Can't use Calcium channel blocker after 48 hours of afib because too dangerous???

My sister, who lives in Greece, has been in afib for four days. She saw the cardiologist yesterday. He told her that she would have to take blood thinners and beta-blockers for a month and then he would cardiovert her. In the past she has used calcium channel blockers to convert but he told her it was too late - you can't use them after 48 hours, it's too dangerous. Has anyone heard of this before? I'm pretty sure this is untrue, but have been out of the loop lately. Her heart rate is very high in afib.
Thanks in advance.
Marg



Edited 1 time(s). Last edit at 09/02/2016 12:20PM by Marg.

I'm guessing he's saying that cardioversion by any means after 48 hours is too risky, without anticoagulation. This is standard. The alternative is to do a TEE and look for clots and then cardiovert if none.

Thanks for your reply, George. For some reason I had always thought that it was just electrical cardioversion that was too dangerous, not drug conversion. I somehow missed this important piece of info. It makes me wonder what happens if we self-convert after 48 hours. Is it also possible we can throw a clot? What are the statistics on that, I wonder? Do they do things to keep you in afib while they anticoagulate you, in case you self-convert?
Marg

Marg - so then, is your sister now on an anticoagulant?

If so, then that helps lessen the clot risk since if one forms, the anticoag should help break it down. The risk of long-duration Afib and high HR is that the blood clearance out of the heart is significantly slowed - conditions which help promote clot formation. So, yes, there is a risk if you self convert depending on your blood viscosity status.

For that reason, those who are not formally on an anticoagulant medication can find some degree of safety and help by taking various supplements that help reduce inflammation which promotes 'stickiness' and elevated thickness (viscosity) such as Omega 3 fish oils, curcumin, magnesium and the fibrinolytic enzyme Nattokinase in regular doses daily....or some just rely on aspirin.

I speak from past experience because I had many long-duration bouts of AF... often very close to the 48-hour deadline and fortunately, did usually self-convert. And, probably because of my regimen to assist with keeping blood thin and slippery, I avoided a clot disaster. That was back before the new oral anticoags such as Eliquis and Pradaxa were on the market and I didn't tolerate warfarin or aspirin so took the Nattokinase and other supplements daily whether in AF or not.

As a further example, one time I was close to reaching the 48 hour mark and went to the local ER thinking that an electrocardioversion would be standard protocol. They tried various chemical conversions that didn't work but did slow my HR but pushed me from Afib into A-flutter. Since they didn't know what to do with the flutter, I was discharged. I even saw the EP on call but nothing was said about the my being in flutter but I recognized the pattern on the monitor and knew what it was. I was just happy to get out of there and the following day, I was able to see a 'real' EP at the Cleveland Clinic who confirmed the flutter and told me to wait a few days and I'd probably self-convert. So, from Wednesday to Monday morning at 9 a.m. when I self converted, I was in some form of arrhythmia. After that, I resolved to make arrangements with a cardiac center and drive the distance for the proper care.

I have always been very thankful for the efficacy of the Nattokinase enzyme I had been using at the time.

Best wishes to your sister.
Jackie

Thanks, Jackie. This helps explain things. Yes, she is now on Eliquis and Metroprolol.
Marg

I never heard of trying to stay in AFIB, fearing a clot, unless a known clot was present that would change things. Also, It's less risky to spontaneously convert than by ECV.

Waiting around in AFIB for 30 days while AC medication takes effect, is old-school here in the US. Even there is still a chance that a clot is present, as AC medication only reduces the risk of Clot formation. Most of the time they do a TEE, to check for a Clot, then if there is none, they do an ECV, that way the Patient is in AFIB for much less time.

Hi Marg,

Sorry for the delay in seeing your post, I'm afraid your sisters Cardiologist in Greece has a few holes in his training .. and even in his practical real world experience, apparently.

First of all, neither a Calcium Channel Blocker - CCB nor a Beta Blocker - BB, both of which are used in AFIB primarily for rate control-only and secondarily for blood pressure control when needed as well. But neither of these drugs have any anti-arrhythmic conversion properties and will NEVER directly convert someone from AFIB/Flutter to NSR.

It is not uncommon for people who still have paroxysmal AFIB to convert to NSR after taking a dose of either a CCB or BB, even if they take it only as a kind of 'pill-in-the-pocket' 'only-as-needed' idea. In fact, it happens all the time, but they are really only converting spontaneously via the paroxysmal nature of their AFIB, even though at times such a grateful recipient of a spontaneous paroxysmal conversion back to blessed NSR will then, at times, wax rhapsodic about the powers of CCB or BB to restore NSR. Some will even be moved to swear on a stack of bibles, if challenged in that belief, that it was the CCB or BB that converted them.

A common phenomenon too, as with other drugs, treatments or supplements too, even those that do provide much benefit over all, but then get credit for many things by association even when they did not have a direct causal impact on the desired effect that happened by itself anyway.

With a CCB or BB they will (or should at least) lower one's AFIB heart rate considerably and making one's episode experience a much more comfortable event at a much slower rate .. and even safer too. In some cases, the slower rate 'seems' to go hand in hand with shorter episodes, but it is NOT acting as a direct conversion tool, such as using specific anti-arrhythmic drugs or electro-cardioversion for a real direct cause and effect restoration of NSR ... at least when either of those methods work.

