afib de ja vue after years of NSR

I came down with afib a week ago. My heart is in afib more than half the time, as noted by my Apple Watch. I had a cardioversion done about 3 years ago, was in persistent afib then. I was in NSR until last week. The cardiologist/EP says to wait until heart is in afib solidly for a day or more then consider cardioversion again. I eat healthy, don’t smoke, limited alcohol, am thin, very active in racquet sports, and 77years old. Taking Lisinopril, Metoprolol, and 10mg Eliquis/day, for years.

I have some questions for the group if I may:
1. I thought I had to be in persistent afib, that is more than a week of being in afib, not just having afib solidly for 24hrs, was the requirement for cardioversion?
2. The physical symptoms of my current afib are not too severe. I’m thinking, perhaps naively, if symptoms do not get much worse, then doing nothing to address the afib is the way to go. If they do get worse, like afib much worse than “occasional” afib, or physical symtoms of getting tired with exercise, then try the cardioversion first.
3. I read on a major health site (Cleveland Clinic, John’s Hopkins, maybe Penn) that having afib reduces life expectancy by 5 years, for someone my age. Thoughts on this?

Thanks in advance!

"1. I thought I had to be in persistent afib, that is more than a week of being in afib, not just having afib solidly for 24hrs, was the requirement for cardioversion?"

There is no time requirement like that, your Dr. set that guidance based on your circumstance. As long as you are in Afib, then you could Cardioverted, but if you might convert on your own, then why go through the Cardioversion. I used to be persistent, so when I would get an Afib episode, I would immediately start to arrange a Cardioversion, as I would almost certainly remain in Afib indefinately if I did not. Now in the last 6 years, that I am able to convert on my own almost all of the time, now I wait about 5 days to start to arrange for an ECV.

20+ years ago my EP said the issue wasn’t cardioverting me, it was what he was going to do keep me in NSR after the cardioversion. I would say the same as true for you and I’d also say that there is nothing about cardioversion that is “stronger“ than converting on your own, in terms of staying in NSR.



Edited 3 time(s). Last edit at 07/13/2025 04:35PM by GeorgeN.

I have had four cardioversions (so, not many by some standards), and the longest duration was 16 hours in NSR, then back into AF. The shortest duration was....zero. My first attempt didn't work at all after three increasingly powerful zaps.

Being symptomatic can be close to hell. I would think that not knowing/sensing AF or ectopy would be next to bliss. But that's not the whole story. Apart from the risk of stroke, there is the risk, as time goes on and the hours add up in AF, that your mitral valve will begin to wear more quickly and eventually prolapse. You get collagen deposition in the substrate of the atrium (and probably in the right ventricle if you have RVR) and accompanying fibrosis. You get atrial enlargement, and possibly cardiac insufficiency (AKA heart failure). So, sure, if you're not symptomatic, and only paroxysmal, I would also do nothing more than to take a DOAC twice daily. But symptomatic, or in AF 'half the time'...that's not a good place to be in my estimation. You would be better off enlisting the help of an electrophysiologist to beat back the AF to the extent possible, even if it's just upping your magnesium/potassium/calcium (or reducing them if they are too high) and maybe using an anti-arrhythmic drug.

If cardioversions worked for me, and for many weeks, I would probably favour them. It hasn't been in the cards for me. Self-converting is great, and I mostly did that until later weeks just prior to my first ablation. If you can control your AF to less than 10% of total beats in a 24 hr period, but self-convert each time, then no need for cardioversion, and no real need for an AAD.

Sounds like you're in and out of afib and therefore your ep wants to wait until your afib decides to leave town or move in. Makes sense. Because as long as you're in and out, cardioversion just may become part of that cycle.

That said, are you going by "afib burden" on your Watch, or are you actually taking ekg's to confirm that you're in afib "more thah half the time". I would only go by ekg's on this.

Don't know about the study you cite, but newer research does suggest that being in normal rhythm is better for your heart longer term, than being in afib, even if your rate is controlled.

Hopefully, you will convert into normal rhythm soon, but if not another cardioversion is one option. Another might be an arrhythmic like Flecainide, either on a daily or as needed basis to get you through rough spots. And of course, catheter ablation for a drug free solution.

Jim

Many thanks to those who responded. I finished a study with a heart monitor RhythmStar, which showed paroxysmal afib, as was expected. I also just completed the 2nd cardioversion (first one lasted 4 years), everything standard, except I requested a TEE test, which was granted, even though I’m on Eliquis compliantly. Had 2 procedures in about 15 minutes, TEE followed by CV while twi-lighted. The TEE showed no clots, and the CV worked with one application.

If AF shows up again in maybe 6-12 months, I’m thinking of trying the drug route. What are the drugs with the smallest side effects/largest benefit? (one respondent commented on flecainide.)

And what about caffeine, I’ve been reading that more recent info do not see a correlation?

Thanks again for such a great resource.

There is only anecdotal evidence that caffeine is a trigger. You could add coitus to that immense list, coughing, belching, bending over and tying one's shoes when one has a lot of visceral fat, caffeine, some inhalers, too much calcium, too little magnesium, too little/much potassium, cold medications, antihistamines, money worries, car crashes......................do you want me to keep going?

The best, and often the most easily stemmed, kind of AF is the early kind, so paroxysmal. This applies to drugs, meditation, medication, cardioversion, and ablation. If needs be, letting it go to persistent. Beyond those two stages, you need a really good EP, and good luck to that person if they have a perfect record of success over all their patients that they'd like to keep going.

I have never seen a study claiming that caffeine should be avoided, although it is mentioned in research that reports what the various members polled say, and alcohol would also be included. I drank caffeine, modestly, all through my life, even when fibrillating. The fibrillation never came on within an hour of ingesting. It happened when I belched, bent over, ate too much at one sitting, or had a horrid thought which brought on an adrenergic response....

The paroxysmal stage is where the most likely candidate for ablation, 80-90% of all patients, is going to be the ostia of the pulmonary veins. The paroxysmal stage is the stage with the fewest 'rogue' cells that try to take over your heart's rhythm. As AF progresses, more and more areas are affected, adding one of the six walls of the left atrium. This progression is not likely to stop, but I believe it can be discouraged if the heart remains in NSR most often, or semi-permanently, which is really all an ablation can offer...long term (ideally) relief from both symptoms and more rapid progression or damage to the valves.

BTW, I see widely stated in journals and in papers that ablation is now considered to be the 'gold standard' of care for AF patients. It might not be suitable, even appropriate, for all patients, even those in paroxysmal AF, but it should not be ruled out just because of imagined inflated risks.

I agree with gloaming's post -- all of it -- and I would add that there are a few studies that show caffeine is actually mildly helpful for afib.