in afib, how long do i have to decide re cardiversion?

Hi
in need of a couple of quick answers:
I went into afib yesterday around 4pm, went to ER as I have a rapid ventricular response (over 200 and more)

they wanted to do electrical cardioversion, I've never had this done so I declined and went home to wait it out (with Lopressor and some potassium pills cuz my potassium is low)

Questions:
how long do I have to get shocked back into NSR without having to go on anti coagulants??

and what does the electrocardioversion feel like AFTER ward? I know they give you propofol while they do it, so I wouldn't feel it, but won't I have a burn on my skin (I have very sensitive skin)
AND I need to know, will I feel extra tired, or something or can I go about my business like nothing happened?

I don't have many afib episodes and thought I'd never have another one but alas, here I am...
and I don't recall all the details and specifics of what is supposed to happen next.

Hi Althea,

It's been around 12 years since I was last cardioverted, I also live in Canada so the procedure may be a little different where you live. You should definitely mention your sensitive skin, because I remember having some slight burn marks after. It also depends on how easily you convert after being zapped. The power source used is measured in joules. If you don't convert at 100 joules they will try 200, then 300. I required 300 joules to convert me.
I wasn't given any ant coagulants at the time, but I think many hospitals do require that now. Considering your afib attacks are infrequent you shouldn't have to stay on an anti coagulants after the procedure.
You will be totally sedated during the cardioversion, and like I said the only thing you may feel may be a slight burn after waking up. You are only out for a few minutes, and can leave shortly after, wide awake and raring to go. You should be able to walk out on your own and return to your business right away.
It's a good idea to consider cardioversion when your afib reaches the 25-30 hr. range.
Best wishes,

Lou

Did you try Anti Arythmic drugs? Probably you already did?

Althea,

The following two links will tell you all you need to know about cardioversion; [www.afibbers.org] [www.afibbers.com]. Please note the importance of being replete in magnesium and potassium before undergoing the procedure.

Hans

thanks for the quick responses and thank you Hans for the links, although I must say the material is a bit too dense and complicated for me with my brain disorder.

I called the cardiologist who saw me at the ER (he was the doc on call today) and he told me it was already too late to go back and get cardioverted/shocked, even though it was less than 24 hrs.

They wanted to give me cardizem in the ER, I refused as it made things worse the last time they used it.
They wanted to use digoxin as well and I refused, that also was a horrible experience and seemed only to prolong the most recent episode.
The discharge instructions said to get rechecked today to see if I am still in afib (I can tell that I am but they don't believe it til they see it on an EKG but the doc's office is closed, the after hours clinic refused to see me, which only leaves the ER and I am not going back there.


They were ready and eager to shock me when I'd just eaten and also had low potassium, just so this doctor could leave for his dinner date!

(he was very upfront about wanting me out of there as quickly as possible, but the ER doc was arguing with him about that) So I signed out AMA . The doc agreed the risk of me going home and the risk of me getting shocked back into NSR were about the same, but of course they need to cover their behinds.

anyway, I'll try re reading those links and hopefully my own cardiologist can see me sometime in the next couple of weeks.

I have the Lopressor, I think they gave me enough for a week or 10 days and the potassium pills.

Most likely triggers, I guess, were: prednisolone I was given for pain (terrible arthritis in neck and shoulders, knees, etc)
low potassium caused by mild dehydration caused by pred and possibly by not eating much, because I haven't been able to do any food shopping, because I can't carry the food home from the store (don't drive and can't find a ride and am too broke to take a cab) because of the horrible neck and shoulder pain.

Interestingly, I just got a small amalgam filling put in a tooth on Tuesday, and the dentist dropped some that I ended up swallowing (her asssistant was terrible)

Another odd thing is that I have been having spontaneous nose bleeds and massive purple bruises from the least little bump. I called my cardiologist to see if I could stop the low dose aspirin and just got word on Friday that it was ok. (I'd actually stopped on my own about a week ago because the bleeding was interfering with my day to day life)

I am on celebrex, so that's probably why I've got the bruising and bleeding. Not really sure, as I told my doctor's nurse when I called about the pred and I do not know if she relayed that info to my doc.

