Is it Persitent Afib Again?

I hope some of you can help me out.

Had persistent afib for approx 3 years before Dr Natale did my ablation a little over a year ago. Stayed in NSR since the ablation with no afib or flutter (no heart meds for last 7+/- months except blood thinner. 6 month and 12 month 7 day monitor were ok.

Then a few days ago my first afib - after an hour to 150m Flec/25mg Metop - NSR 3 hours later
Next episode about 30 hours later - I guess when Flec had diminished- waited 5 hours - took 250mg Flec/25mg Metop- NSR 3-4 hrs later
3rd episode 20 hours later- immediately took 100mg Flec (had already take 25mg Metop)- NSR 3 hours later- took additional 100mg Flec 12 hours later and stayed in NSR.

I wish I knew more about this but here are my questions.

1) Should I have waited longer to see if afib episode worked itself out?
2) Should I stay on 100mg Flec x2 a day/ 25mg Metop?
3) Should I try to decrease Flec to 75or 50mg to see if it still works?
4) Should I assume back I am back to Pers afib and schedule another ablation?
5) All suggestions welcome.

Do you weigh more than 154 pounds? If yes the maximum dose of flecainide is 300mg within a 24 hour period. You exceeded the maximum within the 24 hour window. Be careful of a flecainide overdose.
If you weigh less than 154 pounds the maximum in a 24 hours is 200mg.
[www.afibbers.org]

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Geocappy
I hope some of you can help me out.

Had persistent afib for approx 3 years before Dr Natale did my ablation a little over a year ago. Stayed in NSR since the ablation with no afib or flutter (no heart meds for last 7+/- months except blood thinner. 6 month and 12 month 7 day monitor were ok.

Then a few days ago my first afib - after an hour to 150m Flec/25mg Metop - NSR 3 hours later
Next episode about 30 hours later - I guess when Flec had diminished- waited 5 hours - took 250mg Flec/25mg Metop- NSR 3-4 hrs later
3rd episode 20 hours later- immediately took 100mg Flec (had already take 25mg Metop)- NSR 3 hours later- took additional 100mg Flec 12 hours later and stayed in NSR.

I wish I knew more about this but here are my questions.

1) Should I have waited longer to see if afib episode worked itself out?
2) Should I stay on 100mg Flec x2 a day/ 25mg Metop?
3) Should I try to decrease Flec to 75or 50mg to see if it still works?
4) Should I assume back I am back to Pers afib and schedule another ablation?

1. No
2. No
3. No
4. Assume nothing but consult Natale

In the meantime, use a 300 mg dose for PIP. The whole idea of PIP is to hit it hard and fast. You want to take the PIP as soon as possible after the episode begins, chew the tablets, and swallow with a large glass of warm water. Don't pussy foot around with smaller doses.

I am seconding susan.d’s warning. I weigh less than 154, my EP prescribed 150 mg of Flecainide twice daily and I went into complete heart block—which is very serious. I’d take dosing instructions from your Natale contact if I were you.

I favor the reasoning to hit it thoroughly and hard ASAP. Let's face it, you know AF, and you got it again. It's a sign that a re-entrant has been re-established. No sense in dicking around with part doses in the faint hope that you might return to NSR for months or years again. Your post says it's about 20 hours, and probably falling. So, with Susan's thoughtful warning in mind, no half measures here; knock that sucker onto its butt and keep it there. And call Dr. N right away.

I'm so sorry to see that this has happened. I think about this at least once a day, usually when I'm on this site/forum. I'm seven months out from a successful ablation, but the sign-off phone call from my EP had him inviting me to be referred directly back to him if I am one of the 35+% patients who will have to return for corrective ablation in the months and years ahead. Happens to the best of us, and I'm pretty darned good...if I say so myself.

I received an email from Natale’s nurse who spoke to the Nurse Practioner. She said 1st to use 150mg Flec. When I mentioned 300mg she said they didn’t recommend that. When I emailed back that didn’t work, they said do 100mg x2/35mg Metop. She said talk to Amy about setting up 2nd ablation.

I have seen several of you talk about getting a few episodes and going back into NSR. I guess three episodes in a row means another ablation

I’m happy you received follow up instructions from Dr Natale’s team.

For some, i.e. George N as an example, less (flecainide) is better. He recently posted better results for him after being a PIP advocate. Flecainide is a black box label drug. It’s not a drug to experiment with.

I am sorry. Bear with me as I try to understand this. Is the purpose of the PIP 300mg dose to rid one of the afib in lieu of another ablation or just knock it out til the next episode without having to take daily doses of meds?

It seemed to me when I called Natale’s nurse after my back to back episodes that a second ablation touch up and LAA procedure was inevitable.

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Geocappy
I am sorry. Bear with me as I try to understand this. Is the purpose of the PIP 300 mg dose to rid one of the afib in lieu of another ablation or just knock it out til the next episode without having to take daily doses of meds?

It seemed to me when I called Natale’s nurse after my back to back episodes that a second ablation touch up and LAA procedure was inevitable.

The purpose of the PIP dose of flec is to convert you to NSR. The duration of that NSR is very individual. If the time between episodes is short (no specific definition of short) it makes much more sense to take the flec chronically rather than PIP. Depending on the situation, either can push off the need for an ablation. Of course, sometimes the med can fail to work.

