Magnesium, flecainide, progression, regression and titration

A brief history - My first afib episode was about 8 1/2 years ago. Initially they occurred every 10-14 days, lasting 6-9 hours and self-terminating or with exercise. They were clearly vagal, coming on around 3 AM. After 2 months, I had an episode that would not terminate. It ultimately lasted 2 1/2 months and was terminated with 300 mg of flecainide. I had an EP who suggested I remain out of rhythm as my afib rate was around 80. I suggested a "plan B" of potassium, magnesium and taurine to keep myself in NSR and PIP (on-demand) flecainide (300 mg) when the minerals failed. The first two PIP doses required about 20 hours to convert me, but after that the flec. generally worked in about an hour.

The "plan B" worked very well for over 7 years. I used around 10 PIP flec doses during this time. The last 8 months or so have been less successful. My wife wanted to separate and ultimately divorce. I attribute the increased afib to the large amount of stress associated with the divorce. That being said, my divorce has been amicable and the stress diminished dramatically in the last 4 months. I am now in a new relationship and my relationship stress is non-existent. Even so the frequency of afib continued to increase, though the PIP flec still worked, however it now took as long as 4 hours. In early November, it had gotten bad enough that afib was every other day, again terminated with PIP flec. The week of the 11th it progressed to every day.

Around 11 days ago, I tried 100 mg of flec as a preventative. This did not work and I still needed 300 mg to convert. I decided to take action and employed a concierge cardiologist to support a trial of propantheline bromide (P as a vagolytic. My request was completely out of his experience, but I provided several papers supporting my request and after a discussion, he agreed to take me as a patient and support my use of PB.

As it turns out, PB is not used very much and there was 1 box of 100 pills in my state, at a drug distributor. I was leaving town with my girlfriend for a week, so arranged for the PB to be delivered to a pharmacy at my holiday destination, which would take 3 days (the cardio was instrumental in calling around and making this happen!).

In the mean time, I decided to try 300 mg flec at bedtime (I am very vagal) prophylactically. This worked. In prior years, it has been discussed here that the vagal aftermath of orgasm can be a trigger. Until very recently it was not a trigger for me, but if my heart was a little "off" I would certainly feel ectopics during this time. The flec at bedtime worked well enough that my heart felt very solid 8-9 hours later, after orgasm.

The next night before bed, I titrated down to 200 mg flec. This worked also, and again my heart felt solid after orgasm 8-9 hours after taking the flec. Over the next nine days, I continued to titrate down and am now at 125 mg with the same results.

I plan to continue the downward titration before I start the PB. Of course I may be able to titrate down to 0 mg, in which case I will hold off on the PB for another day.

My interpretation of this experiment is that once I got the afib pattern stopped, the NSR seems to want to continue. Note that before I got the pattern stopped, 100 mg did not work, nor was 300 mg as PIP every night work to prevent the afib the next night.

Several items of note. I always chew my flec pills, either when used as PIP or before bed to increase the speed of absorption. Also, before starting the flec preventatively, I did increase my intake of potassium - from 1 to 2 grams/day and my intake of taurine from 4 to 8 grams/day. I've continued this, and it did not make a difference before starting the preventative flec. My magnesium intake has remained constant at about 2.6 grams/day of elemental mag as dimagnesium malate. This is near bowel tolerance for me.

George

HI George - Sorry to hear about your difficulties. I suspected there was a problem because you mentioned you were going to try PB in a prior post. About a month ago I ended my longest run of NSR in several years because of stress. A creep was observed taking photos from his car of children in my daughters neighborhood. My grandaughter was one of his targets. The night I found out about this i went into AF even though I was cruising along in NSR and feeling good. Stress might be the most significant trigger for AF for me. Some time ago I had some interest in PB but didn't pursue it because I read that there was some unhealthy interaction between K+ and PB. Since I relied heavily on K+ I didn't want to take the risk. Are you familiar with this interaction or did I just misread the precautions? Best of luck to you. Dennis

Dennis,

I could not find anything. My one concern, especially with KCl, is that the lack of stomach motility could cause stomach irritation. However, the half life of the med is fairly short - in standard (not afib) usage - I believe it is suggested that it be taken 4x/day. So I'd tend to time taking KCl away from taking the PB.

PB actually has more side effects than flec, (other than little things like VT - Torsade de Pointes), so I'd prefer the flec actually. My main concern is that I had nothing in reserve on the flec. That is the way things were going, I could not use the flec as a PIP loading dose because I was using a high dose daily. As it is, at 125 mg flec, I comfortable I can still use PIP flec if needed. As I am able to titrate down further, this improves this situation even further and the less inclined I am to use the PB.

By the way, I was trying to put "PB" in parenthesis above and the software turned the B and closing parenthesis into a happy face...

That my heart has been so stable in the aftermath of orgasm encourages me that I will be able to titrate to a much lower dose.

Stress certainly is an issue.

Thank you for your comments!

