initial appt is 2 months away

How can I get started on diag and treatment sooner, e.g. next week?

What could I expect if I went to the ER or Urgent Care during next episode (no symptoms other than fatigue), w/ rate around 150, otherwise low 50's resting rate?

No ama pcp since changing insurance several years ago.

Couldn't get an initial cardio appointment sooner then 10 weeks, after recent Holter Boston Sci read afib, though like afib for years now. Only other heath issue is hypothyroid, medicated.

If a Holter monitor detected afib then you've pretty much got your diagnosis. There's not a lot you can do to get a sooner appointment other than asking for them to give you any cancellations that occur.

If you go into an ER with a rate of 150, they'll probably just put you on a diltiazem drip and let you lay there for hours in the hope it will revert to normal rhythm on its own. If you don't, they'll probably send you home and tell you to see a cardiologist. Or they might even admit you, which you don't really need. They won't cardiovert you because you're not taking an anticoagulant.

Who do you have an appointment with? Are they an electrophysiologist (EP) or a general cardiologist (GC)? If it's the latter, cancel the appointment and find an EP. A GC is not the kind of doctor you need.

I doubt there's anything you can do to get in to see someone much earlier, but what does need to happen ASAP is for you to start an anticoagulant. Since you don't have a PCP you could give a walk-in a try. They might be willing to prescribe one for you if they can confirm afib on an ECG. If nobody will do that for you, I would suggest taking a low-dose (81 mg) aspirin daily (assuming you don't have bleed risks such as ulcers).

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Carey
If you go into an ER with a rate of 150, they'll probably just put you on a diltiazem drip and let you lay there for hours in the hope it will revert to normal rhythm on its own.

If you do decide to go to an ER and they want to put you on a diltiazem drip, ask if they will give you a diltiazem push over about 10 minutes instead. Some of us have found that this works much better than a drip.

CHAD2 score is 1 (female). been taking an asprin a day since holter. on average afib is 5x higher risk of stroke, but AHA guidelines say i'm a one percent-er, that less than 1% of afib patients are under 60yo
and the 2010 study of 855 parox and 1120 perm afibbers had a stoke incidence of about 25 per 1000 life years. I think that is 1 per 40 years, which seems pretty minimal. Don't get me wrong, I fear stroke more than death, but it seems at my age/health/CHAD2 there is no appreciable afib-associated risk or stroke until my CHAD2 goes up. Am I looking at that wrong?

This afternoon was prescribed Metoprolol Succ ER 25/mg, one per day, started on it an hour ago, hopefully nothing untoward will arise from it over this holiday weekend. When is ER MET most effective in the daily cycle? I'd like to time the swallow so that it's most potent period is in afternoon as that is the most likely time of my episodes. It's ER, so probably the curve is pretty flat, but it must be a curve.

Suppose a clot forms during an afib episode. What is time course of risk of stroke? Assuming no electro cardioversion attempts, the clot would get dislodged whenever the heart returns to normal flow in the atrium. It'd then have to move into an obstructing position in the brain (or elsewhere). So it seems the peak risk of stroke is well after return to normal rhythm. So wondering what the time-vs-risk looks like, from say a research study.

If there are no contraindications for you to take an anticoagulant it may be in your best interests to do so, especially if you are weighing up the possibility of a stroke. However, that is something only your EP can advise you with. And finding a well-qualified EP is paramount in treating the condition.

Also, I believe age has no bearing on stroke if you have an arrhythmia.
Studies that go back 12 years have probably been superseded by more relevant studies.

Are you in permanent AF or paroxysmal and if paroxysmal how long do your episodes last? Do you know your HR during an episode?

Why is aspirin no longer recommended?
Although daily aspirin use has been shown to lower the chance of having a first heart attack or stroke, it can also increase the risk of bleeding in the brain, stomach, and intestines.27 Apr 2022 from the medicine plus website.



Edited 1 time(s). Last edit at 09/02/2022 10:28PM by JoyWin.

I’m the last one to be giving advice so I’ll ask a question. In the interim, would taking a supplement such as nattokinase be of any help? I know some here take it as part of their daily regimen.

A rate much higher than about 120 means you're at a high risk for clotting in the left atrial appendage, and you SHOULD BE on apixaban or something like it.

If you go to the ER, especially with intractable and non-reverting paroxysmal AF, the usual guidance from physicians, including my own EP, is that anything over 24 hours should be fixed. So, if you know you've been in steady AF for at least 24 hours, you should go to the ER and get some help. If nothing else, they'll get to know you, and if you keep showing up for urgent care, they'll move you ahead of the pack, or at least well up the list, with a qualified authority, such as an EP.

Okay, you're essentially a CHADS zero since the point for being female has been removed from the guidelines as of 2019. That means you don't really need to be on an anticoagulant, but if I were you I would still consider it and still take the aspirin in the meantime.

Just take the metoprolol in the morning. You're overthinking it trying to find the optimal timing. It will become effective about 20-30 minutes after you take it and remain effective for the remaining dosing period. The curve is rather flat, as you said.

If a clot forms during an episode, the highest risk period is immediately after NSR and normal pumping action are restored. That's why an ER is very unlikely to be willing to cardiovert you without doing a TEE first, and most ERs wouldn't be willing to do a TEE.

So with this new information I'd say you're okay for a while with the metoprolol and aspirin.

