discerning vagal/adren LAF

thanks in advance to all of you who have come before. i'm so grateful to have found so much collected wisdom/research/experience
i think my husband hit a perfect storm leading to first episode of (i think) LAF. FLUTTER to be specific.

my top question is how to discern which pathway (vagal/adren) to explore first, and what tests/records i should insist on for "baseline" just in case we are in the 50% that recurr

he is a 52 yo male 6'8" 200lbs or less for past 20 years
passionate endurance athlete
in 20s BP 140/90 but has been great for 20 years thru exercise and stress management
in 20s complained that chest press didn't feel good on heart (stimuli?)
mild MVP
early 40s two episode of regurgitation - anoxic blood circulated

4 weeks ago bruised upper left ribs
fell direct on speed bump clipped in to bike at 3mph
no exercise for 2 weeks (a stressor? correlated to vagal afib?)
-3 weeks ago complains of upper left muscle ache near ribs (Heart?) beyond rib pain
2 weeks ago begins cycling intervals
1 week ago 60 mile hilly ride at full speed
7 days ago to Japan on biz
2 days ago returns from Japan 10AM (coach - impossible for tall guy)
swims 1 mile in the rain at noon, comes home - looks shaky
eats steak dinner w/ wine
11PM complains heart is racing (2x normal) and beating synchopated
due to history of electrolyte imbalance and flying being a dehydrator...
and his electrolytes being more off on cold days (no perceived heat = no drink)
i give him...hydration mix of
16g sugar, 320MG sodium, 100 mg K, 30% DV Vit C; 8% DV calcium 4% DV Magnesisum, 16% Niacin,40% B6 & B12

he goes to ER diagnosed w/ Flutter,
?by then blood chemistry is normal.
7 different drugs (rhythm and depressants) fail to work so ECV and now normal

what i'm wondering is -
was this a perfect storm? (dehydration/stress/inflammation from fall/lifetime endurance sport)

shouldn't we insist on an echo to get a baseline on his heart er shape?
(we have great insurance)
what else do i need to learn?

how does he go back to exercising?
cardiologist just said, take a week off, ease back in
not knowing that 75-100 miles on weekend bike ride is normal
and when he rides he's out of cell range

we already eat a mostly mediterranean diet
we do eat beef but grass fed
he has stopped caffeine in coffee
and is at one glass wine per night
cardiologist said to stay away from electrolyte supp
but i am pretty sure he doesnt realize how key they are for endurance athletes.
or maybe he thought we were yahooing on 5 hour energy sigh

You really can't tell whether vagal or adrenergic without a pattern of episodes. No ECG's or scans will help here.

Given his endurance activity, my vote would be for vagal, but one never knows.

Best advice, which will be very difficult for him is to detrain (chronic fitness brought me to this dance...)

Most cardios don't have a clue about electrolytes.

Wine may not be a trigger, but can be for many and does deplete the Mg (any alcohol).

I personally now look at any endurance activity as having a cost to me. I now have a very limited (figurative) budget for this kind of activity and never train for or compete. I do supplement heavily with magnesium, potassium and taurine. I perform moderate bodyweight exercises to maintain muscle strength and fitness (TRX Military Fitness). A very low carb, moderate protein, high fat diet has has modified my RQ (respiratory quotient - CO2/O2 ratio) during exercise. Because of this I need less oxygen to perform the same level of output and do not need to train to then go out and ski or rock climb with my friends. It took me several years to have it soak in that being chronically fit at my prior level was not a good way to address afib. Being male, my frontal lobe is of limited size...

If he's only had one episode, then I'd pull out all the stops (detraining, electrolyte supps, getting off wine) for a while and make sure it doesn't happen again. Then gingerly start adding activity, but activity at his normal level is most likely not going to be helpful. Endurance activity is shown to promote inflammation. Since these illnesses are progressive, it is best to stop them early.

Best of luck!

George

thank you George! i'm trying to "pull out all the stops" he's got a pretty big frontal lobe but he is a guy...after he injured himself he rode 100 miles w/ 10,000 feet of vertical.
and even as we were packing him off to ER he started muttering, they are going to ask me to stop exercising.

do you suggest formal detraining? vs. inactivity?
i think i saw on the forum that inactivity for the highly trained is actually a stressor/provoker of episodes.

we just got his bloodwork and they didn't look at CRP so hard to suss inflammation - mildly elevated eosinophil.

cite on specific reco's that worked for this guy....fwiw
no working out 3 weeks.
2, 3 mile runs after that.
symptom resolution.
[pmj.bmj.com]

The unfortunate thing is it is hard to say. I've got more info on afib than flutter as I've never had it. It is fairly common here for afibbers to get their afib ablated and then have flutter and have to go back for a flutter ablation. This can be done in one procedure if you have both. Some have both and a doc will tell them to ablate the flutter (far easier) and see if it fixes the afib. That almost never works.

