No Meds, Uncertain Future

It is a weird feeling to know that I have reached the end of the road for med control of my arrhythmia. I have yet to see the EP for follow up (see him on the 17th). But he made it pretty clear after the Vasculitis from Verapamil that ablation is really the only option left on the table. It just feels a bit overwhelming. I feel very thankful that it looks good for complete resolution of the vasculitis, pending my follow up labs next week.

I now have the same rhythm at night that I have always had (extremely frequent PACs, bigeminy, And multiple short 4 beat runs of SVT). In addition, I have a persistent case of Inappropriate Sinus Tachycardia that is almost as debilitating. My current EP wants to ablate the PACs, but I am weighing my options to see about going to a bigger facility that can also address the IST at the same time. Ready for this saga to end in NSR....

What a grind you're enduring.

You're an extraordinarily complex patient so I think you need the most experienced, most capable EP and center you can find. I don't know why your current EP would want to focus on PACs when those are probably the least of your problems.

Sending good thoughts your way for a successful solution.

Wishing you the best

Hoping for the best for you!

Stay positive and stay strong.

Thank you. I am working on seeing a Specialist for the Verapamil reaction, but that is not fast due to my rural location. After seeing my EP on Wed., I will be asking him who he recommends for adequate follow up and treatment for my IST/etc. I have an appt. at Mayo in September, but have personal issues with Mayos philosophies/ideologies, so am still debating that.

Thanks for all the kind words and support.

Keeping you in our prayers

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Evelyn
Keeping you in our prayers

Hank you, Evelyn, that means more to me than you know!

Megan, I have been following your journey from the beginning, commenting now and then, especially with one of your posts about your sleep deprivation. I, too, hope you find some relief.

Thanks to everyone. I have now had a visit with the EP and a visit with an Immunologist. The Immunologist said that I should avoid all Calcium Channel Blockers and perhaps some ACE inhibitors, unclear about Beta Blockers. The EP is wanting me to try Sotolol again after the SVT was fixed and if no success, then perhaps try Ranolazine. I don't know much about that one. Anyone have any experience with it? I'm not sure about any meds at this point. I feel pretty burned out. I've ordered a Wellue that will take 24 hour reading with AI report. I'll send that out to the EP, wait for my Mayo appt., and see how it goes.

Keep up the good fight! It will eventually pay off.

There are several articles in the forum on Ranolazine. Recent studies have indicated off label use for arrythmias are promising. .I have used this medication in the past for control of PAC/PVC and helped a lot. I use it now with Flecainide as a pill in a pocket with they get very active. Of course you need to check with your Doc if this is right for you.

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sldabrowski
There are several articles in the forum on Ranolazine. Recent studies have indicated off label use for arrythmias are promising.

Here is ChatGPT4 on Ranolazine and afib (with references).

Ranolazine, an anti-anginal medication, has been studied for its potential benefits in treating atrial fibrillation (AF). This drug works by inhibiting late sodium currents in cardiac cells, which can help stabilize electrical activity in the heart. Here is an overview of the effects and potential benefits of ranolazine in atrial fibrillation, supported by relevant references:

### Mechanisms of Action

1. **Inhibition of Late Sodium Current (INaL)**
- Ranolazine inhibits the late sodium current in cardiac cells, reducing intracellular sodium and calcium overload, which helps stabilize cardiac electrophysiology.
- Reference: Antzelevitch, C., Belardinelli, L., Zygmunt, A. C., et al. (2004). "Electrophysiologic properties and antiarrhythmic actions of a novel anti-anginal agent." *The Journal of Cardiovascular Pharmacology*, 44(1), 101-119.

2. **Modulation of Atrial Electrophysiology**
- By modulating atrial electrophysiology, ranolazine can reduce atrial excitability and prolong atrial refractory periods, which helps prevent the initiation and maintenance of AF.
- Reference: Burashnikov, A., Di Diego, J. M., Zygmunt, A. C., Belardinelli, L., & Antzelevitch, C. (2007). "Atrium-selective sodium channel block as a strategy for suppression of atrial fibrillation: differences in sodium channel inactivation between atria and ventricles." *Journal of the American College of Cardiology*, 50(4), 335-343.

### Clinical Studies and Efficacy

1. **Reduction of AF Burden**
- Clinical trials have shown that ranolazine can reduce the burden of AF in patients with paroxysmal and persistent AF.
- Reference: Murdock, D. K., Reiffel, J. A., Kaliebe, J., & Larrabee, P. (2008). "The conversion of paroxysmal and persistent atrial fibrillation with ranolazine: a potential new antiarrhythmic agent." *Journal of the American College of Cardiology*, 51(1), 55-60.

