sinus tachycardia after ablation?

I have had two ablations for afib/flutter.  last one four months ago seems to have worked, but now I have sinus tachycardia quite often.. is anyone experiencing this and is anyone taking diltiazem?  if yes, I'm curious about the dosage. Are you using immediate release or an extended release dose? thanks

I'm sorry that you have had this unwelcome and unanticipated development. It seems that often a procedure uncovers, or exacerbates, an underlying problem in our 'business'. I have learned from my EP that flutter is fairly often a successor to an ablation of the PVI type. I also know that almost all of us experience an elevated HR in the few weeks following a procedure. Are we talking about an HR in excess of, say, 90 in your case, or north of 100?

You'll find answers here shortly from people using all kinds of measures, including diltiazem and simple metoprolol, to control heart rate. I'm just post-ablation, two weeks, and have had my metoprolol raised from 25mg twice to 50 due to an eight hour AF episode last evening. I had been absolutely fine for two full weeks, went on a walk with the missus, a comfortable and slowish pace...just in case..., but was in AF on the toilet immediately after we arrived back home.

As for immediate vs extended, the latter is typically 'prophylactic', or meant to stave off what may happen without the drug, and it is 'timed release' of a sort. This is true of apixaban and of metoprolol tartrate. The succinate variety of metoprolol is more of the timed-release variety, as I have been led to believe. For acute need, say during an attack of arrhythmia, you would want the fast-acting 'pill in your pocket' response to beat the problem into submission quickly.

Please stand by for more comments.

How fast is it and are you sure it's sinus tach and not flutter? Has your EP seen a 12-lead ECG of it?

My HR is often above 90 even at rest...for years...when these episodes come it goes to 120s to 130 at rest, I an SOB, and it's quite debilitating. When I take a 30 mg IR ditliazem it can take over 2 hours for it to work...EP staff told me to check BP and if its systolic > 90 I can take another 30 mg. I have had to do that a few times. One pill usually work though but after a few hours. It seems to be becoming more frequent. I have been sending them tracings from Apple watch and Kardia, where it looks to them like Sinus tachycardia (and that is what the devices say). NP called me today about going for a 12 lead ECG but instead after discussion decided to send another wearable monitor---this one will transmit to them in real time instead of waiting 14 days to use it and then a few more days for the results. I will continue with the 30 IR diltiazem as needed until it arrives, and then wait until an episode occurs to then apply the monitor and capture it....after that we can decide what to do about meds, etc. It seems like an unusual but reasonable strategy to me. All of your comments are much appreciated.
Best,
Barbara

With SOB something is definitely going on. You need a 12-lead during the tachycardia. It could very well be flutter, and that's important to know. Even the device the doc is recommending probably won't be able to distinguish between sinus tach and flutter.

Thanks Carey...If I go in for a 12 lead ECG when I am not having an episode, will the flutter show up? In the last ablation they thought they got the flutter. I will ask about this.

If you're not in an episode when they take the ECG then they won't see it. This is the hard thing about paroxysmal episodes. How do you capture the 12-lead they really need when you can't predict when it will happen? Frankly, the easy answer (at least in the US) is an urgent care center. Almost all of them can do an ECG. So if you find yourself in an episode, drive straight to the nearest urgent care center and tell them what's going on.

Once they get the ECG, they might very well tell you that you need to go to the ER. Just don't. Just tell them you're familiar with your condition, you're under care, and you just needed the ECG. They'll understand and be fine with that.

thanks..so that means if I am controlling it with diltiazem it also won't show up on an ECG?

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bneedell
thanks..so that means if I am controlling it with diltiazem it also won't show up on an ECG?

But apparently you're not if you're having tachy episodes.

Also, flutter is notorious for being resistant to rate control drugs, so that just kind of adds to the suspicion. You need a 12-lead ECG during one of these episodes. That's the one and only diagnostic test that can be done.

The EP has suggested I try flecainide for 2 weeks "for diagnostic purposes" to see whether or not it will help suppress palpitations.

I read online from Cleveland Clinic:

"What are the benefits?
Flecainide is used only in people with serious, life-threatening arrhythmia. The medication can slow or block irregular heartbeat, preventing stroke and sudden cardiac death."

I have been told until now that my heart rate is not life threatening, and that the meds are only to improve my quality of life (which is not good right now).
your thoughts?

Quote
bneedell
The EP has suggested I try flecainide for 2 weeks "for diagnostic purposes" to see whether or not it will help suppress palpitations.

I read online from Cleveland Clinic:

"What are the benefits?
Flecainide is used only in people with serious, life-threatening arrhythmia. The medication can slow or block irregular heartbeat, preventing stroke and sudden cardiac death."

I have been told until now that my heart rate is not life threatening, and that the meds are only to improve my quality of life (which is not good right now).
your thoughts?

Here is a more detailed reference than what you read from the CC: [www.pdr.net] (go to this section: For the conversion of and/or prevention of paroxysmal atrial fibrillation and/or atrial flutter and paroxysmal supraventricular tachycardia (PSVT) prophylaxis in patients with AV reentry tachycardia and other supraventricular arrhythmias associated with disabling symptoms and without structural heart disease.)

I've used flec for more than 18 years, most of that time on-demand to convert episodes

1. You must have a structurally strong heart (i.e. no heart failure). Your EP must be convinced you fall into this category.
2. Overdosing with flec is bad. Basically no more than 200 mg/day if you weigh <154 #'s (70 kg) and 300 mg/day if you weigh more.
3. Flec can cause atrial flutter with 1:1 conduction and is commonly prescribed with a beta blocker to mitigate this risk.
4. If you are continually in afib, it is not recommended

Used properly, I think flec is a wonderful med. It certainly has been for me. It is a drug to be used carefully and not to overdose it.

What George said.

Cleveland Clinic is simply wrong. Originally flec was only used for ventricular arrhythmias, but it has been used for afib off-label for decades. They're just parroting what flecainide's official FDA approval says, which dates from 1985. I can virtually guarantee that section was written by a content creator, not a doctor or pharmacist. I've done content creation, and you'd be amazed how authoritative anyone can sound on subjects they know nothing about by simply spending some time with google. And nowadays, it may not even be a person writing that stuff. Look up ChatGPT if you're not already familiar with it. It's putting content creators out of work left and right.