What is a trigger for one, may not be for another.

Some of these may be useful, if you've not looked at them: <[www.afibbers.org]
Specifically this: <[www.afibbers.org]

How much should you back off? Who knows? The guy in your linked article did not appear to have afib or aflutter, just ectopics. That is a bit of a different situation. The late french cardiologist, Dr. Coumel (who first posited vagal and adrenergic triggers), was big on detraining and made an analogy that a high performance sports car had a lot more issues than one driven "normally."

Your hubby may want to look at the "Body by Science" approach. Essentially the idea is to engage all types of muscle fibers (slow->> super fast twitch). You lift weights very slowly and continuously to failure, with failure occurring in a minute or two for each exercise. You limit your exercises to 5 different muscle groups and only perform this once a week. It may sound very unusual, but the science behind it is good. It is also at the same time, very difficult but not really stressful on the body. <[www.amazon.com] If you do this correctly, you should be still able to perform well in recreational activities.

If he's doing it for heart health reasons, he may want to read through a lot of Dr. Attia's blog posts here: <[eatingacademy.com] Basically there are other ways to address atherosclerosis than endurance exercise.

George



Edited 1 time(s). Last edit at 09/24/2013 11:57PM by GeorgeN.

thank you George. will check it out.

i had read the exercise page -but i guess i'm going to have to get used to reading things multiple times - as i come up to speed.

"At least one member of our afib group has found that forgoing exercise one week out of every four significantly reduced his frequency of episodes. Of course, abruptly ceasing all exercise may carry with it a whole new set of problems, so a gradual approach is definitely in order. This might be worth experimenting with if you are a vagal afibber."

So again - i wonder if going cold turkey on exercise for several weeks after the upper left rib injury (?heart bruise) and resulting dehydration from travel led to this episode.
After listening to all the research he has agreed to forgo his two scheduled 100 mile rides this month.

Feels a little like those stages of grief: Denial/Anger/Bargaining/Depression/Acceptance
so we are in bargaining: well what if i ride 50 miles instead of 75 and at a lower intensity.
But then (armed w/ the text) i read him the quote that multiple ablations is the norm for competitive athletes - certainly got his attention.

we live near a big openspace - and there are a couple of guys that routinely hike for miles there
i will look at the Mg supplementation next - the MoM water looks doable.
with gratitude
P

Welcome, wife (and husband)... and I do hope he will do some reading here as well.

A couple of points that may be useful information.

Conference Room Session 57 discussed the tendency for athletes to have enlarged hearts bringing about a complication called "entrapment"...which may be interesting reading for you both. [www.afibbers.org]

Also keep in mind that endurance athletes are at much higher risk as they generate much more oxidative stress which results in damage and fibrosis in heart cells which leads to the interference of the electrical conduction signals and pathways. See Conference Room Sessions 24 and 75
[www.afibbers.org]
[www.afibbers.org]

Magnesium deficiency also promotes formation of cardiac fibrosis.

There are many observations resulting from studies of endurance athletes and the long-term consequences on heart function. Classically, the argument is for the health benefits of running or in this case biking...along the lines that ...."in various, more primitave cultures and even Paleo man. they did a lot of running" .. But then, retort is that quite often the life span of these people was about half what we expect today. Yet, that's not always the case as reported in this excellent review of the endurance athlete Sy Mah... who did live longer but injured his heart in the process.

Extraordinary unremitting endurance exercise and permanent injury to normal heart
340: SEPT 19, 1992, pp. 712-714
by WILLIAM J. ROWE, MD
[www.femsinspace.com]

Certainly, nutritional supplementation can help assist with functionality since magnesium deficiency is found to promote cardiac fibrosis - even in non-athletes so at the very least, he should have the Exatest to know for sure what his Intracellular Electrolyte status is officially. The serum draws only tell a snapshot in time and the serum magnesium is not reflective of magnesium in heart cells. www.exatest.com. Once he learns the true electrolyte status, it should serve as a very useful guide for repleting if necessary and helping to stabilize his heart.

Highly trained athletes are typically on the vagal or parasympathetic side of Autonomic Nervous System function.

