Medication

I was diagnosed with AFIB in September 2025 and the emergency Doctor at the hospital prescribed : Bisopropol 2.5 mg//d + Flecanide 50mg ( 2/d) + Xarelto 20 mg/d. Since then, I had one episode in October that lasted about 2 hours, and nothing since.. My current cardiologist with a God's complex thinks that this is the right regimen.
I am 73 and otherwise in good health, I watch my diet , I weigh 140 lbs, I stopped drinking wine , and switched to decaf latte.
I tried questioning my cardiologist about stopping Flecanide and I didn't get an answer .
Has anyone in my situation been given all 3 of these meds? I live in Canada and it's too far to travel to get a second opinion from one of your top EPs, like Dr. Natale.
Thank you in advance.

It’s common to be on Flecainide, a Beta blocker rate control drug and a blood thinner to prevent a stroke from afib.

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Carlorea
Has anyone in my situation been given all 3 of these meds?

Literally millions of people have, including a large percentage of the members here (including me). It's a very routine regimen for afib. The flecainide prevents afib, the bisoprolol protects you against a dangerous side-effect of flecainide (and also lowers your heart rate and BP), and the Xarelto protects you against blood clots.

Oh, and you can probably switch back to regular latte, and a glass of wine now and then should be fine. Caffeine has been shown to actually be mildly beneficial for afib in multiple studies, and alcohol in moderation doesn't seem to be a major factor.

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Carlorea
I was diagnosed with AFIB in September 2025 and the emergency Doctor at the hospital prescribed : Bisopropol 2.5 mg//d + Flecanide 50mg ( 2/d) + Xarelto 20 mg/d

The 50 mg flex 2x/d is a relatively mild dose (likely the smallest dose in the literature) as is the Bisopropol 2.5 mg/d. Xarelto 20 mg/d is the standard dose. At 140 pounds, you could be allowed to take an extra 100 mg/day as a bolus, on-demand dose to terminate an episode (if they only last 2 hours, not worth doing). But if they start lasting longer you could ask about this. The original paper on the topic is here.

I tried questioning my cardiologist about stopping Flecanide and I didn't get an answer

That's not good. You really want a partnership, not to be ignored. While these three medications are frequently given for AF, that doesn't mean this is the right combination for you. Some do well on beta blockers such as bisoprolol, some have lots of side effects and do better on calcium channel blockers. Some, inclucing myself, didnt need either for many years early in my AF journey. Same with Flecainide.

Don't know much about your history, but in many cases a trial off Flecainide can be a good reality check to see if it's really needed. But more important, you want a doctor who listens. So if this one doesn't, I would find one that does.

Jim

I agree with Mjamesone.

At 6 months without an episode, it is reasonable to try getting off of some of your Meds. It would be a risk, does the AFIB come back or not? How are your side-effects from your Meds? You don't need a top level EP like Natale to help you with this, just an EP who cares. At least you are on relatively low doses of the Flecaide and Bisopropol.

Thank you George for the link to the paper. It seems that for the In-Hospital treatment the dose given was 200-300 mg of flecainide. However, for Out-Hospital episodic treatments, does not seem to include the dose, Unless of course its the same dose currently taken by the patients.
The reason why I ask is that In February when I met with my cardiologist I told him that I was going to Florida for some sun, and I was concerned having an episode on the flight. His response was to not take another dose, as the P-I-P is given at the hospital while being monitored..
I am concerned as in September I am going on a long flight to Italy and I don't know what to do if I have an episode .. However, I shall ask this question to my new cardiologist in July.
Thank you to everyone for the response.

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Carlorea
Thank you George for the link to the paper. It seems that for the In-Hospital treatment the dose given was 200-300 mg of flecainide. However, for Out-Hospital episodic treatments, does not seem to include the dose, Unless of course its the same dose currently taken by the patients.
The reason why I ask is that In February when I met with my cardiologist I told him that I was going to Florida for some sun, and I was concerned having an episode on the flight. His response was to not take another dose, as the P-I-P is given at the hospital while being monitored..
I am concerned as in September I am going on a long flight to Italy and I don't know what to do if I have an episode .. However, I shall ask this question to my new cardiologist in July.
Thank you to everyone for the response.

The max PIP dose is based on weight with those weighing less than 70kg/154# getting a max of 200 mg and those weighing more getting 300 mg. The PIP dose is the same, in or out of hospital. In the case of someone like you, taking flecainide chronically, I would not exceed the max PIP dose considering the total flec taken in 24 hours. That is the PIP dose plus the daily dose. In your case, since you weigh 140#, your max dose is 200 mg and you are already taking 100 mg/day. Hence your max PIP dose would be 100 mg.

