from the ablation. I'm not saying CC66 should just ignore them. Not at all. I just think an ablation and a pacemaker all at once is too aggressive. She needs a more careful evaluation, preferably by a more experienced doc.

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Carey

It's perfectly fine to keep seeing this guy for management of your AF, but if you choose to pursue an ablation, we need to talk about where and with whom. Bloomington is not the place and an EP practicing there is not the doc. That's not to diss Bloomington by any means. I love that town, but it's not the place to get an ablation. Indianapolis perhaps, but there are better choices still.

Thanks for that feedback; that was my take on things, as well. He really presented the option as something "they do all the time" - like it's no big deal.

Calli

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Pompon
AFAIK, "female gender" is not considered a risk factor any more.

Now I'm confused. That's what I've read and have been told... when was that changed/updated?

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Elizabeth
CC66:
I
You say that you get blackouts upon converting from AF to NSR. I had that happen to me as well, it was quite a few years ago--when going from AF to NSR I would almost black out,........my EP had written that he believed my 1st degree heart block was caused by the beta blocker that I had been taking. Since that time I avoid any beta blockers.

Liz

Yes, they are "almost" black-outs. I have sick sinus syndrome and don't normally take any beta blockers except for the small amount taken with the flecainide.

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susan.d
Once my ep mentioned he wanted to rule out a need for a pacemaker by having me wear a 14 day holter monitor. It showed my heart was fine and there was no need for a pacemaker because I showed him a single Ekg with a few pauses. I mentioned pre ablation to my np about occasional pauses and I think she said that perhaps my heart was trying to convert from af to nsr and wasn’t concerned. it’s worth a try wearing a holter to clock the length of your pauses.

I wore a heart monitor for one month June15- July 15 this summer. This type attached to my chest and sent signals to a smart phone, which uploaded the info to a processing service called Preventice Solutions. I only had one Afib during that time, and apparently that night I had a flutter episode, after which there was a longish pause (so they said- I was asleep and didn't notice).

During the followup with my EP after the monitor, I asked whether there were any other long pauses or whether my heart rate got too low during the month. The doc said I didn't have anything concerning other than the aforementioned episode-flutter-pause.

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Carey
I agree that you should consider an ablation, but conversion pauses don't necessarily warrant a pacemaker. That should be looked at as a separate issue. One thing he really should have done is tried switching you to diltiazem instead of metoprolol. It's possible the metoprolol is responsible for or a contributor to the syncopal episodes. If it is, there should be no discussion of a pacemaker. And I'm sure you'll feel better if you get that heart rate back into a normal range; 44 is borderline dangerous.

Can you explain - why diltiazem instead of metoprolol?

As for my 44 heart rate - it's a resting rate- sitting around, etc. It doesn't make me feel bad when it's low; I don't have dizzy spells or brain fog. During sleep it gets as low as 38 sometimes, but it goes up to low normal range with activity 50-65. I was concerned that he wanted me to take metoprolol with flec --because I have a slow heart rate. So I don't know if it contributes to the pause. I do remember having an occasional pause when I was converting just with flecainide, but after hearing about 1:1 conversion I'm afraid to not use metoprolol.

My doctor mentioned a pacemaker, but didn't think it was needed immediately, based on my 30-day monitor readings.