I'm requesting some input please

At the end of last year, Nov 9, Dec 7, and this year (last week!) on Jan. 13, I was in the ER for tachycardia that didn't resolve by itself. I got back into normal sinus rhythm with a two consecutive doses of Diltiazem in my IV, given about an hour apart.

I only drink water (not even sparkle water!), I don't drink any kind of tea or coffee, I don't smoke or do gummies and such, and don't do drugs or alcohol.

Prior to these very recent once-a-month episodes, there seemed to be quite a few months (ranging between 6 months to 11 months apart) in between episodes.

The 3 different ER docs for the last 3 visits diagnosed 'maybe SVT' and also mentioned 'maybe' re-entrant tachycardia and mentioned 'maybe' possibly flutter. My EP, looking at the 12-lead EKGs after my discharges, said it was all SVT.

During the time of this pandemic, I certainly don't want to have an ablation for this, so I'm looking to control with medication.

With my Metoprolol Succinate, 25 mg once a day because it's extended release, I will often notice a low heart rate, in the very low 50s. I am also on 150 mg of Flecainide (taken twice a day), Pradaxa, Simvastatin and Lisinopril. I supplement with magnesium glyconate to bowel tolerance. I'm tolerating all of these quite well, with no side effects except it's really difficult to lose some pounds!

My EP and I discussed trying Multaq, which I cannot take with Flecainide. I was reticent, and instead, we decided to "up" the Metoprolol Succinate (extended release) to 37.5 mg once a day. My EP also prescribed Diltiazem to take as a PIP, to wait an hour and see if that brings me back into a normal rhythm.

At this point, relying on the collective minds and experiences here, I need some suggestions and maybe a bit of hand holding. I've been really nervous about upping the metoprolol and thinking my heart rate might just tank into the 40s beats per minute, but I don't know--and relying on my spouse as a backup is a challenge with anything medical too--totally not his skill set.

So I'm asking you to predict, knowing mostly we aren't EPs or cardiologists etc, is the increased metoprolol likely or unlikely to cause a low heart rate problem?

If the small increase of metoprolol succinate doesn't work, my EP said we'd have to look at different meds.What other meds are available for controlling rate effectively without too many side effects, that can be taken with Flecainide etc?

Thanks in advance!
Sue

More metoprolol might cause an unacceptably low heart rate. If that happens, you just resume taking your lower dose and that's the end of that. It's not going to kill you to have your HR drop into the 40s for a day.

As for the other meds, there are several but you're not looking for rate control meds (like metoprolol), you're looking for antiarrhythmic meds (like flecainide). There are several others you can try, but antiarrhythmics always have drawbacks. No matter which other one(s) you try, you'll have to stop the flecainide first. The usual options after flecainide are sotalol and then Tikosyn. Tikosyn will require a 3-day hospital stay to start it, and sotalol might as well depending on your specifics.

Medical management of afib isn't an easy thing. If you want to continue down that road then you're probably going to have to try some drugs you might not like much.

Wonder if a calcium channel blocker might be used for rate control in place of th BB?

Calcium Channel blockers like Cardizem cause me to retain fluid,; Edema. I gained 15 lbs in one week. My ankles swelled etc.

Thanks for the replies! I know meds behave differently with each person, but I sure don't need swollen ankles or a weight gain! Calcium channel blockers might be the next thing to look at if the increased Metoprolol doesn't work the way I'd want it to work.

Carey, I guess I'm wondering since my visits to the ER indicate that my rate is fast, but my rhythm is steady, wouldn't it be an option to explore a different beta blocker for rate control (a different rate control medication that might work better with my physiology) rather than taking another look at a different anti-arrhythmic?

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SueChef
Carey, I guess I'm wondering since my visits to the ER indicate that my rate is fast, but my rhythm is steady, wouldn't it be an option to explore a different beta blocker for rate control (a different rate control medication that might work better with my physiology) rather than taking another look at a different anti-arrhythmic?

Maybe. There are bunches of different beta blockers, but for the most part they all have the same general effects, so switching to a different BB isn't likely to do much for you. Diltiazem is the other realistic option. Although it can cause water retention in some people, it doesn't do that in everyone, and if it does it's just water so it will drain off as soon as you stop taking the diltiazem. It does not cause fat gain. And for most people it's nothing like 15 pounds of water. For most it's just some ankle swelling (that was my experience) with no measurable weight increase.

You're taking a hefty dose of flecainide now and talking about switching to something else like Multaq. Although your rhythm is regular, that doesn't mean it's not an arrhythmia. It was diagnosed as possibly SVT or flutter, which sounds likely. So if you can find an antiarrhythmic that reliably prevents your arrhythmia, you won't need a rate control drug at all. I would give the Multaq a try. It doesn't require a rate control drug and it's very low on side effects. If it doesn't work, you can return to your current regimen.

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Carey
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Medical management of afib isn't an easy thing.

Flutter is worse. It responds even less to medication. Fortunately flutter ablation works really well. If that’s what’s going on, I’d probably risk the hospital visit for it if it were me. Hospitals do a good job of isolating the COVID wards from the rest of the population. We’re also likely past peak with the holiday surges. By the time a procedure gets scheduled we should be on the tail end of this mess. The only confounding variable I could think of is this - What does vaccination mean for an ablation candidate? Would vaccination have to wait for ablation, or vice-versa?