I'm not sure who to follow up with, the cardiologist (can take weeks or months to get in to see him) or my primary care doc

how long can I just wander around in afib without it causing a problem?
will going back on low dose aspirin be enough?
and is the bruising and spontaneous nose bleeds any thing I should be concerned about?

yes I know no one here is a doctor, I'm just asking for opinions based on your experiences.
Even doctors vary greatly in their opinions.

Hi Althea,

Next time this happens go for the cardioversion that same day and get back in NSR asap. It sounds like you are past the window now and may have to wait a month on Coumadin before they will convert you.. If you were really at symptomatic 200bpm still, then in my experience you would have been most eager to get back to NSR as soon as possible or at least would have insisted on getting your Heart rate down to a more manageable level the same day ... at least under 150bpm .. though 150 is still pretty uncomfortable.

The thing now is to get your HR down any way possible if it is still so high, especially if you are still at around 200bpm? If so, Im not sure how you have been able to sustain such a high rate for so long?? Nor can I imagine why they let you leave the hospital with no treatment at all if indeed your HR was still at such a high level .. are you still clocking at such a high rate?

Oh I see I just read your second reply above noting that you signed out AMA...

I would check with your Cardio about trying a PIP with large bolus dose of Flecanide or another AAR drug that works PIP at this point in hopes that that might convert you without the ECV (electro-cardioversion).

ECV is easy and there are very little to no real side effects in most cases outside of maybe some mild residual tiredness from the fast AFIB and in some people a bit of after effect from the propofol wearing off. Just take it easy the rest of that day and you will be back doing your normal activities the next morning in the vast majority of cases. I drove myself home 30 miles from my last 4 ECVs within an hour after I got shocked and the fast acting propofol wore off with no problem at all.

Make sure they attach a pad to the front of your chest and directly behind that front pad they should place a second pad on your back and make sure they are firmly attached and stuck on good. Hopefully your ER docs and nurses will know the drill as they well ought too!

Anyway, sorry for your episode now, but 200bpm of symptomatic AFIB is no joke and is certainly nothing to be too cavalier about. In the vast majority of cases with rates so high the person is quite short of breath, head is swimming and often it feels like an elephant is sitting on your chest and so, in my experience at such speeds, you will typically be highly compliant with anything that offers the promise of immediate relief rather than debating for a long while whether to leave or not.

Perhaps in your case when you are going so fast it isn't very strong and symptomatic and so maybe you don't feel it as powerfully?? Nonetheless, any ER team would definitely red flag you as a true emergency immediately and set you up for fast action with any rate above 180bpm, I cant imagine any ER docs that would have you lay around for hours and act like its all up to you whether you wish to stay around a little longer or mosey on home and deal with it on your own?! ....anyway, just saying.

Best of luck on getting this sorted out, but if you are still at a high HR above 150 I would do whatever you need to asap to get that rate lower. at least down to 125bpm or less even if still in AFIB while waiting to get back to NSR which ever way you can.

Take care,
Shannon



Edited 2 time(s). Last edit at 11/13/2012 01:38PM by Shannon.

PS Althea,

the only time you might have any very mild burning is if either the pads are not tightly stuck on in the right places and/or they use a very high joule level to zap you. Ask them to start with 100 joules if you have taken a big dose of magnesium and Potassium pill that they gave you at the hosptial at least 2 hours prior to the ECV. Often that will be enough to convert you IF you have sufficient IC Magnesium and Potassium on board at the moment.

IF that doenst work they can try 150 then 200 and so on. but in the big majority of cases one zap is all it will take and if they do the propofol right which they should, you wont know or feel a single thing. The propofol is pure bliss for about 15 seconds after it hits your IV until the world disappears for 7 to 9 minutes, Then you wake up feeling fine with little to no hangover effects at all in most cases .. assuming they haven't loaded you up with other drugs too, cardiac or otherwise.

And then you should feel clear as a bell in no time and able to leave the ER within an hour or less after the zap though they will usually keep you at least an hour for observation after successful ECV.

Shannon



Edited 2 time(s). Last edit at 11/13/2012 01:40PM by Shannon.

