Best Long-term Treatment For Persistent Afib In Older Person

I’ve had persistent, silent Afib 4 months and had a successful cardioversion 3 months ago. I am on metoprolol (50 mg./day) and Eliquis. I have made many lifestyle changes: no alcohol, no caffeine, reduced stress, more fluids, sleep apnea device, magnesium supplements. I have heard that persistent Afib is more difficult to ablate and NSR doesn’t last as long. I am 77 so my treatment might be different from someone who is 50. With my Afib, I have no symptoms and only discovered it when taking my BP one day. Would a realistic long-term treatment plan be to continue with lifestyle changes, reduce metoprolol (which I hate) to 25 or 12.5 mg./day, and, get a cardioversion when needed (e.g., optimistically, every 1-2 years)?



Edited 1 time(s). Last edit at 10/04/2021 04:35PM by Ice Man.

Id take a wait and see approach, then youll have options. Many your age are Ablated i have a friend ablated at 77 a year ago
You re doing the right things. Trigger avoidance and supplements. To call yourself persistent? Maybe. Maybe not. I do know that Dr Natale has had success ablating persistent afib. Were you anticoagulated during the silent persistent period??? Ill assume not. You dodged a bullet if so

Thanks. My BP monitor has a memory so I was able to determine closely when it started. It’s not like wearing a Holter monitor, but whenever I randomly took my BP, it came up 120-130/min. I started Eliquis within 2 weeks of when my Afib started. Why do you say I dodged a bullet?

2 weeks in afib without being anticoagulated is a decent risk of clot (stroke)
So thus: you dodged a bullet and we re greatful!

Persistent afib is definitely more difficult to ablate -- significantly more difficult, as shown by the success rates for all EPs, which is about 50% at best, but realistically more like 40%. Top EPs achieve much higher success rates, but I can count the number of them in the US on two hands, and worldwide maybe three hands.

Since you're asymptomatic, currently in normal sinus rhythm (NSR), and taking Eliquis, you've addressed all the things that need to be addressed. You should live as long as anyone else who doesn't have afib. If you're comfortable and afib doesn't impact your quality of life, I would not seek an ablation if I were you.

Ah, but you hate the metoprolol. Well, I'm with you on that because so do I. It sucks the life right out of me. But since you're in NSR, why do you need to take it on a daily basis? You should consult your EP and ask about taking it only as needed. If you eliminated metoprolol from your daily life, do you think you could live with the afib and Eliquis? If the afib returns (which it probably will), you might need to go back on the daily metoprolol if your heart rate is over 100.

Thanks. I'm hoping to go down on metoprolol to 25/12.5 mg. in Dec. when I see my cardiologist again. As you suggest, maybe I don't need it all the time.

I concur with Carey. If you are in NSR, likely no need for metoprolol. If you are in afib, then yes, you'd want to keep your rate < 100. If you have an adrenergic trigger then there is a rationale that having metoprolol act as a "governor" on your heart rate might keep you in rhythm. Since you just saw you were in afib from your BP monitor, I'm sure you don't have any idea whether you have an adrenergic or vagal trigger.

Something else to discuss, if your doc thinks it is appropriate for you, is the on-demand (AKA PIP or Pill in Pocket) use of a med to convert yourself without an electro cardioversion if you go out of rhythm. See: [pubmed.ncbi.nlm.nih.gov]

If it were me, I'd try to get a sooner appointment to reduce or get off metoprolol (to be used on-demand also).

Thanks. She told me to take an extra metoprolol if I flip back into Afib. If it doesn's help prevent a return to Afib, it does seem unnecessary.

I'm unclear on whether you're currently taking the Multaq or not. If you are, I'd go ahead and stop the metoprolol unless you flip back into afib and your rate is over 100. If you're not, then I would stop the metoprolol and start the Multaq on the same day. If it works, then no need for the metoprolol (unless you go back into afib > 100).

I've been on Multaq twice and know many others who've also been on it, and neither I nor anyone I know was combining metoprolol with it. If the Multaq works for you then it just doesn't make sense to also take metoprolol, especially since you dislike it.

Here is my take. When I first was diagnosed with afib, 17 years ago, one of the things I heard was that afib was "the hemorrhoids of cardiology."

