continue taking antiarrhythmic during blanket period?

Dear Afibbers,
I have been reading a lot of posts in the last few weeks, and I found them incredibly informative. Thank you!

I am 54, generally healthy. I had the first episode of paroxysmal afib in November last year after my mom's funeral in Italy. I had PVC/PAC on-off for several year, but never experienced afib. When I have afib I can barely sleep -- it is horrible. They converted back using a cardio version. I hoped it would not came back, but it did three more times in 2023. I had been converted successfully every time using the cardio version, but I never converted autonomously.

While all this was happening I was taking metaprolol which did not help at all (in fact it was making my palpitation worse). I started flecanide 50mg BID, and diltiazem 120mg ER daily and I ended up for the fourth time in the ER for a cardio version at the end of March.

Since early April, my EP at UC Irvine increased the flecanide 100mg BID. I am also taking a blood thinner (eliquis). Since then I had no more afib, however my EP recommended an ablation, which is scheduled next week.

I have read in some forums that some EPs recommend to keep taking antiarrhythmic after the ablation to minimize the chances of ending up in the ER with afib that would need a cardio version (I am really tired and exhausted by spending 8-10 hours at the ER every time). When I asked him, he said that he wants me off all meds except eliquis.

My question is whether I should push my EP to stay on flecanide (maybe a lower dose) after the ablation?

Thanks in advance,
Stefano



Edited 3 time(s). Last edit at 04/22/2023 11:57PM by SteLo.

I think what he means is he wants you off flecainide and all the drugs before the ablation. Most EPs want that because they want your heart to be as prone to afib as possible during the procedure so they can find the sources. What he wants you to do after the ablation is a totally different question, and it's likely he's going to want you back on some sort of antiarrhythmic like flecainide for a few weeks. That's pretty standard.

So you need to talk to your EP and clarify what the plan is. My bet would be he wants you off everything the week prior to the ablation but then wants you back on something like flecainide for a few weeks afterwards just to keep your heart calm during the blanking period.

Hi Carey,
thanks for your reply.

My EP wants me off flecainide and diltiazem two days prior to the ablation.

He said that after the ablation he does not want me to take any antiarrhythmic.
I was surprised, but I did not push back.

I would prefer to take some antiarrhythmic after the ablation to prevent visits to the ER.
I will discuss with him after the ablation.

Thanks,
Stefano

SteLo,

Why are you running to the ER so often? A day or two in afib is no big deal (with a blood thinner) for most of us, just give the Flecainide a change to work and convert you back to normal rhythm.

In my afib history, I had well over 200 episodes (up to 72 hours) and only one cardioversion.

Ken, I can't speak for our OP, but I can definitely sympathize because of how I deal with and respond to the effects of AF. I know a retired professor whom I see regularly who had no idea he was in flutter. He and his wife routinely kayak, hike, and bike. I know of others who don't feel their AF when it happens. However, some of us are deeply affected by our symptoms when we are in AF, and I suspect we're hearing from another example in our OP. The sensations, and to an extent what our minds tell us is happening, make our world very small, anxious, insomniac, and in my case grey and looking deathly. The latter according to my wife an friends we see regularly. Going many hours, waking up still in AF, is very disconcerting and builds on the anxiety and the loop keeps the AF thumping and bumping in our left chest wall. At least, that was my experience.

Some of it is poor coping, admittedly, and we need coaching. We get that here and from the various outreach nurses who populate AF clinics all over the globe. While that might take the edge off our feelings, it doesn't seem to do a lot of good with limiting the AF, or how it feels when it is underway. So, we go to the ER and hope to get cardioverted or offered some (more) medication, or different medication.

Most of us were put on a low dose of an antiarrythmic after our ablations for a few weeks to a couple of months. I took Multaq for about 2 months.

Gloaming,

I understand your point and I have a friend that never knows when she is in afib, so it's clear that its impact varies from person to person. I have always been in great physical condition and when in afib, the only impact was that I avoided working out, but everything else went on as normal. When going to bed in afib, sleeping on my left side was impossible, it felt like I was on a vibrating bed. The right side was much better.

I was also highly symptomatic and always knew IMMEDIATELY when afib kicked in. Checking my carotid pulse always was a clear indicator.

So, it begs the question. When your heart (without meds) is jumping around at 150 - 180 BPM, why is the impact and awareness so different from individual to individual? I am pretty lean, with a BMI (body mass index) of 22.1.

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Ken
SteLo,

Why are you running to the ER so often? A day or two in afib is no big deal (with a blood thinner) for most of us, just give the Flecainide a change to work and convert you back to normal rhythm.

In my afib history, I had well over 200 episodes (up to 72 hours) and only one cardioversion.

Not everyone is as non symptomatic as you during afib or STV or flutter and if having dizziness, shortness of breath, high tachycardia feeling of fainting etc, they may exceed your lucky one ecv count and need to go to the ER. Flecainide is great until it stops working. It’s not a cure otherwise ablations would have no customers.

Ken,
you are lucky to be non symptomatic when you afib.

When I have afib or atrial flutter, I feel like having a "war" in my chest. It is very hard to function, and
I am unable to sleep. The longest I have been in this state has been 24hours, and I could not wait to
feel normal again. I have never tried to take a high dose of flecainide to convert.

