Rate or Rhythm Decision

After 10 years of three or four afib episodes a year, in Feb. i became permanent. They tried chemical and electric conversion. The electrophys. Wants to use focainide and do another electric conversion. I am on eliquis and one and a half tabs of metoprolol....36 mg. Pulse is around 80 and heart was normal on nuclear test. My cardiologist thinks if i am feeling good why take a chance on new drug. I agree. I am 70 and have no symptoms but a little fatigue after certain chores.what is the advantage of trying to get back in rhythm? He said something about over time damage to heart would take place. Is that the reason?thanks.

As long as the metoprolol continues to keep your resting heart rate well under 100, the AF will not damage your heart. Your atria may enlarge somewhat, but that's not harmful.

The odds of flecainide + cardioversion getting you out of AF and keeping you out aren't particularly high. So if you're asymptomatic, the metoprolol agrees with you, and you're feeling good, I wouldn't do anything. I would just accept that I'm in permanent AF and will need a beta blocker and anticoagulant for life. That's a perfectly valid choice to make.

Erin,
Have you had an ablation?
Did they ever prescribe any anti-arrhythmics?
Or have you already tried all those avenues?

Have not tried ablation. Only things were the iv and cardioversion.

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Carey
As long as the metoprolol continues to keep your resting heart rate well under 100, the AF will not damage your heart. Your atria may enlarge somewhat, but that's not harmful.

The odds of flecainide + cardioversion getting you out of AF and keeping you out aren't particularly high. So if you're asymptomatic, the metoprolol agrees with you, and you're feeling good, I wouldn't do anything. I would just accept that I'm in permanent AF and will need a beta blocker and anticoagulant for life. That's a perfectly valid choice to make.

I've never understood this train of thought. If a person could take a drug such as flecanide and be AFib free why not go back that route?

I understand that people can be asymptomatic with Afib but why not live in NSR if at all possible. I understand that it would mean adding another drug to the mix but still can't wrap my head around it. Maybe it's because of my own personal experience of being symptomatic that makes it so hard to see.

Carey's response is valid, but if it was me, I would try a few things before accepting Permanent AFIB. The advantages to being in NSR, is that usually people feel better even if it is subtle, Stroke risk is less, and you probably would be less dependent on Anti-Coagulants.

I think it also increases the risk of dementia.

It’s not an easy answer. Age factors in. Certainly a 30 year old in persistent or permanent AF has a different long term risk profile than an 80 year old in the same predicament.

In either case, the prudent first course of action is to get the stroke risk and heart failure risk well under control and then use the time afforded by that to carefully choose one’s next move.

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rocketritch
I've never understood this train of thought. If a person could take a drug such as flecanide and be AFib free why not go back that route?

I understand that people can be asymptomatic with Afib but why not live in NSR if at all possible. I understand that it would mean adding another drug to the mix but still can't wrap my head around it. Maybe it's because of my own personal experience of being symptomatic that makes it so hard to see.

I understand how you feel, and I felt the same way about it for a long time, but after meeting more completely asymptomatic permanent afibbers whose lives were utterly unaffected by their AF and hearing their perspective, my views have softened. If you're completely asymptomatic and on the only two drugs necessary to protect yourself and have no side effects, why take AADs that are all notoriously chock full of side effects? Same with ablation. What are you treating and what is the desired endpoint? Being asymptomatic? You're already there. Having the same stroke risk and lifespan as people who take AADs and do ablations? You're already there.

I think it is being symptomatic that colors your (our) perspective on this. It's just so hard to imagine having AF for years and not even knowing it, but there are plenty of people like that out there. They don't come here much because they're not looking for solutions.

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Carey
It's just so hard to imagine having AF for years and not even knowing it, but there are plenty of people like that out there. They don't come here much because they're not looking for solutions.

Many elderly afibbers I know personally are in this category. When they tell me they have afib, I'll ask if they are in afib now. They'll typically say no. I'll ask if I can feel their pulse. When I do, they are universally in afib.

We don't talk much about rate control/permanent AF; although it sits uneasily in the back of my mind. The question I have if you are asymptomatic or your AF is well controlled with a minimum Rx at a point in time, will your AF worsen over time to where your options become more and more limited (just like with rhythm control)? When I discussed this with my local EP (after two failed ablations with him) a couple of years ago and before I went to Natale, he told me he would aggressive reduce the rate and pace the HR up with a pacemaker. This didn't seem like a good option. I agree with Rocket. Essentially, whatever option (or poison) you pick, between rate or rhythm, you will be on some drug(s), unless you are lucky enough to get some relief through a successful ablation.

Thanks for all your input. My results from nuclear tests were supposedly normal, but when i talked with ep. yesterday he disagreed.. said there was a blockage so i i coildn't use focainide. Said if i chose cardioconversion, he would use multaq. He discussed the negatives of each. It is my decision and he also said needs to be made soon. Said cardioversion had 50 prt cent chance and ablation75.