As you know, the two big risks of afib are stroke (which the Eliquis mitigates) and cardiomyopathy leading to heart failure from extended rates over 100-110 BPM. The metoprolol will mitigate this. So the doc has done their job to keep afib from killing you with those two prescriptions. Many afibbers are like you in that they don't feel any different when they are in afib, and don't know they are in afib. Because of this, docs may be hesitant to do on-demand prescribing. You are different in that you regularly monitor yourself and your BP machine will indicate when you are in afib. You could also likely learn do feel afib in your radial (wrist) pulse. The irregularity is very distinctive, though this may be more muted while on metoprolol.

I would lay our a plan for your doc on how you will monitor (like how frequently) yourself to make sure you are not in afib. If you do go into afib, you will immediately start the rate control - metoprolol - at a dose that keeps your rate under 100 BPM at rest.

George he could buy a Kardia to monitor his afib? I have one but like Carey said : put it away! Due to my almost ocd pulse ckg. My rates are always high so i dont need Kardia to know im in a bad rythm. But the slow asymptotic afib is different

Thanks. I'm going to propose this approach to her. It makes sense. Plus, since I will still be taking Eliquis, she can schedule another cardioversion ASAP (she performs them herself).

Thanks. Never heard of Multaq, but would its side effects be worse than Metoprolol's?



Edited 1 time(s). Last edit at 10/06/2021 10:11AM by Ice Man.

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Ice Man
Thanks. Never heard of Multaq, but would its side effects be worse than Metoprolol's?

It tends to have few if any side effects. I never noticed any.

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Poppino
George he could buy a Kardia to monitor his afib? I have one but like Carey said : put it away! Due to my almost ocd pulse ckg. My rates are always high so i dont need Kardia to know im in a bad rythm. But the slow asymptotic afib is different

Sure, but if he goes off the metoprolol, then his BP monitor works also as the rate will be higher.

Not trying to be negative but Multaq did not work for me. It is also very expensive.

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smackman
Not trying to be negative but Multaq did not work for me.

That's what I told Natale, and he put me on it anyway following my ablation. And it worked.

Multaq is a "mild" antiarrhythmic that probably won't help with a hard core case of afib, but it is good at calming down an inflamed heart following ablations, and it's worth at least trying for almost anyone since it's so free of side effects.

Thanks. I never heard of it, but it may be worth mentioning to my cardiologist as a replacement for metoprolol.

Thanks everyone for all the ideas. After a message to her, my cardiologist advised me to discontinue metoprolol and monitor my heart rhythm. If I leave NSR, I should take metoprolol to switch back. I will continue to take Eliquis.

Ice Man, is your cardiologist also an electrophysiologist (EP)? EPs are cardiologists who specialize in heart rhythm problems, and that's who you need to be dealing with. It sounds like you're seeing a general cardiologist because it's really unlikely an EP would tell you to just take metoprolol if your afib returns. Metoprolol doesn't prevent afib, so it's not a solution.

My cardiologist is very experienced (> 20 years experience). She is not an EP. Metoprolol can be used to help people flip back to NSR. At a minimum, it will keep my heart rate from getting dangerously high until she does a second cardioversion. I think you are suggesting that an EP would recommend an anti-arrhythmia drug, but I have never taken any of them. Thanks for your concern.

I'm not questioning your cardiologist's experience. I'm questioning her training for your specific problem. I'm sure she's a fine cardiologist but she simply doesn't have the training to deal with afib that an EP does. We see this all the time here. General cardiologists just generally don't follow current medical standards for the treatment of afib because they're not up to date on what those standards are. I strongly recommend you find a good EP and get a second opinion. Yes, an antiarrhythmic drug is a likely solution, and you might find yourself in NSR all the time with the right one (without having to take metoprolol). Almost everyone on this forum has taken some sort of antiarrhythmic at one time or another, many of us for years. Like any drug, they can be a blessing or not, but if you have afib it's definitely worth investigating. To not even offer one to you is an example of the lack of training in this field.

Thanks again. You may be right. All these ideas are percolating in my brain and are not forgotten.

As the saying goes, Cardiologists are plumbers, EP’s are electricians.



Edited 1 time(s). Last edit at 10/29/2021 09:57AM by JoyWin.