Cardioversion or wait it out?

I have a friend who is new to Afib who has been in AF at about 80 BPM for over a week. His doc gave him the option of having a TEE and then cardioversion or to get on anticoagulant medication and wait for a month to see if he can convert on his own and then do the carrdioversion.. What would you do? He elected to wait it out on the anticoagulant while he reads up AF, Dr. John Day's book and gets his Mg tested to see if he's too low.

At 80 on eliquis id wait too. 80 just not devestation feeling and he might convert. Surprised ep didnt offer something? Flec or rythmol to see if itd convert him
I cant remember if they want to observe you the first time using? Back in 08 i was given 4 150 mg propafanone and sent home to take. A loading dose. That load dose may be less now. See if Carey chimes in?

If it's been over a week then it's persistent AF. Very unlikely flecainide or anything else is going to convert him. Since it's a normal rate I would just wait.

Quote
Carey
If it's been over a week then it's persistent AF. Very unlikely flecainide or anything else is going to convert him.

Not saying this would happen to anyone else, but in 2004, I'd been out of rhythm for 2 1/2 months. EP gave me a script for PIP flec, and was going to give me some immediately in his office. Then he came back and said no, the literature said it wouldn't work and for me to schedule a cardioversion. I scheduled one for 10 days hence, then filled the script. On my own, I took the flec that evening and converted the 2 1/2 month episode. Took 20 hours, but it worked. I had an episode a month later (atria were likely still "stunned" from the long episode) that also took 20 hours to convert with flec. After that, flec has typically worked in an hour or two.

As to waiting. My philosophy has always been to minimize the amount of time I'm in afib, primarily to minimize electrical and physical remodeling that happens in afib. This is why I chew the foul tasting PIP flec. Hence I would go for an immediate cardioversion if offered.

And here is a perfect example from 2 experienced knowledgeable afibbers and me and the thinking is all over the place. Take flec! No flec wont work. Wait it out. No don’t wait
I too sometimes think that the longer youre in the bad rythm the more likely its to return sooner. Not sure science backs that up. It all goes back to Jackie: we re all experiments of one. I read an interesting article last night on athletes. Especially tall that have heart issues. Martina Larry Bird many. Bird makes a good point. You dont see 90 yr old 7 footers walking around. He is 6’9. Bobby Jones shopped my store for yrs. 6’9. NC USA olympic team. Phil 76ers. He got afib. I sent him to Holshouser 10 yrs ago

Quote
GeorgeN
On my own, I took the flec that evening and converted the 2 1/2 month episode. Took 20 hours, but it worked. I had an episode a month later (atria were likely still "stunned" from the long episode) that also took 20 hours to convert with flec. After that, flec has typically worked in an hour or two.

As to waiting. My philosophy has always been to minimize the amount of time I'm in afib, primarily to minimize electrical and physical remodeling that happens in afib. This is why I chew the foul tasting PIP flec. Hence I would go for an immediate cardioversion if offered.

Just a warning (so you don’t end up with a flecainide overdose like me and spend time in icu) there are strict dosing requirements. If you weigh less than 154 pounds then 200mg in a 24 hr is the maximum dosage for PIP. If you weigh more than 154 pounds then 300mg of flecainide within a 24 hr period is the correct dosing if your liver enzymes are working well and you are not taking another CYP450 family drug that could act as an inducer.

My cardiologist took a flecainide serum test to determine my maintenance dose of 200/day. You get your blood drawn exactly 23 hrs after your last dose. I recommend this test.

IMOP i want out ASAP......I am 1st trying the chemical route in mega doses if nec. (with susan's advice above) if not then Cardiovert.....YESTERDAY....when i was in Afib my mindset was similar to looking for the nearest exit while i was in the middle of a raging movie theatre fire.

Lani's friend most likely experiences few if any symptoms. People with a low ventricular rate usually don't. I know that's hard for people with paroxysmal AF and a RVR to understand, but it's true. Many people with persistent AF experience no symptoms whatsoever.

Remodeling isn't really much of an issue over a 30-day period. Remodeling generally takes many months, even years, and a normal ventricular rate probably minimizes it.