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wolfpack
. We’re also likely past peak with the holiday surges. By the time a procedure gets scheduled we should be on the tail end of this mess.

I believe Sue is in SoCal, which is a COVID mess at the moment.

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wolfpack
. The only confounding variable I could think of is this - What does vaccination mean for an ablation candidate? Would vaccination have to wait for ablation, or vice-versa?

Good question. I’m curious if anyone knows.

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GeorgeN

. We’re also likely past peak with the holiday surges. By the time a procedure gets scheduled we should be on the tail end of this mess.

I believe Sue is in SoCal, which is a COVID mess at the moment.

Big mess. Los Robles hospital where Dr Natale is attending is using tents with heaters. It is very cold today with a bad rainstorm. He had to cancel his last visit for ablations. I wasn’t quick enough to book a Pfizer vaccine appointment near my house. The la public health website was having technical difficulties. I waited 13 hours 10 minutes on the phone trying to get through. Unfortunately at 10:30pm I was disconnected. I was able to join a membership (100% subsidized by the health department) at a concierge doctors group an hour and a half away. It will take longer with this rain and I have to rely on a Lyft driver

Thanks, Carey for the additional info. My EP and I did briefly visit the option for Multaq. At this point, I feel we're doing a process of try and see with different meds. I'm hoping I can get a specific definitive dx from him when I email him on Monday -- unless this a-fib stuff is nebulous even with a 12-lead EKG.

Wolfpak and George, yes, I'm in So Cal and things are a worse mess with the vaccine NOT actually being available, plus the nearly impossible task to even get an appointment for the first dose IF it's even available (& if they don't run out while you're waiting in line to get jabbed because you got the appointment), and with newly hospitalized COVID cases and no place to put them--things are more of a mess than you hear about on the national news.

Good question regarding vaccination and ablation. Maybe someone will ring in with info.

I very seriously doubt anyone would tell you to avoid vaccination before an ablation unless it was within a few days of the procedure. Same with after the procedure: wait a few days then go for it. I don't have any authoritative sources to cite on this but that's the general practice with surgeries and invasive procedures in general. A vaccine isn't as big a deal to your body as your brain would lead you to believe. It's just another one of the hundreds (thousands?) of new proteins presented to your immune system every day. Vaccines really just don't have much to do with things like ablations.

Back to the medication-related question.
Carey, I started the increased dose of Metoprolol Succinate Extended Release (1-23-2021) and before I took the increased dose at 9am, I took a Kardia reading at 8:50 am, and two other readings -- one reading was just past noon, and another reading at 9:44 pm).

I don't know how to "interpret" the Kardia readings, but the link to them is below. Some of the lines look wonky to me (artifacts? problems? accidentally moved my knee?), I guess because I like seeing everything neat and orderly and in a nice rhythmic pattern unless I'm having issues, then I expect wonky.

I'd appreciate your input, and remember, this gal tends to frighten easily!!!

You can see the Kardia readings here:
[postimg.cc]

Sue,

If you create a pdf and take a picture and share, then have more to look at. On mine press the envelope icon in upper right (when looking at the ECG) and select share pdf. Skip the password. After that the pdf should show. You can then screen image the pdf page and share.



Edited 1 time(s). Last edit at 01/24/2021 07:45AM by GeorgeN.

George, thanks, but I don't think I can do that on my old computer. I click on the envelope icon on the upper right, but don't get anything about share pdf, I just get a message about email.

Let me try another way to link:








Edited 1 time(s). Last edit at 01/24/2021 11:48AM by SueChef.

Those recordings are all perfectly normal.

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wolfpack
We’re also likely past peak with the holiday surges. By the time a procedure gets scheduled we should be on the tail end of this mess.

When looking at case counts this is correct. The problem is that hospital, ICU and death counts lag case counts by 2-6 weeks.

Hospitals in So-Cal will be chock-a-block at least until the end of Feb and into mid March.

Do you want to go for a procedure when everyone is exhausted from the previous 6 weeks of activity?



Edited 1 time(s). Last edit at 01/24/2021 12:30PM by NotLyingAboutMyAfib.

Thank you, Carey!!!

Good point, NLAMAF.

If it were me and the meds were working(-ish) I’d probably schedule the ablation 3 months out and work the vax route first. One less thing to worry about when the procedure time comes and we all know how important peace of mind is as we go through it.

Re the vaccination and ablation timing question, before Los Robles cancelled January ablations I asked Natale's NP there about going ahead with a vaccination close to my then scheduled abalation date.

She said is was fine to get either vaccine whenever I could as it wouldn't affect the ablation.

I was given the Moderna vaccine last Wednesday, I didn't get to vote on which substance was used, with a little pain at the site for a day and no other side effects to date.

No new schedule on Natale visits for maybe February as of Friday, when the hospital was completely full. Maybe an update coming out this week.

It appears the new Covid caseload rate is dropping in SoCal and I'd guess March will definetely have a schedule.

Gordon