The only options I was given at the ER was (1) cardio version or (2) stay in afib/flutter until it resolves on its own.

I have never had the courage to take (2) because of the debilitating symptoms.

Stefano

SteLo, be careful with taking too much flecainide at one time. If you weigh less than 154 pounds, the maximum dose in a 24 hour is 200mg. If you weigh more than the max is 300. Below is my flecainide overdose story. It ruined my heart and the ICU told me I was lucky to not had died.

[www.afibbers.org]

I had 52 cardio conversions, the hospital record until nothing worked. I had 12 admissions in November and stayed practically the entire month.

Many here have your symptoms and need the ER. It’s not that easy with high tachycardia to self convert with flutter or STV.
The only relief in that case for those symptomatic is the ER for a BB drip or get an ecv. You are not alone.

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SteLo
The only options I was given at the ER was (1) cardio version or (2) stay in afib/flutter until it resolves on its own.

When I had my first episode of Afib I went to the ER with very high BP and HR. They gave me an IV push of Diltiazem over about 10 minutes which converted me in minutes. Some others here have had the same experience, whereas a Diltiazem drip doesn’t seem to be nearly as effective. Later a cardiologist then gave me a prescription for oral Diltiazem to take at home but I found that I had to take a hefty initial dose for it to be effective—if smaller doses were spaced out over hours, it did relieve symptoms but the half life was too short and I would eliminate it before the accumulating high a enough concentration in the blood stream. So these a a few more options: go to the ER and ask for a Diltiazem push or get an oral prescription to use at home. Since my worst symptoms came from elevated BP and HR, Diltiazem relieved them until I converted.

Quote
Ken
Gloaming,

... When your heart (without meds) is jumping around at 150 - 180 BPM, why is the impact and awareness so different from individual to individual? I am pretty lean, with a BMI (body mass index) of 22.1.

Until I came down with AF within blocks of home during a 10 km run in 2017, I too was a life-long competitive runner with a low BMI. Turns out I had severe sleep apnea on my back, but that, too, went unnoticed until the AF showed up.

My HR was 148 - 180..........WITH.......meds. When the internist says they want to raise your metoprolol dose to get your heart down under 100, and you're at a mere 118 lying on the gurney, there's a semblance of hope rattling around in your brain. That should be doable. And it eventually happens. But when you're running full tilt at 160-180, the goal is a little more elusive. Typically my HR in AF is between 95 and 135. When I had my angiogram a year ago, the surgeon told me to raise my dosage to 100 mg from 50 as he discharged me because I was at 183 on the operating table. Whhhaaaaaaaaaa....?!?! The ever-changing, and unpredictable, nature of paroxysmal AF drives some of us to distraction. For some of us, we feel it acutely, and it is very intrusive. I couldn't sit still watching TV with my wife. I would have to get up and walk around to try to calm myself or to mask the sensations in my chest wall. I'd have to sit and watch TV with both hands clasped above my head because the pressure of my upper arms and elbow seated normally was too much and seemed to be exacerbating the AF. I dunno what you think of that description, but it was aitch ee double hockey sticks behind my eyeballs.

Thanks for wading through all that muck.

Daisy,
I forgot that the last two times at the ER they gave me 10mg of Diltiazem via IV.

It did not convert me. Maybe it was not enough?

Stefano

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SteLo
Daisy,
I forgot that the last two times at the ER they gave me 10mg of Diltiazem via IV.

It did not convert me. Maybe it was not enough?

Stefano

It isn’t a sure thing and I don’t remember how many mg they gave me, but for me an IV push over a few minutes worked much better than an IV drip.

Quote
Daisy

They gave me an IV push of Diltiazem over about 10 minutes which converted me in minutes. Some others here have had the same experience, whereas a Diltiazem drip doesn’t seem to be nearly as effective. Later a cardiologist then gave me a prescription for oral Diltiazem to take at home but I found that I had to take a hefty initial dose for it to be effective—if smaller doses were spaced out over hours, it did relieve symptoms but the half life was too short and I would eliminate it before the accumulating high a enough concentration in the blood stream. So these a a few more options: go to the ER and ask for a Diltiazem push or get an oral prescription to use at home. Since my worst symptoms came from elevated BP and HR, Diltiazem relieved them until I converted.

Like you a 10 minute bolus push (straight into vein slowly) worked successfully for me for about 20 times. I would get resistance at the ER but I would say either ask Robert, a RN who knew me as a patient about 40 times or do it and watch the clock as we watched on. 2-3 minutes shy the nurse once said I converted and I told him I didn’t and to “wait for it”. He high 5 me saying a crazy you are my best friend because I did convert after a 10 minute push but never as a drip. Unfortunately/fortunately if one becomes an ER regular they start believing you and you can get doctors or nurses to verify what works for you since everyone is different.

Get a rx for daily time release Diltiazem and then take a regular fast acting Diltiazem PIP if you are allowed by EP and your HR doesn’t crash.



Edited 1 time(s). Last edit at 04/24/2023 05:37AM by susan.d.

SteLo- I am a fan of the pulse ablation technology. It’s safer because there is no heat, show’s promise and you should try to get on a trial if you can hold off. It’s only for those who never had an ablation, like yourself. A fellow participant of this forum had one and it was very successful.