As for flecainide, I'm not saying it can't or won't convert it, but I think George's experience is unusual, and flecainide isn't the safest drug in the world. Hence, if I were asymptomatic, I would just wait. And since nobody here knows if her friend has a cardiac history that would make flecainide contraindicated, I sure wouldn't suggest trying it without his EP's blessing.

Quote
Carey
I sure wouldn't suggest trying it without his EP's blessing.

I certainly agree.

Ok educate me (us) why is Flecanide a type of risk? I used loading propafanone 600 mg back in my afib days. Worked 60-70 % of the time
But that was in the era of inside 48 hrs ok to cardiovert. Last week when i was cardioverted an EP who id never met told me a clot can form in 15 mins!
Im just not sure about that. We went from 48 hrs to 15 mins?!

Quote
Carey
flecainide isn't the safest drug in the world. Hence, if I were asymptomatic, I would just wait. And since nobody here knows if her friend has a cardiac history that would make flecainide contraindicated, I sure wouldn't suggest trying it without his EP's blessing.

It’s why I cringe when PIP advice is given. From experience, I agree with Carey, one should get their EP’s blessing beforehand.

Quote
Poppino
Ok educate me (us) why is Flecanide a type of risk? I?!

[www.afibbers.org]

Scroll from top to bottom. Flecainide has a black box label category (can cause death. [www.google.com] ) and isn’t the drug to recklessly experiment with.

Quote
Poppino
Ok educate me (us) why is Flecainide a type of risk? I used loading propafenone 600 mg back in my afib days.

Tom, either propafenone or flec have risks. Your EP had obviously determined your heart was structurally sound, therefore a low risk and prescribed the med for you for that purpose as had mine. In my case, he specifically said I was a good candidate, he just didn't think it would be effective for someone who'd been out of rhythm for 2 1/2 months, however I was free to use it PIP. I'd been anticoagulated on warfarin for several months also.

When they first developed flec, they thought it would be good for those with heart disease This is from the CAST trial

"CONCLUSIONS.
There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide."

From this review article, "Over the last 25 years, flecainide has been used extensively worldwide, and its capacity to reduce AF symptoms and provide long-term restoration of sinus rhythm (SR) has been well documented. The increased mortality seen in patients treated with flecainide in the Cardiac Arrhythmia Suppression Trial (CAST) study, published in 1991, still deters many clinicians from using flecainide, denying many new AF patients a valuable treatment option. There is now a body of evidence that clearly demonstrates that flecainide has a favourable safety profile in AF patients without significant left ventricular disease or coronary heart disease. As a result of this evidence, flecainide is now recommended as one of the first-line treatment options for restoring and maintaining SR in patients with AF under current treatment guidelines. "



Edited 1 time(s). Last edit at 07/25/2021 06:35PM by GeorgeN.

Ok thanks G. Just wanted the education. I never have afib anymore so its not of use to me anyway. Ive only had atypical flutter
T

Speaking of cardioversions. I've had somewhere between 12 - 20 ECV in last 13 years. It depolarizes every cell in the body. I love it, because it nearly always works. Recently (day 6 of my longest ever episode AF) I've been to 2 local hospitals who explain that the risks outweigh the benefits of ECV. I'm "low rate" (still high for me) according to all their protocols (based on mostly age 60-70 white male research; no offence but i'm tired of this being the protocol leader for ED things so often), and i'm on blood thinner. So they send me home w some metropolol or flecainide (alas doesn't work on me; procainimide used to, a long time ago in canada) and tell me how lots of people just "live in AF". I'm unlikely to die of heart attack or stroke. But. I'm very symptomatic (super weak), and feel like crap.
Previously, I had a current letter from my EPCardio that explains my situation (age 50, athlete) and to please ECV, and hospitals have often heeded this letter. I'm waiting to hear from my EP... either to explain the risk of repeated ECV, or for a new letter / directive.
This last 2 years I've been able self-revert several episodes at home, so I have not gone right into the ED. But on day 6 now, and heading towards what will soon be classified as 'persistent'.... bring on the ECV. if it's safe.
Is anyone current on this risk analysis of repeated ECV? Shannon perhaps? or Susan D.
Thanks heaps in advance.

Quote
strongHeart
Speaking of cardioversions. I've had somewhere between 12 - 20 ECV in last 13 years.
Is anyone current on this risk analysis of repeated ECV? Shannon perhaps? or Susan D.
Thanks heaps in advance.