Hi Shannon, I will insert my replies in bolded italics, I hope that will make it easier to read:


Shannon Wrote:
-------------------------------------------------------
> Hi Althea,
>
> Next time this happens go for the cardioversion
> that same day and get back in NSR asap.
I've never had electrocardioversion and was extremely nervous about it. I wanted to go home and read more about it, and frankly, after reading about it, I''m still very nervous about it and would prefer to avoid it if at all possible.
It sounds
> like you are past the window now and may have to
> wait a month on Coumadin before they will convert
> you..
I am hoping to convert on my own- I've never just waited it out, isn't that better than a lot of chemical intervention?

If you were really at symptomatic 200bpm
> still, oh I can assure you I was at 200 and over for a couple of hours.It took 3 infusions to get it down to around 140. then in my experience you would have been
> most eager to get back to NSR as soon as possible
> or at least would have insisted on getting your
> Heart rate down to a more manageable ;level day at
> least under 150bpm .. though 150 is still pretty
> uncomfortable.
I am confused about this as well, since during my last episode I was horribly uncomfortable and wanted it to just stop. This time, I don't know why it didn't bother me as much, for the most part. I was on the bus going home from grocery shopping and even thought about taking my food home first and walking back down the hill to the ER afterward!! and this is with beats over 200! But from time to time, I would get a terrible feeling of pressure and pain in my neck and I thought perhaps I was having a heart attack and not afib at all, so I got off the bus at the ER, and they brought me right into a room without even checking me in- something they have never done before. They rushed around like I was in danger of dying at any moment. I am guessing this is because they didn't know for sure that I was just in afib and not having a heart attack? I don't know.........heart stuff scares me so much I can't think straight. I am still having some pain from time to time but enough for me to go and spend days in hospital.

I left the hospital with spikes around 150 I think, on the monitor, but mostly under that. I have not checked as knowing that my HR is high actually makes it go higher, I have issues with anxiety. I guess I should check it, just to be sure it's not spiking any higher, huh?
>
> The thing now is to get your HR down any way
> possible if it is still so high, especially if you
> are still at around 200bpm? If so, Im not sure how
> you have been able to sustain such a high rate for
> so long?? Nor can I imagine why they let you leave
> the hospital with no treatment at all if indeed
> your HR was still at such a high level .. are you
> still clocking at such a high rate?
OK I just tried to check my HR and I can't. I'm still in afib and I just cant' get it.

but I do feel like most of the time it's not that high. I can't say for sure because I felt like it had gone down at the hospital, and they had to show me the monitor where it was still running around180-200.

I told them a couple of times that I thought I had converted, because I couldn't feel any palpitations at all, and they laughed and said no.
Maybe it's got something to do with the steroids I'm on?? I have no idea!

Oh, they did treat me: with 3 infusions of lopresser, O2 and er, I don't know if they gave me any thing else- Oh, and potassium when the blood work came back that it was very low.
And they sent me home with potassium pills and some more of the lopresser/metoprolol. The cardiologist thought I should be on that all the time instead of the verapamil that I take for hypertension. I don't know, they all disagree about what the treatment should be, so how am I to decide??
>
> Oh I see I just read your second reply above
> noting that you signed out AMA...
>
> I would check with your Cardio about trying a PIP
> with large bolus dose of Flecanide or another AAR
> drug that works PIP at this point in hopes that
> that might convert you without the ECV
> (electro-cardioversion).
I'm sorry, what is PIP? oh you mean pill in a pocket? not one of the 5 or 6 cardiologists that I've seen have known what that is.
About those AAR drugs, do you have to be in the hospital to be on them? I want to avoid that.
>
> ECV is easy and there are very to no real little
> side effects in most cases outside of maybe some
> mild residual tiredness from the fast AFIB and in
> some people a bit of after effect from the
> propofol wearing off. Just take it easy the rest
> of that day and you will be back doing your normal
> activities the next morning in the vast majority
> of cases. I drove myself home 30 miles from my
> last 4 ECVs within an hour after I got shocked and
> the fast acting propofol wore off with no problem
> at all.
>
> Make sure they attach a pad to the front of your
> chest and directly behind that front pad they
> should place a second pad on your back and make
> sure they are firmly attached and stuck on good.
> Hopefully your ER docs and nurses will know the
> drill as they well ought too!
>
> Anyway, sorry for your episode now, but 200bpm of
> symptomatic AFIB is no joke and is certainly
> nothing to be too cavalier about. Oh I agree. My very first episode happened when I was in the hospital after being hit by a car at the age of 18. Hit and run, no less.
I had a fractured tibia and fibula and shattered pelvis.
I had a pulmonary embolism. Talk about scary! I couldn't breathe without extreme pain and had no clue what was happening. They did a pulmonary angiogram, another scary thing for a teenager all alone- and my heart reacted. The pounding felt like my heart was going to explode, the room was swimming, the pressure and pain in my ears was unbearable, I truly thought I was going to die. I do not know what they did to slow it down, but it was some sort of injection that made my whole body jerk. It was horrible!