George

George,

Sorry to hear about your travails. Before I decided to go the ablation route, I could end daily or every other day episodes of afib by increasing my Flec intake. At one point I was at 250 mgs a day and then I titrated down to as low as a 75/100 daily. At this level, I still had episodes, and thus, I was never able to eliminate the Flec completely. One thing that I also did when I increased the Flec was to start the IM mag shots. This really helped and also shortened my episodes. I agree with you, there does seem to be a pattern towards an either greater or less frequency of episodes, and in my case the Flecainide was the only thing that broke that pattern.

The only cautionary word I have is from my discussion with Pierre Jais who when I first visited him in Bordeaux said don't let it go too far. He was the only one who said to me, you are a persistent case, so if it starts to get worse, schedule an appointment.

You have always done such a good job of controlling "the beast,(an inspiration for all of us)" I really hope that you can do it again.

Good luck with everything---I head overseas tomorrow for the "touch-up." Hopefully ablation two will end the saga.

Steve

Steve,

I appreciate your caution. If I'd not turned this around quickly, my first call was going to be to the boys (and girl) in Bordeaux. We'll see now. I'm always the optimist that I can keep this in the box, but am very aware that I don't want anymore remodeling.

Thanks!

George

My successful downward titration continues. I'm at 100 mg pre-bed now.

George – a couple of thoughts ....

On the PIP protocols, current recommendations are to use 300 mg flecainide all at once after using something to
lower the heart rate-- BB or CCB.

1. Are you monitoring your tissue pH? You’ve undoubtedly followed the posts on low pH equating to low voltage.
If you are consistently low in voltage, the tendency to slip into arrhythmia becomes easier…just as low IC potassium levels (and therefore low voltage) cause a shortening of the refractory period which sets the stage for arrhythmia. Speaking of potassium, are you optimizing intake or monitoring?

2. Heart Rate Variability (HRV) is another highly probable consideration. Since you are undoubtedly highly vagal, iand it’s not uncommon for very physically fit people to be far right from the median measurement assessment of the ANS function, it would be logical that a post-orgasm influence could put you too far into parasympathetic mode because the ANS response to orgasm is very vagal. Those with overactive sympathetic tone are often highly stressed individuals who also have various forms of sexual dysfunction. Just as the fight-or-flight tone produces one response, the vagal equivalent is feed or breed. (Consider that when fleeing from the saber tooth tiger, one doesn’t stop to enjoy a meal or sex.)

When I began my restorative energy treatments about 18 months ago, one segment of the ANS profile assessments includes HRV testing. The comment on that segment of the evaluation results says:

“The Heart Rate Variability exam helps the doctor to determine your overall ability to adapt to the environment. It does this by looking at the timing of your pulse and determining the balance and tone of your nervous system. Proper balance and tone are associated with better adaptability and a healthy life style. Low heart rate variability is associated with aging and poor heart health. Published research has shown that specialized chiropractic adjustments (spinal alignment) have a beneficial effect on HRV.”

My initial HRV was 92.5 which is in the Excellent (90-100) range and a subsequent evaluation six months later improved to 95.52. I’m due for another total evaluation and expect even more improvement.

The chiropractic physician treats me with a highly specialized (hybridized) version of Subluxation techniques to balance the ANS which is different from the typical HRV discussions found at Heart Math and similar. She collaborates with several Colorado associates and instructs at the workshops held in Colorado Springs. Practitioners of this highly-specialized treatment technique are not abundant across the US. If you are interested in learning of a contact, I can get info for you. Even very physically fit people can have imbalances that can be corrected.

Here’s a quote from an early Conference Room session by PC..:

HEART RATE VARIABILITY (HRV)
Finally, heart rate variability (HRV) is a measure of the small variation in heart rate from beat to beat. It is a
direct measure of autonomic tone and decreases with age. Elevated HRV implies greater vagal tone and has
always been an independent prognosticator of longevity(108). Greater vagal tone translates to longer life, all
else being equal. Perhaps the “defective substrate” of VMAF is nothing more than the combination of many
years of poor diet, skipped meals and poor hydration along with excessive exercise in individuals already
possessing a slow heart rate. But it’s never too late to change. Increased dietary Mg and regular moderate
exercise with plenty of hydration will increase ANP(38,53), the antialdosterone hormone. This will help flush out
excess Na and oppose the deleterious effects of RAAS. It will enable glucagon to help moderate glucose levels
and it will promote proper balance within the ANS. All this should help keep LAF at bay. Besides that you’ll
sleep better (more serotonin and melatonin) as well, because Mg is required for the synthesis of both(94).
(Source: CR Session #14 by Patrick Chambers, MD)

Jackie

Hi Jackie,

Thank you for your comments.

I am aware of the PIP protocol using BB's, but after 8 years of doing without and having it be very effective, I'm reluctant to change. My own protocol has always been to chew up the 300 mg of flec just as soon as I know I'm in afib. The only downside is the taste is less than stellar...