I had yet another ECV last night. My HR was 145-148 with highs in 150. My record (not proud) is 45 ECV. 33 in ER and 12 during ablations. After my last ablation we tried chemical conversion but my heart tried to self convert by sinus arrest (pauses), up to every 5-10 minutes my heart would stop for 4-15 seconds for two days. I spent 8 days in icu. I ended up with a pacemaker because my AV was weak (prolonged AV conduction now) after my ablation. Ten days ago I self converted, 19 days before that I was hospitalized for 3 days with a BB drip. Adenosine doesn’t work and actually resulted in a type 2 MI. I’m running out of choices. I had a flecainide overdose and can’t be on it, sotolol they tried but wide QRS concerns if used long term and currently Multaq helps just a little. I can’t use ecv as afib/flutter/STV control each time my hr gets to 190.

Since I’m now 10 days apart, I can’t continuously get ecv. 29 days and two episodes ago I was offered an ecv and I hesitated since my pacemaker was new so it resulted in a three day hospitalization to get me back to nsr. Ecv I’m in and out.

I don’t think there is a clear answer whether to be ecv or not. I speculate it’s based on symptoms and stress to the heart and person to person..

Quote
susan.d

Speaking of cardioversions. I've had somewhere between 12 - 20 ECV in last 13 years.
Is anyone current on this risk analysis of repeated ECV? Shannon perhaps? or Susan D.
Thanks heaps in advance.

I had yet another ECV last night. My HR was 145-148 with highs in 150. My record (not proud) is 45 ECV. 33 in ER and 12 during ablations. After my last ablation we tried chemical conversion but my heart tried to self convert by sinus arrest (pauses), up to every 5-10 minutes my heart would stop for 4-15 seconds for two days. I spent 8 days in icu. I ended up with a pacemaker because my AV was weak (prolonged AV conduction now) after my ablation. Ten days ago I self converted, 19 days before that I was hospitalized for 3 days with a BB drip. Adenosine doesn’t work and actually resulted in a type 2 MI. I’m running out of choices. I had a flecainide overdose and can’t be on it, sotolol they tried but wide QRS concerns if used long term and currently Multaq helps just a little. I can’t use ecv as afib/flutter/STV control each time my hr gets to 190.

Since I’m now 10 days apart, I can’t continuously get ecv. 29 days and two episodes ago I was offered an ecv and I hesitated since my pacemaker was new so it resulted in a three day hospitalization to get me back to nsr. Ecv I’m in and out.

I don’t think there is a clear answer whether to be ecv or not. I speculate it’s based on symptoms and stress to the heart and person to person..

Wow Susan....i thought getting that PM would give you peace....but Natale being furious after hearing you got 1 is understandable now.
I like you are out of suggestions...although Chewing a small amount of Propafenone did WONDERS for me but the combination of you not reacting well to PIP's + your heart being pretty stubborn at this time acting up as it is i could very much understand you not even considering this but that's the only small suggestion i can give you... its a very small amount of drug not the normal amount of a PIP conversion dose that does amazing work in short time...Win Win...something to at least consider somewhat although i know so little about the implications of having a pacemaker is a PIP option even ok for you now...i am talk out of my hat on this 1.



Edited 2 time(s). Last edit at 07/26/2021 01:10PM by vanlith.

While on multaq I can’t take Propafenone.

Interested fact— these past three times (could be more but I didn’t connect the dots) my episodes occurred 11 hours to 11 hours 55 minutes after my last multaq dose. Perhaps it’s half life effects renders it ineffective, or somehow it’s an antagonist effect of blocking the full effectiveness of Multaq in combination of something I’m taking? Why does this happen minutes before my next dose? It can’t always be a coincidence.

Well if a lay person would ask you if multaq is doing little to nothing for you why cont?

Quote
GeorgeN

As to waiting. My philosophy has always been to minimize the amount of time I'm in afib, primarily to minimize electrical and physical remodeling that happens in afib. This is why I chew the foul tasting PIP flec. Hence I would go for an immediate cardioversion if offered.

'

I brought this up with my PA. She said no. But I do have an appointment with EP on Monday (I've been in Afib for a bunch of times and this time did not convert via ECV at the ER). How do I convince him to at lest let me TRY this?? (I am on dofetlidie which apparently isn't working..