deciphering the new EP visit

Please share your opinions of my experience with my new EP. I had hoped to come away with a better plan to manage my Afib.
1. his first choice was ablation as he feels I am a good candidate for success
( I have no insurance and not prepared to face that yet, if ever)
2. first drug of choice would be sotalol ( I explained that after trying it my heart rate shot up, he said it wasn't because of the sotalol, very disappointing)
3.consider just rate control during episode with metoprolol, 50mg
4. nattokinase will not be enough, coumadin necessary
5. recurrence of Afib has nothing to do with "triggers", just coincidence
6.episodes will continue to worsen leading to permanent Afib no matter what I do, except having ablation
7. left me saying he would not insist or push any particular treatment plan, it would be up to me to decide (??) and added that "patients like you are difficult to work with because you believe everything you read on the internet. Think about it and come back and see me in a few months".

Can you imagine how disappointed I was walking out of that office?! Even though I believe strongly in the supplement and nutritional approaches to dealing with Afib, I was trying to be open-minded about adding drugs if necessary. Now I don't know what to do or how to proceed. Any thoughts would be appreciated. Jill

My personal take on what he said.
1) He feels you are a good candidate for ablation with that being the best way to eliminate your a.fib so thats why he mentioned it to you.
2) Since sotalol has beta blocking properties that should help slow your heart rate so its a fair assumption that the patient (as usual) is just mixed up and confused.
3) He thinks if you slow your rate during and episode that would be a good idea and that alone may help you to convert.
4) Obviously he would say that to cover himself from a legal point of view if you throw a clot.
5) He just hasn't got a clue if he really thinks this but was probably thinking you are obsessing about your a.fib and should forget about triggers because you will get it anyway no matter how hard you try to eliminate it.
6) That explains his previous five answers.
7) I am not going to make the choice for you so whatever happens it's your choice not mine.

Just my take on his thinking from a clincal perspective I am not suggesting for a second the validity or wisdom of what he said just guessing for you the reasons for his answers.

The others on this site George etc will help you with great advice through the mine field of a.fib

Mark

Jill: Sounds like pretty much by the book E. P. advice to me. I've heard Natale say those same thoughts if not those same words. You must have a pretty straightforward form of fib.

In the olden days they used to want you to fail on two drugs before considering you for an ablation but I think they're confident enough of the procedure and they have enough data now to perhaps omit that.

One thing to consider is that you may not always be a good candidate for an ablation.

However, if you can control the fib for the immediate future with drugs and the side effects of them are tolerable, it might be worthwhile to wait as the ablation procedures are only going to improve with time.

Seems to me that you should be getting some insurance sooner rather than later.

Gordon

Jill,

Do you think your triggers are vagal or adrenergic?
<[www.afibbers.org];

George

Hello Jill. Did you tell us who this EP is and i just missed it? Might be a useful thing to know. If it were me i would just look further for another EP. Best to you.
PeggyM

#7 would have been the clincher for me. Docs who are insecure when a patient is willing to read, learn, ask questions and advocate for themselves are not the docs that I will ever hire. I would look for a different EP.

Tony

Hi Jill,

I think your EP answered your questions like most would. Doesn't make it right but you might look a looooooong time to find an EP with a different take on things.

Debbie

George- I believe, from reading descriptions here, that I am vagal.

The thing I am most disappointed about is not coming away from this appointment with a plan. I had resigned to agree to start some kind of drug to try to stay out of Afib. Now I don't feel like I have any plan or Doctor to turn to. Does it sound like this EP is expecting I will come back and say, ok, I want to try this drug and would you write the prescription? By the way, I've had 3 episodes this year, March, June and September 1st, all electrocardioverted. Before that, one episode in 2008, 2007 and 2006, none in 2009. Jill

Jill,
If you send me an email, I have a thought for you.
George

George- I'm not sure how to get your email. I notice beside my name is not my email address but "consolidated.net". I would love to hear your thought!

Jill
Press on George's name in blue and it will bring up his email address.
Cyndie

Jill just click on George's name which should be highlighted in blue. As a person held in high regards for my clincal descision making by the medical profession I can only say you probably won't get better more balanced advice than that from George and it's for free ....wow.

Mark

Cyndie and Mark, Thanks but when I click it I don't get an address! I would so much value Georges advice, help!

Jill,

Unfortunately clicking on your name does not give an address. Mine will show. Cyndie & Louise, your emails came through.

I plan to do a much longer post on the vagolytic med approach to dealing with vagal afib. It will take me a while to accomplish this because I have my business, family and a demented mother as other demands on my time. In the interest of giving you something to go on, I will give this a stab now.

The problem with vagal afib is that the autonomic nervous system tone can shorten the refractory time during which heart cells won't depolarize & after a beat, known as AERP. The relationship is as follows:

Atrial ERP shortening due to (P cells + low potassium + ANS tone) => AF Risk

See this post on AERP <[www.afibbers.org];

and

<[www.afibbers.org];

Essentially AERP is the refractory time after a heart beat during which the cells won't beat again. If this time gets too short, then premature beats (PAC's & PVC's) can occur as well as afib. People in good condition have vagal ANS tone. In general this is good, but in a subset of people prone to afib, it is too much of a good thing.

One way to do this is with a vagolytic med. In essence it reduces vagal tone.