One more question: Have you simply felt your pulse? Is the rhythm regular or irregular? A rate of 150 is always suspicious of being atrial flutter (AFL) rather than afib. Treatment is the same for both and the two go hand in hand, so it's kind of a moot point, but stroke risk is probably a bit lower for AFL simply because the rhythm is coordinated and pumping does continue to occur (just my opinion - I've never seen data to support that).

Also, how often do these episodes occur and how long do they last?

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Daisy

If you go into an ER with a rate of 150, they'll probably just put you on a diltiazem drip and let you lay there for hours in the hope it will revert to normal rhythm on its own.


If you do decide to go to an ER and they want to put you on a diltiazem drip, ask if they will give you a diltiazem push over about 10 minutes instead. Some of us have found that this works much better than a drip.

A 8 minute push works for me, but I have a pacemaker so it’s safe and 15mg is the only dose that works. A drip have never worked.

Spouse replying here. She's in bed nauseous likely from the initial 25mg MET yesterday evening.

CHAD Score: Not knowing there are both a CHA₂DS₂-VASc Score and CHADS₂ Score, we misspoke and wrote CHAD2 when we meant CHA₂DS₂-VASc

https://www.mdcalc.com/calc/801/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk

https://www.mdcalc.com/calc/40/chads2-score-atrial-fibrillation-stroke-risk#next-steps

The CHA₂DS₂-VASc link fwiw has at the bottom some interesting Q&A with the Dr who developed the score. That page says "1 points: Stroke risk was 0.6% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 0.9% risk of stroke/TIA/systemic embolism."

The AHA CHA₂DS₂-VASc PDF © Copyright 2021 also has Female +1. Sorry for using the term CHAD2.



Edited 3 time(s). Last edit at 09/03/2022 02:46PM by Kwilk.

Flutter & duration: She has trouble feeling her pulse under any circumstances. We've been using a Kardio 6L for about a week now, but it is only Normal/PossAFib/Brady/Tachy and does not have ability to report AFL. Looking at lead II during periods of Poss Afib, flutter is seems to be there given what we've seen this morning online image search. But online images are often cherry-picked to make a point.

I (spouse) question the Holter recording. I suspect the 24hr recording was simply run through some AI algorithm owned by Boston Scientific, and at best only superficially scrutinized by an anyone, let alone an EP.

Yesterday evening, about 3 hours after the MET pill the L6 reported brady in the upper 40's. Every handful or so of beats was a double beat. Looking over some the NSR recordings from past week, the double beat was there, though less frequently. So her real heart rate last night and this morning is more low 40's, with the extra beat upping it to high 40's.

Most recently, shed had 54 hours of normal, then poss-afib in the 125-150 ranges, which self converted 10 hours post onset, during sleep. That is typical scenario, afib on the 6L, 3-7 times per week, self convert, a half to a dozen hours duration, almost always self conv during sleep.



Edited 1 time(s). Last edit at 09/03/2022 02:46PM by Kwilk.

25 mg of metoprolol is a pretty low dose, so if that's dropping her heart rate into the 40s she's obviously very sensitive to it. I bet if you check her BP at those times you'll find it's very low, and that's probably what's making her nauseous. She might want to try cutting the pills in half and see how she does with that.

PS- No worries about the CHADS-Vasc thing. The proper acronym, CHA₂DS₂-VASc, is the most ridiculous acronym anyone ever invented, so I just assume anyone talking about their CHADS score means CHA₂DS₂-VASc. I almost never bother typing that nonsense myself and just say CHADS score.

You could get an Rx for a Blood Thinner from your Primary Care Dr., or probably an ER Doc or Acute care facility.

"Suppose a clot forms during an afib episode. What is time course of risk of stroke? Assuming no electro cardioversion attempts, the clot would get dislodged whenever the heart returns to normal flow in the atrium. It'd then have to move into an obstructing position in the brain (or elsewhere). So it seems the peak risk of stroke is well after return to normal rhythm. So wondering what the time-vs-risk looks like, from say a research study."

Alot of factors here, even if there was a clot, it doesn't necessarily mean that it would get dislodged after resuming NSR. The clots attach to the wall of the heart, and after 2-3 weeks they get absorbed in to wall of the heart. So 3 weeks out after restoration of NSR, it is accepted that if there was a clot from the AFIB episode, then it is no longer a high risk. The usual guideline is 3 weeks of anti-coagulation after restoration of NSR.

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KWilk
Suppose a clot forms during an afib episode. What is time course of risk of stroke? Assuming no electro cardioversion attempts, the clot would get dislodged whenever the heart returns to normal flow in the atrium. It'd then have to move into an obstructing position in the brain (or elsewhere). So it seems the peak risk of stroke is well after return to normal rhythm. So wondering what the time-vs-risk looks like, from say a research study.

At this point, my understanding is the weak-if-any temporal correlation between an AF episode and a stroke is no where near strong enough to explain the generic 5-fold stroke risk increase. So my question was ill phrased at best.

Had a great ER session. They did two pushes, which didn't convert the rhythm to NSR, but did slow it down. EP offered electro-conversion which I turned down after discussion. Swallowed a flec and went home. A couple hours later the 6L showed NSR, and has remained ever since. On flec and card twice a day with no side effects after a day or two. Discussed anticoags, chadvasc etc, but mutually didn't take that path. As for ABC-Stroke not sure if the bloodwork grabbed those two biomarkers. I didn't know it's superiority at that time. Seems researchers are also looking at AF / Dementia possibly due to cumulative micro-strokes, due to anticoags, or due to lack of them. Eventually my chadvasc is going to go up (age, at least) so I suspect anticoags will be recommended down the road unless my atrial cardiomyopathy reverses.