The pH may be an issue. Things did get worse in August when I started traveling a lot. At that point, I switched from a combination of Mg including WW (mag bicarb), MgCl2 water, Mg Glycinate and dimag malate to just the malate as it makes traveling a lot easier as well as the bowel tolerance titration exercise. I may try subbing WW (Waller Water) for a portion as it is so basic. Good point! Even though I was the one who originally found & posted on the Cardymeter potassium testing idea, I've never purchased one. It would be a good idea. I don't take in a lot of sodium as most of my food is prepared from scratch. I do add a little Celtic Sea Salt as I know that those who are ketogenic (me) tend to excrete more sodium. I do have a significant K supplement intake.

My HRV has always been high. Since I'm taking flec on an ongoing basis right now, it will change those results. Flec is vagolytic and about 25% of its efficacy is due to this vagolytic effect. [www.ncbi.nlm.nih.gov]

I know the ANS is a huge contributor now. Sometimes I can drop my heart rate to 40 BPM by drinking something very cold. I try not to be stupid and do this and then get prone in bed. As I noted, right now the vagal effect after orgasm is not an issue, but was before my recent switch to using flec before bed.

I'm not familiar with the HRV range or data you are quoting. Most of the data I've reviewed come from fourier transforms of the data and the units are in ms2 (milliseconds squared) or a ratio of Low Frequency to High Frequency data. I'm guessing it is specific to some machine your chiro uses.

I may try the HRV adjustments at some point, if I get off the flec and can have unadulterated data. Even though I remain very fit, I did stop competing in and training for endurance activities years ago. I am very aware that I can easily push the ANS to far in the vagal direction with too much exercise. As I write this my heart rate is about 60 BPM, which may still be under some influence of last night's bedtime flec. In any case it is not scraping bottom.

I will add WW back into my mix and make arrangements to make it on my travels.

I will purchase a Cardy meter and see what it tells me.

I am very encouraged I've been able to titrate down as low as I have and may be able to go even lower. It does buy time to play around with these other ideas.

Thanks again!!

George

George and Jackie,

You may be interested in my report on heart rate variability and atrial fibrillation. You can find it here: [www.afibbers.org].

Hans

(I am aware of the PIP protocol using BB's, but after 8 years of doing without and having it be very effective, I'm reluctant to change.)

George dont hesitate to take bb before flec. It did a big difference to me .some times I can abort afib with bb alone ,I take concors 5mg as soon as i get the first ectopics and wait , if there is no improvement i take fleck 100 mg which converts me in about 4 hours or less. That helped me use less fleck and keeps its effectiveness.

Ben

Ben,

Thanks! I asked for and got some metoprolol tartrate to have on hand for the day the flec did not convert, if I needed rate control. I've never needed it. I may try some the next time I have afib. I'm not that patient that I like to wait 4 hours to convert. I'd rather use the large loading dose which has usually worked in an hour and minimize the remodeling.

My understanding is that flec dose not lose its effectiveness, that the lack of effectiveness is due to disease progression from remodeling. It is this progression I'm attempting to stop.

So far so good.

George

George - good that you'll be trying the BB. While you didn't need it initially, I was originally told years ago that to have an effective chemical conversion, most people needed to slow the HR first with the BB prior to the antiarrhythmic. As for the flecainide not having a shelf-life...I was recently told that is not correct....it does lose potency. ??

Consider the fibrosis connection to afib progression. Have you had an Exatest evaluation lately? If not, it would be very important to know all your electrolyte levels and the ratios.

Jackie

As to shelf life. It does have a shelf life. I tried some of the flec from 8 years ago recently and it didn't work. That being said, as my primary guy told me one time, it doesn't just fall off the cliff. The 8 year old stuff is all I had for a long time, and it worked for probably 6 years anyway. More recently, shelf life isn't an issue as I've been going through it too fast. The original 60 pill bottle still had a lot of pills in it. I think I got a new batch in 2011 and then again this year.

I've not done an Exatest for 8 years as I'm pretty sure on the the mag it would show as deficient. I already know this & keep pouring the mag in. I did casually mention to my new cardio about injections, but he wasn't wild about it because of the effect on the kidneys, as I recall. I'm guessing he meant them having to process so much. It is something we can address at another time.

Fortunately the flec continues to work preventatively.

Thanks Jackie!

George

George - remember my history... 8 years of progressivly worsening afib until I had it daily or every other day often 24 hours and longer...while using 300 mg flec daily. As a last resort, I signed up for ablation and then had 6 months to do heroics to reverse the afib trend...which I did in the final couple of months... went from daily afib to zero for two months until ablation time...so the idea that you can't reverse or afib gets progressively worse with time it may not be true in all cases. It also did not increase my risk of not having a successful ablation.

There could be some elements you are missing besides the magnesium optimizing. In my case, I'm sure it was both the Mg and K optimizing but likely also some of the other influences including pH monitoring, quite a bit of taurine and CoQ10 and high dose Omega 3's to improve the lipid layer of the cell envelope... along with reversing the leaky gut syndrome and improving intestinal lumen health. Lots to consider and what makes it so complicated is that it's highly individualized so testing from the functional medicine side of treatment was also very useful. Most tests that I had were not available through my primary care.

I certainly hope you can get back to your previous state of a calm heart.
Regards,
Jackie