Changing from Rate to Rhythm

I have been on metoprolol for a number of years. The record of my afib episodes has been spotty, but tolerable.

My original cardiologist retired a few years ago, and the succession of doctors I have seen to replace him have hinted, more or less strongly, that I should switch to a rhythm control drug.

So, I thought I would ask if there are any out there who have undergone a similar change, and what your experiences were.

I am currently experiencing about one episode a month, lasting 12 to 24 hours, starting, mostly, in the afternoon, often associated with disturbances in my gastro-intestinal tract (whether as cause or effect is unknown).

Thanks in advance,
Gordon

Hi! I was where you are about 24 months ago. I had been controlled, with two cranky months in each of '20 and '21 near Christmas, probably due to the stresses of family gatherings. But otherwise, I was active and my metoprolol of 25mg per day seemed to do a good job. In fact, my cardiologist felt that it's possibly more important benefit to me was to keep my borderline hypertension in the 'kewl' zone. Then, things began to get worse. And worse. Eventually, I sought an ablation. It failed within six days. I was placed on amiodarone during an acute care stay in hospital due to HR upwards of 160. Amiodarone stopped my AF cold, and I went off it completely in 8 weeks. Two months later, I was back in AF and could not be cardioverted for more than a few hours. A second ablation has me in blissful NSR for eight months now.

My triggers at the time, nearly two years ago, were also gastric, lots of belching after meals, but even laughing during a sitcom would set me off. So, the list of triggers, whatever they are for any one of us, seems to grow in time.

If you follow a similar trajectory, you will experience more frequent, and perhaps more uncomfortable and more disconcerting, episodes. It may happen on a low gradient, or you may find one week that your otherwise decent history with AF has taken a dramatic turn. Happened to me.

At this point, I don't see what could hurt resorting to an anti-arrhythmic drug to help get you further along to what will probably eventually be more persistent AF, and then an ablation. I think most of us here almost beg for that intervention, but only from really top-notch electrophysiologists. Even then, just so you know, about 30% of initial, or 'index', ablations are NOT successful. Subsequent attempts, even by the same EP, have a much better statistical record of success.

An episode per month lasting 12-24 hours? Yep, I would definitely either begin an antiarrhythmic or seek an ablation. I don't know if you knew this, but rate control drugs don't actually prevent or stop afib; they only lower heart rate and BP. Lowering the rate once you go into afib is important, but depending on the antiarrhythmic chosen, you might be able to switch to using a rate control drug only when you're in afib rather than daily.

Tell me, is your cardiologist an electrophysiologist? (EP) If not, you'll be better off finding a good EP. General cardiologists aren't usually up-to-date on afib management.

You likely don't need the metoprolol chronically (unless you need it for another reason, like blood pressure). You may need in combination with a rhythm med on demand. Here is the original paper for relatively rapid on-demand conversion using flecainide or propafenone. [pubmed.ncbi.nlm.nih.gov]

I've successfully used flecainide on-demand for my infrequent episodes since 2004.

@gloaming: Actually, in the past 2 years, the frequency of my episodes decreased (from ~2/mo to <1/mo) when I followed the 'reduce calcium intake' advice I found here. I love cheese! But I hate afib.

@Carey: My Cardiologist was not an EP. I live in a relatively rural area, and EPs are hard to come by.

@GeorgeN: My episodes always self-terminate. I once tried to have an episode terminated with cardioversion: they tried twice, without success. Then, after something less than 24 hours, the episode terminated itself as usual.

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wwoofbum
My episodes always self-terminate.

I could say the same thing for 8 years. The episodes happened once or twice a year, were reliably 6 hours long, and then self-terminated. So I didn't see anybody about it; just put up with it. And then the episodes started becoming more frequent and lasting longer. That trend steadily increased until I was having multiple episodes per week and they were lasting 12-18 hours. Unfortunately I just went with the EP my PCP recommended, and that was a mistake. He had great credentials and reputation. Unfortunately, neither one makes you a good ablationist, and he wasn't. I should have done more homework.

Afib is progressive, so my advice to you would be to start looking for an EP now. Okay, so you'll have to drive a few miles. When I finally got smart, I flew 2000 miles for an ablation. Trust me, it matters that much.

I'd say your frequency and duration is borderline, meaning you could arguably remain where you are on rate control, move to rhythm control, or go to a Pill in Pocket (PIP) approach. A lot has to do with quality of life, including how well you tolerate your current drugs as well as the episodes themselves.

I've been on all three strategies, and if I had your frequency and duration, I would probably want to try PIP first. That way, you would not need daily antiarrhythmics and you could also arguably get off your daily beta blocker. Should the frequency start to increase, then you could move to a daily antiarrthymic strategy and compare your QOL to your current rate strategy. At some point ablation may make more sense. In my case that was in my mid 70's and figured better to do a procedure now when I was relatively healthy, rather than later, not to mention I feel better off the drugs than on them.

Jim