I realize you are on overload with reading, but if nothing else, learn about the Exatest and have him read Dr. Rowe's report on endurance exercise and heart injury.

Jackie

thank you Jackie. i am hooking him up w/ some reading. he's just less comfortable putting himself out there.
i do note that we are in an odd period of lower exercise than usual - given his prior rib injury.
...so that it's hard to believe any of this is "representative" ... but i like being able to get a test done w/out having to convince a doctor to order it!
thanks for the pointer

in case - you don't already know about this. fun site where you can sort bottled water by different mineral content
[www.mineralwaters.org]

P-

"Feels a little like those stages of grief: Denial/Anger/Bargaining/Depression/Acceptance so we are in bargaining: well what if i ride 50 miles instead of 75 and at a lower intensity. "

I know this well. As I mentioned, it took me two years to figure out I should not compete in high altitude endurance races.

Most of us do these activities because we enjoy them and have programed ourselves to believe we are helping ourselves and are, in fact, healthier because of it. Learning that all of this may not be true is a shock!

At the very least, endurance activities don't help with arrhythmias. In the extreme, they probably don't help with atherosclerosis, as described by Jackie's linked article of Dr. Rowe.

The operative question is "how much is too much." This is something we each have to figure out for ourselves. I'm sure mag depletion was a huge contributory factor in my case. As a result, I supplement now with mag to bowel tolerance. For me this varies between 2-3grams of elemental mag/day, a huge amount.

I personally have worked out a supplement and exercise program that keeps me in NSR and still allows quite a bit of activity. Most normal people think I'm a bit excessive on the exercise, but compared to friends who do much more than I do (or my past), I've moderated a lot. With the exception of a year with large personal stress where I also added in too much calcium from diet, I've managed to keep this beast from progressing for 9 years.

What you don't want to do is push this thing to the point of no return, except for an ablation, if you can help it. The meds don't have a wonderful track record. We are all different and our disease has different paths. It is hard to predict what is too much.

Cheers,

George

Hi wife of....
Welcome, and good luck.

I also come from a very typical profile for some afibbers. Lots of sports, workouts, good living, hard work, wine coffee etc. along with a slender build.

What we all realize sooner, or in my case later, is that afib is only a symptom of an underlying physical illness. What brings us to this place took years to manifest, and it takes a big commitment to recover.

Treat your cardiologist as one member of your team. They are the plumbers of the heart and make sure your pipes are flowing. They are also trained by the pharmaceutical companies to prescribe drugs and to dis any kind of diet or natural remedies.

The electrophysiologist will be your next level of cardiologist and they look after the wiring and perform ablations, but are also out of the loop when it comes to wholistic healing.

There is a range of other health care providers who are more open to working with you to discover and correct the underlying issues. This could be a medical doctor who has seen the light and practices integrative medicine, and was my choice. It could also be a naturopath, but avoid homeopathy and other forms of voodoo. Basically you need someone who is tied to the medical community and able to get you some of the tests, such as the Exatest mentioned by Jackie, and also guide you in the use of supplements. There is no benefit of even mentioning your involvement with wholistic healing to the cardiologists.

I would suggest asking either your cardiologist or regular MD for a 48 hour holter test. This is basically an EKG in a fanny pack that you wear with wires taped to your chest while going through your daily life. Have him take the test on a day he insists on a heavy workout. It was this test that really opened my eyes to what is going on, and scared me into submission.

The good news is you arrived at the best possible place to figure this out.

Best of luck, Ron

I'm very familiar with the writings of John Little from many years in bodybuilding and writing about bodybuilding training myself.

A fine writer Mr Little has always been an advocate of brief but intense training and the method detailed in this book is no exception.

It is definitely stressful on the body and I believe 'husband' should avoid it.

Ron and Sam - thank you for writing. Chuckle.
My husbands name is Jaap and i am Patricia.
Sorry to have been rude about names.

we are going in to Stanford arrhythmia service today for the basic tests.
echo, stress etc. i will request the Holter thank you.
Agreed re the biases we all bring to this.
my own doctor is part of a practice that is integrative.
go in with a migraine, you could get a pill or accupuncture and a dialog about trigger mapping.
depending on how open your mind is.

hopefully i can find sometihng linke that for Jaap.