2. **Adjunctive Therapy**
- Ranolazine has been studied as an adjunctive therapy with other antiarrhythmic drugs, showing potential to enhance their efficacy and reduce the incidence of AF.
- Reference: Bhandari, A. K., Saba, S., & Mehdirad, A. (2015). "Ranolazine as adjunctive therapy with amiodarone for recurrent ventricular tachycardia or fibrillation: A case series." *Journal of Cardiovascular Pharmacology and Therapeutics*, 20(1), 59-64.

3. **Improvement in Outcomes Post-Ablation**
- Studies suggest that ranolazine may improve outcomes in patients undergoing catheter ablation for AF, reducing the recurrence of AF post-procedure.
- Reference: Miles, R. H., Passman, R., & Wadhwa, N. (2011). "Effect of ranolazine on the symptoms of atrial fibrillation." *Journal of Interventional Cardiac Electrophysiology*, 31(3), 173-178.

### Safety and Tolerability

1. **Adverse Effects**
- Ranolazine is generally well-tolerated, but it can cause side effects such as dizziness, headache, constipation, and nausea. It has a relatively favorable safety profile compared to traditional antiarrhythmic drugs.
- Reference: Chaitman, B. R., Skettino, S. L., Parker, J. O., et al. (2004). "Anti-ischemic effects and long-term survival during ranolazine monotherapy in patients with chronic severe angina." *Journal of the American College of Cardiology*, 43(8), 1375-1382.

2. **Drug Interactions**
- Ranolazine can interact with other medications, especially those metabolized by CYP3A and CYP2D6 enzymes, so careful management and dose adjustments are necessary.
- Reference: Jerling, M., & Abdallah, H. (2005). "Clinical pharmacokinetics of ranolazine." *Clinical Pharmacokinetics*, 44(5), 467-480.

### Conclusion
Ranolazine has shown promise in the management of atrial fibrillation, particularly by reducing AF burden, serving as adjunctive therapy, and improving outcomes post-ablation. Its mechanism of action, involving the inhibition of late sodium currents, provides a unique approach to AF treatment. However, further studies and clinical trials are necessary to fully establish its efficacy and safety profile in this context.

### References

1. Antzelevitch, C., Belardinelli, L., Zygmunt, A. C., et al. (2004). "Electrophysiologic properties and antiarrhythmic actions of a novel anti-anginal agent." *The Journal of Cardiovascular Pharmacology*, 44(1), 101-119.
2. Burashnikov, A., Di Diego, J. M., Zygmunt, A. C., Belardinelli, L., & Antzelevitch, C. (2007). "Atrium-selective sodium channel block as a strategy for suppression of atrial fibrillation: differences in sodium channel inactivation between atria and ventricles." *Journal of the American College of Cardiology*, 50(4), 335-343.
3. Murdock, D. K., Reiffel, J. A., Kaliebe, J., & Larrabee, P. (2008). "The conversion of paroxysmal and persistent atrial fibrillation with ranolazine: a potential new antiarrhythmic agent." *Journal of the American College of Cardiology*, 51(1), 55-60.
4. Bhandari, A. K., Saba, S., & Mehdirad, A. (2015). "Ranolazine as adjunctive therapy with amiodarone for recurrent ventricular tachycardia or fibrillation: A case series." *Journal of Cardiovascular Pharmacology and Therapeutics*, 20(1), 59-64.
5. Miles, R. H., Passman, R., & Wadhwa, N. (2011). "Effect of ranolazine on the symptoms of atrial fibrillation." *Journal of Interventional Cardiac Electrophysiology*, 31(3), 173-178.
6. Chaitman, B. R., Skettino, S. L., Parker, J. O., et al. (2004). "Anti-ischemic effects and long-term survival during ranolazine monotherapy in patients with chronic severe angina." *Journal of the American College of Cardiology*, 43(8), 1375-1382.
7. Jerling, M., & Abdallah, H. (2005). "Clinical pharmacokinetics of ranolazine." *Clinical Pharmacokinetics*, 44(5), 467-480.

Thanks so much, George. I have been extremely hesitant to tty any new meds after the Verapamil induced Vasculitis debacle. I appreciate this information. I will research to my hearts content while I decide what to do! I am on hold right now as I decide. My EP wants to go in and try another ablation in the left Atrium. I am hesitstn hesitant to do any interventions at this point, medication or otherwise. I am currently taking supplements and Ivabradine for the IST and just dealing with the 30% burden of ectopics. Last monitor showed 30,000+ in a 15 hour period. Anyway, thank you so much! I will definitely do some research!

Megan, sorry to hear the ectopics are back. Hoping for some relief for you.