Afterward, they told me that my HR broke a hospital record- and the person who held that record before me had died. I have never forgotten that, and I think my heart rate goes up faster just from the fear of that possibility.
I was in such shock that I didn't catch what they said my top HR was, except that it was of course over 200. I am glad now that I don't know, because if I ever saw mine get close to that again and knew it, I'd probably faint dead away.
In the vast
> majority of cases with rates so high the person is
> quite short of breath, head is swimming and often
> it feels like an elephant is sitting on your
> chest and so in my experience you will typically
> be highly compliant with anything that offers the
> promise of immediate relief rather than debating
> for a long while whether to leave or not.
>
> Perhaps in your case when you are going so fast
> it isn't very strong and symptomatic and so maybe
> you don't feel it as powerfully?? Nonetheless, any
> ER team would definitely red flag you as a true
> emergency immediately
Yeh I was red flagged for sure, taken into trauma as the cardiac room was in use- they were rushing around like I was having a heart attack, which apparently can actually cause afib?? and set you up for fast
> action with any rate above 180bpm, I cant imagine
> any ER docs that would have you lay around for
> hours and act like its all up to you whether you
> wish to stay around a little longer or mosey on
> home and deal with it on your own?! ....anyway,
> just saying.
>
> Best of luck on getting this sorted out, but if
> you are still at a high HR above 150 I would do
> whatever you need to asap to get that rate lower.
> at least down to 125bpm or less even if still in
> AFIB.
>
> Take care,
> Shannon

thanks! I will try to get my HR so I'll have some good info for the doc when I call on Monday. If my rate feels like it's shot up again, I will go back to the ER for more meds but I really don't want to be there.

Hi Althea,

Thanks for the added details, that makes more sense. It sounds like possible high speed flutter or Supraventricular tachycardia runs ... 180 bpm to 220bpm is classic Flutter territory, perhaps in your case mixed with AFIB? When its going that fast its not always easy for ER docs to get the exact diagnosis right. And yes they will always move you to the head of the line when your HR is that fast.

I understand your anxiety, but perhaps you can get some Ativan or some such med to take too at least when such episodes happen to help calm you down a bit and help you make clearer decisions at such a time? That can help keep the rate slower as well sometimes.

I would really get this checked out by a good EP electrophysiologist and not depend on only regular cardios. You need a solid diagnosis and a better treatment plan including the possibility of ablation if you cant get this under control with more natural means once you know what you are dealing with.

How long does it take you to convert on your own normally? How long has you longest episode been?? Also, font bother trying to count your heart rate with you finger when it is that high about 150bpm! Taht is pretty much hopeless to get an accurate count. You would need a Polar watch or a portable mini-ECG to get it down more accurately.

Anyway, try not to fear a cardioversion, be brave, you will do fine with it next time. If you can convert on your own in a short while reliably that is fine. But staying in high speed FLutter/AFIb for days is not a good idea, even if it isnt terribly symptomatic! The type of pain and pressure in your neck (also can be in your chest) that you describe is very common when you are getting 1 to 1 or 1 to 2 Flutter, by the way.
How old are you know if I might ask, when your first episode was at 18 after that bad accident?
Wishing you the best! Just don't put this off and get a definitely diagnosis from a good EP! Ask for your latest hosptial ECG copies to show the EP.

