Advice needed please - Shannon? Carey?

My husband, age 79, was diagnosed with persistent AF in February, during treatment for something minor, not heart related. He was asymptomatic so we have no idea how long he had been in AF. Until that time he had been in good health, going to the gym three times a week.

He was put on Apixaban (Eliquis) very quickly but then his EP appointments were all cancelled because of Covid. By August he was breathless and quite ill but refused to call the doctor, despite my urgings.

He subsequently collapsed with a heart rate of 180, pneumonia, heart failure and cellulitis, and spent 3½ weeks in hospital. He has recovered, is on a lot of medication but feeling much better, and is now back in the system receiving treatment. The EP has proposed a plan for the next stage and I would welcome views from our experts on whether it is a good one.

They suggest that they first check his arteries for blockages. That seems ok to me. If all is well they would then try to convert him to nsr with short term amiodorone and a cardioversion to see if he feels better in nsr. If yes, they would consider ablation. If no, they would stop the amiodorone and aim at rate control. I asked if they would consider using a different drug and they said that amiodorone was the best bet for keeping him in nsr.

I pointed out to my husband the horrible side effects of amiodorone but it seems that short term they might be manageable. He certainly would not want to take it long term.

If ablation is the outcome we would probably want to go to Bordeaux once travel is allowed, but we have no way of knowing how long that would be, ie how long he might have to take the amiodorone. Or we could try the best ablationist in UK, possibly Sabine Ernst, which would possibly be quicker.

Shannon? Carey?

Gill (ablation and touch up in Bordeaux Jan 2003, nsr since then)

Has any other antiarrhythmic drug been tried? Flecainide or propafenone, for example? Although amiodarone no doubt is his best bet for remaining in NSR, it's not the only choice. I think his docs are just being a bit stubborn on that point. They should be willing to try other drugs if you insist.

But, really, if he was so asymptomatic that he never even knew he was in afib, why not just skip the antiarrhythmics and cardioversion and just go with rate control until he can travel? Besides, doing that will make the ablation simpler. EPs usually want all antiarrhythmics out of your system prior to an ablation. Clearing most antiarrhythmic drugs from your system takes about 5 days, but clearing amiodarone takes months. So sooner or later he's going to have to come off the amio anyway, so why even start it? That's what I think I would do: rate control + Eliquis and just wait things out.

Wonder if the heart failure you mention, Gill, is the reason they aren't suggesting other meds, like flec?

George provided a great link:
[www.afibbers.org]

Carey - he has decided to do exactly what you suggested, will stick with rate control until travel is allowed, then we will head for Bordeaux.

George - yes, it’s because of the heart failure.

Gill



Edited 1 time(s). Last edit at 12/03/2020 12:19AM by Gill.

Gill,

I have a couple of questions. I might have missed something... Did they already attempt to cardiovert him into NSR? And Is he in NSR or afib now?

Jeff

Jeff

He has been in AF since it was first detected in February, asymptomatic so we don’t know how long he has had it. No cardioversion so far, the EP has proposed one with amiodorone on board. He is still having investigations/treatment for heart failure and we don’t yet know if he will be a candidate for ablation.

Gill

Hi Gill
I had two ablations in Bordeaux, 2006,2007. At returned this year. I will have ablation in Adelaide on 14 December. If I could I would go to Bordeaux again. Not possible now. I am wondering why doctors will not cardiovert your husband to NSR? I am refractory to all anti arrhythmia that's why I had and am going to have ablation. The doctors who will perform was working with team in Bordeaux for 4 years. Thanks that this forum still exists. 😀

Hi Aldona, so good to hear from you again after all this time - I well remember our chats when you were going to Bordeaux.

The EP has suggested a cardioversion but with amiodorone, and husband isn’t happy to take that drug. As well, my own experience with three cardioversions (2 external and 1 internal) was that they lasted only a few days before AF returned. We don’t know yet what damage has been done to his heart by his rate being 180+ for several months.

When all the investigations have been completed, if he is a candidate for ablation, we will head for Bordeaux as soon as travel is permitted. In the meantime he will stay on rate control.

Gill



Edited 1 time(s). Last edit at 12/10/2020 08:44PM by Gill.

Quote
Gill
We don’t know yet what damage has been done to his heart by his rate being 180+ for several months.

Several months?! I didn't catch that part in your earlier description, but now you know where the heart failure came from.

Gill,

Sorry to hear about your husband's situation.

Surely his ventricular response rate in AF hasn't been circa 180BPM since he was diagnosed in February has it?! I don't see how anyone could be asymptomatic with AF running a VRR of 180BPM! I had an episode in 2002 that was running at that speed (first time I was hospitalised - and given Digoxin..... not good at all - and I could barely get up off the bed! And surely he'd have been given rate control in Feb? Just thinking out loud here is all. Agree with Carey about avoiding the Amio.

Hoping things are on the mend for him soon.

Mike F

Hi Mike

He had appointments at King's cardiology in February and March but they were all cancelled because of Covid. They did get him on to Apixaban very quickly but nothing else. We don't know when the high heart rate started, he had felt quite ill for months by the time he collapsed in August but refused to contact the GP despite my urging. So in some ways it was his own doing, plus collateral damage from Covid.

He is having a CT angiogram in early January to check his arteries - we don’t know yet if he is a suitable candidate for ablation. He is on a lot of medication and is having regular blood tests. We also check his BP, HR snd oxygen levels several times a week at home, though it’s difficult to get good readings with automatic machines when he is in AF.

Gill