Diltiazem and Digoxin for Persistent A-Fib?

I have a friend who is 75 years young. She has been in persistent a-fib for the past year. She has silent a-fib so she didn't even know she was in a-fib until it was discovered during a routine physical last summer. Her doctor put her on diltiazem and Eliquis at the time and told her to have a nice day.

About a month ago she decided to see an EP because she wasn't comfortable with her heart being in a-fib all the time even if she couldn't feel it. He recommended a cardioversion and daily flecainide (flecainide leading up to and after the cardioversion). She had the cardioversion one week ago and it was a temporary success. While she was in NSR immediately afterwards, she had a checkup with the EP today and her EKG showed her back in a-fib.

Since the cardioversion didn't work, the EP took her off flecainide and put her on digoxin. Her daily meds now are digoxin, diltiazem, and Eliquis.

This isn't my first rodeo with a-fib as I've been an afibber since 2006. I've had two successful Natale ablations, but I don't know much about drugs for the treatment of persistent a-fib. I would just like some info that I can pass along to her, or guide her in some way.

She doesn't have any money and her health insurance isn't great (just Medicare) so going to Natale isn't an option. She told me even if she had the money or the insurance to cover a Natale ablation she wouldn't be interested as she doesn't want to travel (she lives in the Midwest). She also doesn't want to deal with the prospect of having multiple ablations given her complex case. Bottom line, an ablation is off the table (at least for now).

With my limited knowledge of drugs and dealing with persistent a-fib, I don't know what to tell her if an ablation is out of the question. Based on my limited research in this forum, digoxin is not a good drug to be on and shouldn't be prescribed for a-fib. Doesn't diltiazem and digoxin do the same thing anyway (slow the heart rate)? Why would he prescribe both drugs? And isn't digoxin a very archaic drug? I'm inclined to tell her to just stick with diltiazem and eliquis for now and seek another EP for a second opinion on the best drug therapy. Thoughts???

Thanks,

Travis

P.S. I told her that if she is deciding to just live with silent persistent a-fib she should at least get an annual echo to stay on top of the overall health of her heart. With an annual echo, she would be able to see any early signs of heart failure. She brought this up to her EP and he said you can't have an echo when you are in a-fib so getting an annual echo isn't an option. Is this true?

Please allow me to be frank....

Her first doctor was correct and her second doctor hasn't learned anything since med school. Stop the damn digoxin, continue the diltiazem and Eliquis, and go about about her life in comfort knowing she will live as long and as well as someone who doesn't have afib. As long as the diltiazem keeps her rate consistently under 100 bpm, she doesn't have to worry about heart failure or anything else. And if it doesn't, it can be changed to a higher dosage or a beta blocker instead. This is a very manageable problem. Many, many people live happily for decades taking exactly what she's taking and doing nothing more.

Absolutely, positively forget an ablation. It makes no sense for her at all and that's probably what Natale would tell her.

Thanks Carey! She'll be thrilled to hear this. These recent events have been very stressful for her so hopefully this will put her mind at ease.

Thanks,

Travis

I must say I'm surprised that any EP would prescribe digoxin for afib in 2023. It's a dicey drug with a very narrow window between the effective dose and toxic dose. And like you said, it does the same thing the diltiazem does, so what's even the purpose?

My ep wanted me on it. Thanks Carey because I had said no. I am a huge fan of Cardizem.