New guidelines for blood thinners? And Flecainide?

My new electrophysiologist told me today that blood thinners are now recommended for women 65 and older (I'm 68). Not 75 or older as it used to be, and not just people with afib. What do you guys think?

I take one baby aspirin a day, and fish oil supplements. I average about one afib episode a month-----take a PIP flecainide----and that's been working fine now for almost 7 years. I know when I'm in afib, and I'm not convinced I need to be on blood thinners just because I'm over 65!

He also said I should be taking 12.5 mg Metoprolol every time I take my 100 mg Flecainide for my episodes, to prevent a flecainide-induced double-speed arrhythmia (sorry, I don't know the name for this---he said if you take flec when you have flutter not afib, it causes this issue). When I read the contraindications for Metoprolol, they include 2 things that I have: bradycardia and sick sinus syndrome. My heart rate at rest is around 40-44 bpm, sometimes going down to 38.

Thanks in advance for your replies,

Calli

If your EP truly said you must take a true OAC (Oral Anti-Coagulant) such as warfarin/coumadin, or any NOACs such as Eliquis, Xeralto, Savaysa or Pradaxa just because you are a woman of at least 65 years old and whether or not you have ever had AFIB or any Atrial tachy-arrhythmia, ... ( let me repeat for emphasis) ... including even if you have had zero episodes of any atrial tachy- arrhythmia of any kind for many years ... or even never had any such episodes ... and he or she still insists you require life long OAC due to your age and sex alone, then I would seriously look into finding a new EP ASAP!!

Be well,
Shannon

The cardio i saw told me to take Eliquis (5mg 2x/day) because i'm 67 and was in permanent AF for about 4 months.
Now, since i've been without afib for about 2 years he says that if i take it my risk of hemorrhage is 1 to 1.5 in 100 and if i don't take it my risk of a thrombus is about 1.5 to 2.
But when/if i reach 70 the recommendation is an anti-coagulant on a regular basis.

I stopped taking it but i eat 40g of Natto/day and 1/4 clove of raw garlic/day as well as having a high vegetable and low meat diet. Don't know if i'm a fool but it is my body and my choice.

[www.dukehealth.org]

The doctor told me it was for all women, afib or not. Maybe I misunderstood him...

He didn't insist, but he wanted to inform me that these are now the new guidelines. I was surprised and it didn't make sense, so I told him I wouldn't start them. He said it was my choice.

But I really expected to get more information in order to make a choice. I wanted to hear his opinion on the recommendation, based on my risk factors, but he didn't offer it.

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CC66
He also said I should be taking 12.5 mg Metoprolol every time I take my 100 mg Flecainide for my episodes, to prevent a flecainide-induced double-speed arrhythmia (sorry, I don't know the name for this---he said if you take flec when you have flutter not afib, it causes this issue).

The term you're looking for is 1:1 ("one for one") conduction. This is something that can happen if you're in atrial flutter and you take a drug like flecainide. The short explanation is that if this 1:1 conduction happens, your ventricular rate will climb to match your atrial rate, which will mean a heart rate well over 200. (Been there, done that, you wouldn't like it.) The way you prevent this from happening is with beta blockers, so that's why your EP recommended it.

That's standard advice for most people taking flecainide, but then you said:

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When I read the contraindications for Metoprolol, they include 2 things that I have: bradycardia and sick sinus syndrome. My heart rate at rest is around 40-44 bpm, sometimes going down to 38.

Wow. If I understand correctly, you've been using flecainide as a PIP successfully for 7 years without problems, you have SSS and bradycardia down to 38, and he thinks you need to take a beta blocker?

I hope there's a big misunderstanding here. Please don't take a beta blocker until you get a second opinion from another electrophysiologist.

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CC66
He also said I should be taking 12.5 mg Metoprolol every time I take my 100 mg Flecainide for my episodes, to prevent a flecainide-induced double-speed arrhythmia (sorry, I don't know the name for this---he said if you take flec when you have flutter not afib, it causes this issue). When I read the contraindications for Metoprolol, they include 2 things that I have: bradycardia and sick sinus syndrome. My heart rate at rest is around 40-44 bpm, sometimes going down to 38.

Calli,

I assume you DON'T have bradycardia when you are in afib, so this would likely not be an issue for you. Jackie has posted a similar protocol for on-demand flec. She takes her beta blocker and waits 30 minutes before taking the flec. <[www.afibbers.org] Flec, at least in me will leave me with a heart rate in the 80's after conversion. This slowly drops, over a number of hours, back to my normal 50's.