The in hospital PIP is normally for the first time. They'd like to take a 12 lead ECG after you take it to make sure there are no issues. This is not universally done today and sometimes just being where you can get the ECG may be sufficient.

I've used PIP flec for over 20 years. I've kept my afib burden very low (< 0.05% most years after a 2.5 month episode in my first 4 months) with a protocol I developed for my specific situation. When I got CV 19 vaxes, my afib burden increased 15x. I started taking flecanide chronically at 50 mg/day, which was enough to keep the afib at bay. I then reduced it to 25 mg/day (only in the evening), which also worked. I would periodically see if I could stop completely and was successful after I was 8 months in time away from a CV vax. My recollection is the lowest dose I found in the literature was 50 mg 2x/day. I'm a minimum effective dose perosn, so am willing to take the risk of an episode to experment. In my case, I was initially prescribed 300 mg for PIP, I figured out much later that 200 mg worked better for me, even though I weigh 170#. I've self-manged my case since 2004 (not that I recommend this for others), so not sure what a doctor would go along with. When I was taking flec chronically at these low doses, if I did have a breakthrough episode, I would subtract whatever I was taking from 200 mg and only take the difference as PIP (and actually, at my weight, I could have gone up to 300 mg).

Some docs prescribe a PIP protocol where a person initially takes 100 mg, waits a few hours and will take another 100 mg if they've not converted (assuming 200 is their max and they aren't taking any flec chronically).

Again, with 2 hour episodes, I would not mess with PIP flec. If you are lucky, that is a common time (or somewhat longer) it would take the flec to convert you.

The reason why I ask is that In February when I met with my cardiologist I told him that I was going to Florida for some sun, and I was concerned having an episode on the flight. His response was to not take another dose, as the P-I-P is given at the hospital while being monitored..

Flecinide is a medication that requires what is usually termed as a "structurally sound heart". But in practice, that is up to interpretation. It may be that your cardiologist is very conservative, or that they do not feel that an unsupervised PIP dose is safe for your heart profile. For example, my EP only allowed me a 100mg PIP dose (150 on board total), while others are allowed 300mg. And maybe in your case, the 50mg, 2x/day, is all that they consider safe in an unsupervised setting.

So it's not really comparing to others, it's finding out what your safe dose is. As I mentioned before, if your doctor won't have this conversation with you, find one that will, but in the meantime, better to be prudent and follow their advice.

Jim

At 72 and just securing my 16 year Pin as an Afib Veteran, my perspective on Meds has changed from an as needed PIP to a low dose to circumvent an episode. An ounce of prevention. Staying out of afib now has become priority over going into it at any moment, anywhere, from 1-48 hours, and with or without anyone who could possibly help me. One time in a remote part of Mexico and an hour drive to civilization. Ive dialed in a small dose for me, 75mg, just before bed, and I feel no side effects but the waking up with a racing HR at 2-4am is well under control. As a 90% nocturnal afibber, that is manageable. I have on hand the BB and the NOAC for the longer episodes, but so far still in the med cabinet. Sure the PIP was great for 12 years, until it wasnt. But, Youll know.

This was your first afib episode? And you have gone 8 months without another episode, but on three meds?

For my first episode, cardiologist wanted me on daily diltiazem and daily anticoagulation. I declined and saw a different cardiologist. Let's just say that the second one told me at the hospital to go home and "forget it happened." So I encountered two ends of the spectrum.

It has been 11 years now and I still have episodes once a year, once every two years, sometimes twice a year. I am not on any regular meds, only PIP as needed. I haven't yet used any anticoagulation, and have taken diltiazem a handful of times.

I used to go to the ER because I have rapid ventricular response with heart rate around 190. Also low blood pressure makes treatment harder Hospital did bolus diltiazem then drip and monitored blood pressure. I discovered that simethicone (Gas X) stops my episodes so I don't go to the ER anymore and I don't take diltiazem.

I am in my mid-70's and still not on anticoagulation or any regular meds. My episodes have become shorter- under 20 minutes- knock on wood, and my electrophysiologist says no need for Eliquis until episode is longer.

My case may be quite atypical. Most people get worse over time and I probably will at some point. I will say that the first cardiologist I saw has told me that I was probably right and that he now thinks "we are overmedicating people." I am not posting to suggest that is true for anyone else but it would have been true for me. So I guess this is just a view from a different angle.

Hello, I have been AFIB free for ~ 5 months, and then in May and June I experienced 3 episodes . They lasted about 2 hours and reverted back to normal rate. The meds are doing their job by keeping the HR < 104.
However, I am looking at my apple watch Heart Rate variability and have noticed that during the June 14 episode it got to 307 mS. My normal variability is between 26 and 45 mS.
I am seeing my new cardiologist in 3 weeks. Has anyone had a similar experience? and what does this mean?
Thanks