A doctor who has written on this is James A. Reiffel, MD. He retired in June from Columbia University [asp.cumc.columbia.edu]. Here are quotes from a couple of his papers:

Selecting an Antiarrhythmic Agent for Atrial Fibrillation Should Be a Patient-Specific, Data-Driven Decision James A. Reiffel, MD

"In patients who appear to have a parasympathetic contribution to the development of AF (as with nocturnal, postprandial, or bending-associated onset), a regimen that possesses anticholinergic properties may be particularly useful (e.g., disopyramide), whereas vagomimetic drugs (e.g., digitalis) may be profibrillatory. Although the literature does not contain prospective series contrasting drugs with different autonomic profiles in such patients, my own experience suggests that nocturnal paroxysmal AF can be totally or substantially limited by the pre-bedtime administration of either propantheline bromide (without an associated AAD) or controlled-release disopyramide without a repeat dose in the morning."

and

Have Sanctioned Algorithms Replaced Empiric Judgment in the Selection Process of Antiarrhythmic Drugs for the Therapy for Atrial Fibrillation?
James A. Reiffel, MD

"These include autonomically mediated AF (vagal, sympathetic), usually in patients without SHD, where, for sympathetically-induced AF, β-blockade may be sufficient as the AAD of choice whereas for parasympathetically mediated AF I have found that vagolytic agents (eg, propantheline bromide, urecholine, tincture of belladonna) may be sufficient as a preventative therapy (or may be added to another AAD) and disopyramide may have uniquely advantageous efficacy."

The suggestion is to investigate propantheline bromide. It should not be taken if supplementing with potassium and that potential adverse effects include tachycardia, constipation, blurred vision, hypersensitivity to light, urinary retention, and dry mouth. The main use for propantheline bromide is in the treatment of peptic ulcer and irritable bowel syndrome. The recommended dosage for peptic ulcer is 15 mg 3 times daily before meals and 30 mg at bedtime.

Unfortunately, Dr. Reiffel does not give people much to go on in his published writings. There is a single case study where the patient describes his experience in detail. For those with vagal afib who are having trouble controlling it otherwise, I think this is worth investigating.

The author of the case study has corresponded with Dr. Reiffel. I specifically asked the author if Dr. Reiffel had statistics on this approach. His quote of Dr. Reiffel, "My own experience suggests that nocturnal paroxysmal AF can be totally or substantially limited" by this treatment."

The author's experience is that propantheline bromide can be used successfully & without issue. I would pay careful attention to his details. Propantheline bromide is a med and must be paid careful attention to. But so are flec and all the AAD's we take.

George

β-blockade is supposed to be beta blockade. The funny characters were supposed to be beta.

George, Thank you so much for the information! I read every link. I have much more studying to do, but the account by Bedson of his experience using Propantheline is very interesting. I appreciate you taking the time to write that out for me. I will also look forward to reading your future post on the vagolytic med approach. Thanks again! Jill

Jill, left click it.
PeggyM

Hi Jill (and others),

I can email you copies of Dr. Reiffel's paper's. In my browser, if you right click my name, the option of copying my email address comes up. If you left click, it will bring up an email program, if you have one installed, with a new email addressed to me.

Because the author of the case study has shown very poor behavior on this board, I asked Hans for permission to bring up ths topic. He agreed, as long as I didn't mention the author's name. I would ask that others do likewise.

I am not trying to promote the case study author, however I do believe the vagolytic med has promise for vagal afibbers and the concept details should be made available.

If you do pursue this with your physician, I would ask that you report back here. It would be nice to have more data beyond the one case study & Dr. Reiffel's comments. Certainly Dr. Reiffel's experience carries weight. Here is a presentation by Dr. Reiffel from a few years ago, not on the vagolytic topic, but you can at least watch him present. [cme.medscape.com]

George

So Medscape doesn't cooperate unless you start with Google. Try this: [www.google.com] and select the first link.

Another opportunity to watch Dr. R - again1st on the list from this Google search [www.google.com]

Hello Jill,
so glad George came to the rescue!
The experience with your new EP reflects that of mine with the first lot of heart specialists I saw and, from my reading of this BB over the past 6 years, the same as that of many others who like to be involved in the treatment of their own bodies.
When I tentatively objected to being prescribed digoxin at one stage (having read the archived BB's and Han's books) I was treated to a loud, frustrated sigh from the man in white and told that too many people were reading 'stuff' on the internet and didn't have a clue what they were talking about.
It's always disappointing to be told you can't have things the way you want them when you have researched the issue.
Re: point 4 of your post -
I took nattokinase along with warfarin, from pre- through post ablation - with absolutely no problems and with great peace of mind.
Here is part of a letter I received from Dr Ralph E. Holsworth Jr, Director of Clinical and Scientific Research at N-zymeCeuticals Inc., P.O. Box 278
Pagosa Springs, CO USA 81147 Cell 970-560-0011
"Nattokinase is safe to use in combination with Coumadin. Coumadin inhibits the Vitamin K dependent clotting factors, Factor II, VII, IX, XI which form a blood clot. Nattokinase increases your body's production of plasmin (an enzyme your body produces to prevent excess blood clotting). Coumadin is an anti-coagulant but technically not a "blood thinner" as so often referenced. Nattokinase decreases the thickness of the blood without adversely affecting the coagulation cascade. A person on nattokinase who cuts himself with form a clot to stop the bleeding. As you know a person on Coumadin with a cut will have a prolonged bleeding time becuase the clotting factors have been impaired by the Coumadin.
I have several hundreds of patients that I am aware that use nattokinase with Coumadin because the nattokinase provides additional prevention against blood clots than Coumadin as a solo therapy.
I feel certain that you would be safer from the development of a blood clot during the EP procedure if you were taking nattokinase. In addition, the nattokinase would not place you at a risk of excessive bleeding from guidewire puncture, etc... Coumadin would not afford you that favor."
Dr Holsworth even offered to talk with the doctor for me if the doctor was willing,
Hope this helps in some way,
warmest best wishes,
Emmie