Persistent Afib/flutter Rears its Head -- Again

Not so brief background. An 80-year-old active guy with 22-year history of afib/flutter originally diagnosed in 1999. Paroxysmal episodes increased in frequency and duration following a transcontinental bicycle trip in 2001 and condition became persistent in mid-2016 following multiple cardioversions that would not keep me in NSR. The TCAI Maestro performed a major ablation in Aug. 2016 followed by a second in Feb. 2017. Things went along fine for 3 ½+ years when, sometime in the past year, I went out of NSR but was asymptomatic and cannot pinpoint a date. The situation became known a couple of weeks ago during an echocardiogram in preparation for my annual cardiologist appointment and was confirmed by an ekg at the appointment. The primary symptom missing is SOB. Before ablations it was so bad I could barely get enough air to breathe normally and could not withstand any significant exertion. Since the ablations I routinely do at least five days/week of cardiovascular exercise at 70-85% of my THR for at least 30 min with no other symptoms. The three bad signs of the recent echo are mildly dilated right ventricle with preserved systolic function, severe tricuspid regurgitation, and severely dilated right atrium (dilated to the point it is stretching the tricuspid valve flaps out of position and compounding the regurgitation).

My cardiologist, who claims to be conservative, says the afib/flutter is again persistent but I have a strong heart and wants only to increase the frequency of echocardiograms to six months with continued Multaq 400 mg 2X/day. He did not address cardioversion at all, not that I am averse to his decision because I experience no SOB during exercise and don't want to go down that road again having them not work. I am on the list for a tele-visit with Dr. Natale in Jan.

The big question: am I being slow rolled by my cardiologist?



Edited 1 time(s). Last edit at 10/30/2021 03:54PM by JayBros.

From the MULTAQ site: [www.multaq.com]

"Do not take MULTAQ if you have a type of atrial fibrillation (AFib) called permanent AFib. You should not take MULTAQ if you are in AFib and your doctor is not planning to change you back into normal rhythm. People with permanent AFib who take MULTAQ have a higher risk of death, stroke, and needing to be treated in a hospital for heart failure."

I would see no reason to take the med if you aren't going to get cardioverted. You'd need to be off it for the ablation anyway.

Thank you, George. Dr. Natale had me taking Multaq through my TEE in fall 2017 and said I could stay on it or cease as I saw fit because of travel distance to TX. In '18 or '19, don't remember which I contacted Nurse Educator about stopping is and she said I could quit it if I chose, no taper necessary, but if I stopped and went out of rhythm it would be back to TX. Don't know how much my cardiologist knows about Dr. N. as he's never said but he does know that if The Maestro says more work is necessary I'll be on my way.

I can't fathom your cardiologist's thinking. There is absolutely no reason to continue the Multaq if you're not going to attempt to stop the afib. Persistent afib + no intention of trying to stop it is what defines permanent afib. You saw what the Multaq product literature says about that. I would stop it immediately if I were you. It serves absolutely no purpose and presents a threat to you.

Thanks, Carey. That's why I asked if some folks thought I might be getting slow rolled. I know some of these large specialized practices like to keep all the work in house and, despite the fact that my cardiologist knew from the start that Dr. Natale was my EP, I sought him out after my first ablation. I had left my original cardiologist's large practice because wanted me to see an EP from his large firm and I'd had afib longer than that individual had been a doctor. Have stopped the Multaq and am weighing how to present my case to the cardiologist. Since I'm on Xarelto for life (Dr. N. switched me from Pradaxa to Xarelto before first ablation) because of CHADS VASc Score I can accept the risk until I get to speak with The Maestro.

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JayBros
Since I'm on Xarelto for life (Dr. N. switched me from Pradaxa to Xarelto before first ablation) because of CHADS VASc Score I can accept the risk until I get to speak with The Maestro.
.

What is your resting heart rate now? Would like it under 100 BPM if you are persistent. Otherwise, a rate control med would be indicated. If it is, I'd get it post haste. A long duration (days/weeks) high resting heart rate could expose you to cardiomyopathy leading to heart failure.

Oh, was he using Multaq as a rate control drug? I sure hope not, but if so and your resting HR is over 100, I would do as George suggested.

And if so, that really lowers my estimation of your cardiologist's knowledge of managing arrhythmias. Using a drug with a known lethal side effect in place of perfectly safe rate control drugs? I sure hope that's not what's going on here but I've seen general cardiologists do worse.

Thanks, George and Carey. My resting HR is and has been since the echo showed I was out of NSR around 90 and < 95 (via BP monitor) except when I intentionally run it into my exercise training zone. I sent my cardiologist a note this afternoon informing him I'd stopped the Multaq and my rationale therefor. Maybe I'll pop for a KardiaMobile although I really see no reason for one because I can tell from my carotid pulse. Will let you very helpful folks know that the doc says.

Okay, so you don't need rate control either. Maybe it would be better to have your resting HR down around 60/65 instead of 90/95 just to reduce the workload on your heart, but you've got time to figure that out.

I'll be interested to hear what your cardiologist's response is.

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GeorgeN
From the MULTAQ site: [www.multaq.com]

"Do not take MULTAQ if you have a type of atrial fibrillation (AFib) called permanent AFib. You should not take MULTAQ if you are in AFib and your doctor is not planning to change you back into normal rhythm. People with permanent AFib who take MULTAQ have a higher risk of death, stroke, and needing to be treated in a hospital for heart failure."

I would see no reason to take the med if you aren't going to get cardioverted. You'd need to be off it for the ablation anyway.

do you know if the same is for dofetlidie? (dang if I can ever spell that). I am dealing with afib since July 7- didn't covert with ECV. first time ever. I have kept on the dofetilide on advice of EP because if they do an ablation I could just go home and not stay for 3 days to re-do it. But I have been wondering the risks. Since I am in afib. (ablation was stopped due to a blood clot sighting on a TEE but the CT 2 hours later it was not.. I am waiting to see if/when I want to try again.).

If you plan on staying in afib forever, then taking a rhythm drug does not make sense. However, if you plan to convert or get an ablation, that is a different story, especially for a med like Dofetilide that requires a hospital stay to restart.

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GeorgeN
If you plan on staying in afib forever, then taking a rhythm drug does not make sense. However, if you plan to convert or get an ablation, that is a different story, especially for a med like Dofetilide that requires a hospital stay to restart.

yea. I was just wondering if it had the same warning as the Malaq. I will google a bit. I want an excuse to stop it. but I haven't made my decision yet on what to do at the moment.

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bettylou4488
yea. I was just wondering if it had the same warning as the Malaq.

No, it does not, and it has been specifically tested on persistent afib patients.

But I agree that it makes no sense at all to be taking any sort of antiarrhythmic if you're not going to at least attempt to restore NSR. That's all risk with no benefit.

Am still awaiting reply to my note to cardiologist, hoping somewhat that I haven't whizzed in my own punch bowl but must wait and see.

Heard back from my cardiologist today concurring in my stopping the Multaq and my general assessment of my current afib/flutter situation. No, no cardioversion because of my history of it just not working in my persistent state. HR is still consistent at about 90 on the BP monitor I had it up to 156 working out this a.m. and was not the least bit anaerobic on the hardest set of intervals with a THR of 140. Am keeping my fingers crossed for an early Jan televisit w/- Dr. Natale.