As such, this cardiologists assumption that your sister would be a greater risk of a stroke by continuing to take her CCB drug past the 48 hour window from the start of her episode, until 30 days later after a full month of Warfarin use to break up any possible clot forming in the LAA or LA before he can do a ECV (Electro-cardioversion to safely reestablish her NSR and hopefully for a long time) is flat out wrong and a bunch of baloney that could do more harm than good.

So, instead of allowing her to lower her "very high speed AFIB" you describe above that she has (which to me means it ranges typically from 140bpm to 170bpm ... above 170bpm and even from around 160 up, it's increasing likely to be Atrial flutter (AFlutter) or Supra-Venticular Tachycardia (SVT) and not AFI.

In any event, this cardiologist is forcing your sister to truly suffer for a full month simply to satisfy his entirely erroneous misconception that the same precautions needed before Electro-cardioverting someone who has gone past the golden safe time window of from 24hours [the idea window] to 48 hours [the very late window] after you know for sure that an AFIB/AFlutter episode has started, must be used even if they are only taking a rate control drug, which itself, is not only not going to convert the person directly, but even if that were true, it would be a very mild physical event and not at all any more likely to cause a clot dislodging stroke than any natural spontaneous conversion to NSR her own body and heart are very likely to do anyway during that month of waiting, assuming she is truly still in paroxysmal AFIB.

Tell you sister to call her Cardio and share this thread with him if she wishes, and implore him to confirm this advice you are getting here with a well regarded Greek EP to sort this all out to his satisfaction and to for your sisters well-being.

Furthermore, as Anti-AFIB noted above, your sister can easily be cardioverted much sooner than a month if she could nudge her cardiologist (or preferably better yet an EP who should be much more familiar with the nuances of AFIB treatment) to order a TEE ( trans-esophageal echocardiogram) and if that TEE confirms no clot or SEC (Spontaneous Echo Contrast or 'Smoke' being present in the LA or LAA.) as it almost surely will even if she had any clots form so soon after start of her episode and before she started the Warfarin, after she had been on an the blood thinner for a week to ten days or so prior to the TEE.

I hope that clarifies the situation Marg, and I'm sorry your sister has been made to suffer with very high speed AFIB so un-necessarily. The preliminary TEE might be a lot tougher to pull off getting it done in Greece compared to America, at least based on feedback from other Greek EPs at the various AFIB conferences I have attended where they often bemoan the nonsensical application of 'red-tape' that too often hinders otherwise good common sense procedures there.

Best Wishes to your sister and you in any event,

Shannon



Edited 1 time(s). Last edit at 09/04/2016 05:34PM by Shannon.

Thanks, Shannon.

My title was a bit confusing, I'm afraid, and I wasn't quite sure what she had been telling me when I first wrote this. She was taking a CCB with previous episodes (she has had very few, the last one two years ago) to convert and they did help (as you say, maybe the conversion would have happened anyway.) This time, because it was past the 48 hour mark he gave her Metoprolol to lower the rate, and Eliquis to prevent clots. He said he could not give her an anti-arrhythmic until 30 days had passed. My sister is not used to taking any drugs at all, and is suffering from side effects - probably from the beta-blocker. The Metoprolol is keeping her heart rate below 100 but she is on a high dose, I think 50 mg twice a day. If she tries to reduce that, her side effect symptoms ease, but her heart rate goes up.

If I understand you correctly, your advice is that she should be asking her cardio to get her a TEE once she's been on the blood thinners for a week, to check for clots and then they could cardiovert her sooner, depending on whether she has a clot or not? She has so far been on the Eliquis for 4 days.

She is on Crete, near Chania, where her cardio is. Do you know of any EPs there? It would be wonderful if she could see someone who is more knowledgeable.

Thanks again, Shannon.

Marg

Sounds like your sister could be taking a CCB. That wold help lower her rate, so she would'nt need as much Metropolol.
CCB's are not Anti-Arrythmics.

Also the way I read Shannon's reply is that he's saying your sister would have been on AC medication for 7-10 days, if she tries to get the Dr. to order an TEE as soon as she can. He is not saying you need to wait 7-10 days. I have never heard of having to wait a period of time to get a TEE done, and I have had more of them done than anyone else that posts here.

Oh thanks for that clarification. I thought the idea was that by waiting 7 to 10 days there was more chance of any clot disappearing.

I've not heard of taking a CCB along with a BB. Don't they both do the same thing?

Marg

Hi Marq,

No Anti AFIB is correct, there is no need to wait any time whether on or off OAC drugs to get a TEE, that is test to see if you have a clot or not in the first place... Among many other various parameters a cardio or EP might use a TEE for to investigate in your left atria.

Shannon



Edited 1 time(s). Last edit at 09/08/2016 09:33AM by Shannon.

Yes BB and CCB both lower HR, but by different mechanisms.

CCB's don't cause the side effects like sedation that BB's do.

Thanks, Anti-Fib and Shannon.

Just my story,
My first ever episode (2001) I was within 48 hrs, the hospital said they couldn't be sure (I was) so they wouldn't electro cardiovert me.
I was put on digoxin and warfarin for 6 wks before cardioversion, my rate walking up steps very slowly was close to 200 due to flutter.
Shocking, shocking times, I had been an athlete until that point (never since)
Never got passed 48 hrs since always converted in hospital setting now with a nice shot of heparin to the stomach area. No chance of TEE back then.
I always wonder how much damage that did to me.

Just my story

Mark