Shannon

PS yes PIP is 'pill in the pocket' .. that none of your docs has heard of it is all the more reason you need a reliable EP ASAP.

replies inserted

Shannon Wrote:
-------------------------------------------------------
> Hi Althea,
>
> Thanks for the added details, that makes more
> sense. It sounds like possible high speed flutter
> or Supraventricular tachycardia runs ... 180 bpm
> to 220bpm is classic Flutter territory, perhaps in
> your case mixed with AFIB? When its going that
> fast its not always easy for ER docs to get the
> exact diagnosis right. And yes they will always
> move you to the head of the line when your HR is
> that fast.
I'm not sure I understand what you are saying...? my diagnosis IS afib with a rapid ventricular response, at least that's what my medical records say LOL
>
> I understand your anxiety, but perhaps you can get
> some Ativan or some such med to take too at least
> when such episodes happen to help calm you down a
> bit and help you make clearer decisions at such a
> time? That can help keep the rate slower as well
> sometimes.
I have other medical conditions and can't add more meds at this time
>
> I would really get this checked out by a good EP
> electrophysiologist and not depend on only regular
> cardios. You need a solid diagnosis and a better
> treatment plan including the possibility of
> ablation if you cant get this under control with
> more natural means once you know what you are
> dealing with.
I can ask for one I guess but I am not sure my insurance will cover it. This is my cardiologist: [www.catholicmedicalcenter.org]

This is the cardio doc I saw in the ER: [www.catholicmedicalcenter.org]

I go to CMC's Heart Institute, it's supposed to be one of the best in the area? but it wouldn't matter if it wasn't, I have no other options due to insurance, transportation difficulties and disability, etc
>
> How long does it take you to convert on your own
> normally? How long has you longest episode been??
> Also, font bother trying to count your heart rate
> with you finger when it is that high about 150bpm!
> Taht is pretty much hopeless to get an accurate
> count. You would need a Polar watch or a portable
> mini-ECG to get it down more accurately.


This is only my 4th confirmed episode. with each one it has taken longer to convert and I have not converted on my own, however I have reason to believe that I've had un- confirmed episodes that were mild that did convert on their own. My second episode was in 2002 I believe, the 3rd in 2008 and then this one.
I converted in about 8? hrs in the ER in 2002, I spent 3 or 4 days in the cardiac ward in 2008
>
> Anyway, try not to fear a cardioversion, be brave,
> you will do fine with it next time. If you can
> convert on your own in a short while reliably that
> is fine. But staying in high speed FLutter/AFIb
> for days is not a good idea, even if it isnt
> terribly symptomatic! The type of pain and
> pressure in your neck (also can be in your chest)
> that you describe is very common when you are
> getting 1 to 1 or 1 to 2 Flutter, by the way.
> How old are you know if I might ask, when your
> first episode was at 18 after that bad
> accident?
I am now 56, will be 57 in Feb
> Wishing you the best! Just don't put this off and
> get a definitely diagnosis from a good EP! Ask
> for your latest hosptial ECG copies to show the
> EP.
>
> Shannon
>
> PS yes PIP is 'pill in the pocket' .. that none of
> your docs has heard of it is all the more reason
> you need a reliable EP ASAP.

I am going to have a friend print out the links to the afib report etc to bring with me next time I see my cardiologist and see what he says.


In the meantime I am totally confused about what to do!! the discharge instructions are contradictory, when I called the hospital and the on call cardiologist I was told it ws too late to do anything as far as the electro cardioversion but no one has said what I do instead.
Shouldn't I be on an anticoagulant now? is taking aspirin going to help at all? is the bleeding I was having a sign of something more serious?

To update, I am still in afib, but I have no clue what my HR is. I won't be able to find out til I can get an appt with someone.
Is there something I should be doing at home to help? I take the beta blocker they gave me and the potassium and trying to stay hydrated, what else can I do?

There was a white paper written on the correct way to undergo electrocardioversion and there is a reference to it on here somewhere. My first ECV was done by a doctor who had no clue as to what he was doing. It was not successful.

