VA's new policy

As a generally satisfied user of VA's medical services, the one area I felt they let me down on was trying to convert me when I was having a prolonged afib episode. Thirty years ago when I had my first afib episode the VA did use a rhythm controlling drug to convert me, But starting some time about ten years ago they would only administer a rate controlling drug and send me home still in afib. Last night I showed up at the VA emergency room and they downloaded my pacemaker to ascertain I had been out of NSR for 20 hours and promptly proceeded to cardiovert me which was successful on the first try. Oh happy day.

I would like to see their AFIB treatment protocols. Treatment of AFIB is very complex to be reduced to a simple policy. Are you sure it's that rigid a set of guidlines, or are you just getting ER Dr's who tend to treat in a certain way. Whenever I am in that spot (not the VA) it is a combined decision how to treat including me, my Dr. and the ER Dr. As long as I go in less than 48 hours from episode onset, then I can get Cardioverted if I want to. I tell them I am a cronic Afibber, and that I have gotten many ECV's in the past that were always successfull. I then tell them that I am requesting an ECV to treat the situation. The ER Dr. just checks with my Cardiologist to get a recommendation/approval, and then I sign some forms, and I get Cardiozapped into NSR.

I admit that I don't have any direct knowledge of the VA protocols...just my personal experience, And that experience included at least three occasions about a decade ago when the VA ER did nothing more than administer rate control drugs to bring my heart rate below 100 b/m despite the fact that my INR indicated adequate anticoagulation. At about that time I recall there was a very influential study that indicated patients given rate control lived as long as patients who were treated with some sort of rhythm control therapy. I surmised that the VA protocol was based on this study. This most recent episode two days ago I think they just took my word that I was properly following my apixaban protocol and preceded with the cardiovertion forthwith.

Josiah,

You are likely referring to the Affirm trial: <[www.nejm.org]

The results are as you state. When you look at it in detail, the reason that the rate control & rhythm control arms had similar outcomes is that rhythm control meds really didn't keep people in rhythm very well (not much has changed on that front).

George

After I posted, I thought of some things. There has been a shift in all ER rooms, in regards to the time frame, that an episode could last, and the patient still be Cardioverted. Some ER's used to follow a 24-hour rule, and now 48-hours has become standard. Also ER rooms are more apt to ECV than before, as some new studies supported Early ECV strategy. What did you do when they sent you home still in AF? Did you follow-up with a ECV scheduled through your Cardiologist, or did you eventually convert on your own?

ER protocols for ECV can vary by location.

It's smart to check out ahead of time what you might expect at various locations and if they actually will do an ECV without formal hospital admission. That way, should you need help, you can minimize the time and frustration of the whole ordeal.

I thought it would be standard to show up at the local ER affiliated with the Cleveland Clinic well within the 48-hour rule if not on an anticoagulant and have an ECV. But as I quickly learned, iIn order for that to happen, I would have to be formally admitted to the hospital by an EP and scheduled for the ECV the following day or whatever worked into the schedule. But by going through the main campus of the CC and provided one is in the care of an EP, I could call for an ECV there and be worked in to the schedule. I learned after the fact that the area ER's contract out the services and ECVs aren't included in that contract.

So at that local ER, they treat the AF with the IV rate control. It didn't convert me from AF but rather moved it to A-flutter, which was far more comfortable but definitely showed flutter on the monitor. However, I was released after about six hours and told that my HR should "normalize." The EP that signed off on my release didn't mention I was in flutter; perhaps didn't recognize it... but when I saw an EP at the main campus the next day, he compared the ECG from my discharge to the one just done before the consult and he pointed out the flutter waves that were identical in both (which I already knew). That was on a Friday and he said he expected I'd self convert in a few days and by Monday morning, I did convert. I thought that was a minor miracle because I'd never previously converted out of a-flutter.

For future needs, fortunately, I was able to work out an agreement with Dr. Schweikert (Heart Rhythm Associates) in nearby Akron (an hour's drive away) to call ahead and be scheduled for an ECV. That was most helpful because I needed it frequently. Thus - ablation #2.

Jackie