So if I tried the 300mg PIP (I did 250mg) and it comes back in 20 hours chances are I need another ablation if I am ever getting off meds. Taking 100mg x2 Flec is never going to improve my afib and it will most likely get worse to the point an ablation may not work?

Does the fact my initial ablation for persitent afib 3years) kept my afib away for a year a good thing or bad as it relates to the potential success for a touch up/LAA ablation. Or am I just better off on Flecainide if it is working?

If it comes back in 20 hours, you likely need an ablation and I would switch to a daily dose of flec in the mean time. While no set duration, if episodes are closer than a week apart and maybe even much longer, on average, I'd go to a twice a day dose as prescribed.

There are a number of people here with persistent afib here who were "fixed" by Natale on the 2nd ablation.

Thank you for your response. It just seemed crazy that I had nothing in a year and a solid 1r 7 day monitor and then boom. I hadn’t taken some of my supplements (magnesium and D3) for a week or so and thought that or some other deficiency might be it. Oh well. Maybe I am lucky my persistent afib even went dormant for a year.

It's a progressive disorder, most disappointingly, and I have all but resigned myself to feeling the dreaded palpitations again one day. Might be next week, might be next year, but the odds are around 50/50 for every successful ablatee. Even one full year free of the symptoms would make it all worth it...for me.

Sorry, Geocappy.

That is interesting you mentioned symptoms. I feel that I have never really felt symptoms (I.e. dizzy, chest pain, light headedness, nausea, etc). The most I can say I felt is a racing heart rate. So, I got the 1st ablation because I didn’t want to be on additional meds long term (I was already on 7) and The had increased my Flec to max 150x2 so I knew that may not work much longer. Now I am on 100mg Flec x2/25mg Metop with no obvious symptoms trying to figure out if 2nd ablation for my persistent afib is the way to go. Is it now or never. I am 69 year old taking meds for diabetes, high blood pressure, cholesterol, and CPAP. Other than that I am quite healthy.

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Geocappy
That is interesting you mentioned symptoms. I feel that I have never really felt symptoms (I.e. dizzy, chest pain, light headedness, nausea, etc). The most I can say I felt is a racing heart rate. So, I got the 1st ablation because I didn’t want to be on additional meds long term (I was already on 7) and The had increased my Flec to max 150x2 so I knew that may not work much longer. Now I am on 100mg Flec x2/25mg Metop with no obvious symptoms trying to figure out if 2nd ablation for my persistent afib is the way to go. Is it now or never. I am 69 year old taking meds for diabetes, high blood pressure, cholesterol, and CPAP. Other than that I am quite healthy.

The symptoms you mention above aren’t really the typical ones—more commonly we just feel a racing, irregular or pounding heart. Do you have your ablation report yet to see what he actually did a year ago? I assume he didn’t isolate the LAA or you would have mentioned it. In my touchup, it only took him a few minutes to do the extra work. I felt different after the touchup with a much lower resting heart rate. I know that it is a whole palaver to go to Austin again, but the situation you are in now is also distressing. Good luck.

My first two episodes of AF were, firstly, at the tail end of a 19 km run, and secondly about five weeks later while seated at my computer, mid-day. In both instances, the chest wall thumping was what alerted me, but on that 10 km run it was as I was seated on the curb waiting for my hear-rate to subside. It didn't, so I walked the rest of the way home. For the computer episode, after 30 minutes, and having been to the ER recently for the first episode, I figured I had better hie myself to the ER once again. While walking from the parked car, I could feel shortness of breath, and felt faint and weak while awaiting my turn at triage. They got me in right away when I said I was about to faint.

All other episodes since have not had any other indicators except chest wall thumping and what my Galaxy watch told me about HR.

Our church organist and his wife are active hikers, bikers, and kayakers (we live on the east coast of Vancouver Island, so temperate rain forest so mild winters). He never did realize he was in flutter until he was told about it from his physician. His case was expedited because nobody could say how long he had been in arrhythmia.

Yes, we are all different, but the outcomes narrow down to a finality over time...no variation. Unless we get on top of it ASAP.

I don’t have it yet. He did not do LAA but nurse said he most likely would do that on 2nd ablation. I remember him saying he could not that aggressive even though based on past experience he suspects he will need to do more later

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Geocappy
I don’t have it yet. He did not do LAA but nurse said he most likely would do that on 2nd ablation. I remember him saying he could not that aggressive even though based on past experience he suspects he will need to do more later

Request him to install your watchman after your LAA during another procedure. It’s quick. He is a pure artist. My veins were crooked and there was some tweaking getting the watchman through and my LAA was irregular and I had a big shoulder and he did his magic. I had a GI bleed at the time and he squeezed me in for an emergency watchman so after 24 hours I was able to stop Eliquis for 5 days to get a colonoscopy. He did a couple of TEEs while still under to reassure it was closed since I was stoping eliquis temporarily and I am a CHAD 5-6. Best decision ever getting my watchman. I, like others, have decided to remain half dose on Eliquis and if I miss a dose or have surgery I can stop it temporarily. I have no side effects except bruising which I don’t care about.

Is there some other choice between 2nd ablation or a life of med management starting with of Flec/25mg Metoprolol I should be considering?