What I can recall........
Your INR should be in a therapeutic range.
You should be on an antiarrhythmia med of some kind.
You should be pumped up with Magnesium IV beforehand.
You should have your Potassium in therapeutic range beforehand (i.e. 4.5 ish)
You should have your back and chest SHAVED (if you are a guy or a hairy gal)
They should use conductive PADS and not paddles.
The jolt should be done at 300+ joules the very first shot. And it should be done using state of the art equipment where the MD only tells the machine when to look for its opportunity to shock your heart.... the machine chooses the exact moment based on the ECG that is running.
There are a perhaps a few other protocols that should be followed but this gives you the general idea.... and results in a significantly higher success rate in ECV than otherwise possible. Find the white paper or my post on my ECV. They said they were going to give me something to relax me and the next thing I remember is me in a room with a nurse unhooking and putting things away and telling me all went well. And it did as I have apparently been in NSR on TIKOSYN since Dec 2011.

Not all ECV's are the same. It is once again a matter of finding a cardiologist/EP that knows what the heck they are doing. My first did not. My second certainly does and I thank God every day that I found him and was referred to him successfully.

Good luck to you.

Murray L

--------------------------------------------------------------------------
Tikosyn uptake Dec 2011 500ug b.i.d. NSR since!
Herein lies opinion, not professional advice, which all are well advised to seek.

thanks for that info Murray L
hopefully I'll never need it, but it's surely good to have. I'll have a friend print it out for me.

I am so glad I refused the cardioversion on Friday, my potassium was only 3.
I don't know how long it takes to get it back up in a normal range but they were talking about converting me before they even got the blood work results back!


I converted back to NSR around 9pm tonight basically on my own (with the beta blocker, that is)
woohoo! so happy and relieved

Murray,

Here is the reference: [www.afibbers.org]

Hans

Hi Althea,

I agree with the list of recommendations that Murray and Hans reference, the only acception being starting at such a high joule rate as 300 joules. No doubt that is likely to do the job with one shot, BUT if you first insist on getting your magnesium up with a Magnesium sulfate IV and sufficient potassium in whhich they will give you Potassium Chloride time released pill of 20MilliEquivalent dose, then you should jsut as easily conver with 150 jourles or possible even less on the first zap and then if you need another zap they can immeidately dial it up to a higher joule level.

With sufficient magnesium and potassium on board studies show the ability to reliably convert to NSR with significantly less shock energy > MY hunch is that the studies showing greater first zap conversion rates into NSR were done mostly with a study group of patients who had not have confirmed IV magnesium infusion and potassium repletion prior to ECV.


Also having taken an AAR drug like Flec or Sotalol prior to the ECV can also help insure success.

What you should do now, if you are still in arrhythmia, is to get on Coumadin for a month with your cardio's help and then get the ECV as soon as he will do it. You could also ask for a trans-esophageal echo-cardiogram (TEE) as soon as possible which is what I would really demand in order to rule out any possible clot formation within the left atrial appendage and left atrium, in which case, they could go ahead and do the ECV immediately after the TEE results are known.

That way you don't have to wait so long before getting the cardioversion since during all of this time you are in AFIB/Flutter your heart tissue is continuing to remodel to accept AFIB as your normal rhythm making it easier and easier to get triggered into AFIB and harder and harder to convert back to NSR until eventually you go into 24/7 persistent AFIB which is sounds like you are starting to move toward with the longer times each episode before you can convert and if I understand you correctly you are still in AFIB now for almost a week??

Your two Cardio's at CMC both may be decent general cardiologists though both seem quite young judging by their photos, but regardless how good they are in thier area of cardiology you definitely need a good electro-physiologist PERIOD!! Don't settle for an interventional cardiologist (stent squishers) for your condition ... if you had cardiovascular disease then by all means use them ... but they will not be as up to speed on your issue as a true specialist in arrhythmia which is what an EP is. Insist on the best EP they can refer you too in your region, if your situation doesn't allow you the flexibility and freedom to go anywhere in the US to connect with the very best EP available.

Shannon