Flec converting to to flutter is a risk - ask Shannon, he's experienced it.

I don't use a beta blocker, however I do get prone after taking the flec until I convert. This lack of exertion also reduces the flutter risk.

George

Thanks to everybody for all the help and the link to PIP protocol.

This is very similar to what my first EP doctor told me. He said that if my heart rate was over 110 in afib, to take 25mg of metoprolol, wait for an hour to see if I convert, and if not, then take 100mg flecainide and repeat in an hour if episode is still ongoing. He was aware of my bradycardia, but didn't mention anything about one-for-one conduction....

But I've always just taken the flecainide right away, because I just want it to go away as quickly as possible! Maybe I shouldn't be so impatient?

When I get afib, my heart rate is usually 70-90 bpm irregularly (I have a puls-ox finger tester). Like I said, I don't wait very long to take the flecainide. Since I usually get afib during the night, I get up, pee, go to the kitchen, drink low sodium v8 juice (or .5 gm potassium supplement powder in water), plus a couple of 200 mg magnesium glycinate capsules. Then I crush a flecainide in warm water and swish that around in my mouth awhile and then swallow. I usually just go back to bed then, and try to go back to sleep. It usually takes about 1-1.5 hours to convert. My heart rate then is in the 50s or 60s I think. Probably not the slower rates I sometimes get. Have to check on that in the future.

I definitely don't want to get the one-for-one conduction, and will re-think my protocol, now that I know about it. I don't know if I recognize what "flutter" feels like. I get rhythm that I call "runs"--a run of fast beats that only lasts a very short time---a few seconds---that doesn't seem to be related to my afib episodes. I'm pretty sure I know what my afib feels like---sometimes like a squirrel in a squirrel cage in my chest---but sometimes it's much gentler, just irregular jumpiness.

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GeorgeN
I assume you DON'T have bradycardia when you are in afib, so this would likely not be an issue for you. Jackie has posted a similar protocol for on-demand flec. She takes her beta blocker and waits 30 minutes before taking the flec. <[www.afibbers.org] Flec, at least in me will leave me with a heart rate in the 80's after conversion. This slowly drops, over a number of hours, back to my normal 50's.

Flec converting to to flutter is a risk - ask Shannon, he's experienced it.

I don't use a beta blocker, however I do get prone after taking the flec until I convert. This lack of exertion also reduces the flutter risk.

George, just because you convert to 80 doesn't mean she will. A beta blocker on top of a heart rate in the 30s/40s is truly dangerous. The risk of flecainide-induced 1:1 conduction is very low; so low that many EPs don't even include a beta blocker with flecainide. But the risk of giving beta blockers to someone who's bradycardic is very high.

I've experienced 1:1 conduction too. Many times in fact. It wasn't caused by flecainide, but one thing I learned is that when you have a heart rate of 250 and you're barely hanging on, someone giving you metoprolol to try and bring that rate down can have dire consequences.

I absolutely don't think she should touch a beta blocker until she gets a second opinion from another EP.

Carey,

Of course, however, since Calli has experience with flec, I assume she will know what rate she converts to. My understanding is that flec has a somewhat adrenergic effect, hence conversion to a higher than normal resting rate. This rate will decline as the concentration of the flec decreases in the system. The average half life of Metoprolol is 3-4 hours and flec 12, so the adrenergic impact of the flec will typically be longer in the system than the Metoprolol. Also assume, since she can remain conscious after taking the meds, she can monitor her heart rate and do some activity to raise it if it starts dropping too low.

Alternatively, she can just stay quiet and mostly prone till conversion happens to mitigate the flutter probability.

Thanks. I think it is good advice to get a second opinion about the metoprolol. My new EP left me a reply this afternoon, about my metoprolol concerns; he thinks 12.5mg taken with the flecainide won't be harmful, based on "it's such a small amount."

I actually don't know what rate I convert to. I've looked at my pulse monitor and have noticed 50-60 bpm, but I usually go back to bed after I take flec, so it might go lower. Guess I'll have to stay awake and pay attention if I choose to take Metoprolol.

Calli

If you are staying in bed, my understanding is that drops the risk of flutter. I believe that instruction was from EP Dr. John Mandrola, who himself is an afibber and has used flec.

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CC66
My new EP left me a reply this afternoon, about my metoprolol concerns; he thinks 12.5mg taken with the flecainide won't be harmful, based on "it's such a small amount."

It is a small dose. Maybe try it to see what it does to you under normal circumstances? That beats finding out during your next afib episode.

That's a sensible idea...thanks!