we saw an electrocardiologist at Stanford yesterday.
on the upside:
he spoke to us like he had all the time in the world;
he said ablation works better and is less complex in flutter (than fib);
he agreed Mg plays a role, admitted tall guys are prone,
cautioned me that flutter is much different than fib.
of concern,
due to prior family stroke history, frequent international travel, he said yes on balance aspirin would be a good idea since husband had CV (but candidly admitted the recommendation is controversial and there are arguments for/against (i think here Hans is on balance against))
and was (as we knew he would be) somewhat pro ablation.
the EKG was normal yesterday and we are to come back for the imaging and stress test to help assess potential risk.
i still think the Holter would be a good idea. one challenge there is that due to rib injury DH has not been riding at previous distance/intensity for almost a month now.

one of the management challenges is the frequent int'l travel. it's not hard to imagine a flight stressing my giant husband and the idea that he would need cardioversion in another country -say Japan or china is tough.
we also are predictably big ecotourist folks...
so being in a remote area i'm guessing not really in the cards going forward?
or backpacking much more than 1 day out.

Patricia,

A couple of thoughts. An event monitor may be of more value than a Holter. I'm not sure how they work today with new electronics, but in years past, they would record a 90 second - 3 minute loop of ECG data. When you sensed something, you'd push a button and they'd freeze the recent history and record the next couple of minutes. The data could then be transmitted over the phone for interpretation. I'm guessing newer ones may sense episodes on their own and record longer. In any case, they'll give you an event monitor for a month or so. You've got a much bigger probability of seeing one in cases like Jaap's.

As to being in remote areas - I'd wait and see how this plays out. Maybe yes, maybe no. Too early to tell. I just did a two week paddle trip in the Grand Canyon this summer. It is pretty remote though helo evac is possible. I'm not as familiar with atrial flutter. Is there an on-demand ("pill in pocket") med that could be used for chemical conversion? In my case, I don't go out of rhythm often and I have a med I can use to convert myself if I do, so I can stray off the beaten path, though it is more of a consideration in the 3rd world. You also might look at medical evac services/insurance and what they could do for you.

Sam,

"It is definitely stressful on the body and I believe 'husband' should avoid it." My experience is that my heart rate only moderately elevated and with "super slow" lifting the weight is not that heavy or stressful on the joints. The muscles do fatigue, but overall, it is not a stressful workout for me.

George

i like the idea of an event monitor. as somone that rode for many years with a heart rate monitor - he's pretty in touch with his heart rate.
wrt chem conversion - i'm told that we might be able to understand what chems could work better based on the next set of tests - but in the ER chemical conversion didn't occur and we resorted to ECV. i suppose that would be the litmus test though -- if pill on demand is possible - that might make us feel more open (pardon) hearted. to continue adventuring.

i should start a new thread. maybe (de)training with LAF/flutter?
but as part of the journey... i just went thru the inevitable closet full of sport supplements that any endurance athlete has. here are just a few
i'm kind of thinking both forward/back...working to see if any of these could have be related to the flutter.
also as we try to figure out what intensity/level of sport is tolerated - a goto electrolyte solution is desired.
sometimes when you are out there - water doesn't cut it.
seems like you all are working on the appropriate formulation for your selves - but i wondered is there really nothign off the shelf that could come close?

For many years Cytomax was the goto on every ride. 14mg Mg and 6mg Ca. in one serving w/ many many servings ingested.
so i know to watch out for Ca now - but what struck me was the 50mcg of Chromium.
i have not yet turfed up anything solid - but have seen that some suspect possible connection to arrhythmia. and of course it modulates how insulin works.
so that seems out. plus it has fructose so that's out.

The Carbo-Pro - medium chain glucose /maltodextrin - that is sipped during exercise also seems questionable
but if "real food" isn't tolerated...hard to know what to replace with ..i mean at least it's not fructose

Recoverite also seems pretty high in Chromium.
and just one Nuun had 15% of dv sodium so that's out.

so that left me with the osmo as the least troublesome.
adding Mg and Postassium.

links
Cytomax (w/o caff); cyto info
Osmo Nutrition active hydration osmo info
Hammer ReoverRite hammer info
Carbo-Pro carb-pro description
Nuun nuun info

Patricia,

You may want to read this (Dr. John is an EP blogger):
<[www.drjohnm.org]
Especially:
"15. ...Yes, it is true that atrial flutter often requires an intervention, but the chances of a second procedure or more treatment decrease with simple lifestyle choices. Athletes with atrial flutter pay attention here. If you keep inflaming yourself incessantly after flutter ablation, do not be surprised that you are in the 50% who develop AFib. (And please do not ask how much exercise is too much. That answer is unknowable.)"

George

i have read that. and so has Jaap and written to him. i think he's awesome! too bad wrong side of country from us.