afib and QT interval and alarms

I usually have afib with rapid ventricular response, once a year, since 2015. I always end up in an ambulance and in the hospital.

I just went two years, three months without an episode but was taken to the hospital by ambulance last week. Pulse 184.

The EKG's done showed a prolonged QTc Interval of 462. I looked back at prior episodes and it was as long as 504. Long QT intervals can mean increased risk of ventricular fibrillation. Torsades to Pointes and even cardiac arrest in certain circumstances.

Does anyone know if an afib episode lengthens the QT interval? I have read conflicting studies (which deal with different calculation systems).

I just rented an apartment that has a loud building fire alarm in my bedroom. I did not notice it at the time. I have never seen a system like this inside a unit. There are only 3 apartments in the building.

Alarms can trigger afib (this happened once) but I am also concerned about the QY interval and the effect on my heart of an alarm in the middle of the night.

Are you male or female? A QT of 462 isn't alarming if you're female. If you're male, a bit more so but it's still not all that alarming. Doctors aren't going to get concerned until it's over 500.

I don't think QT is going to be affected by afib. And why are you so concerned about QT? Have you been told it's a concern for you? Have you been diagnosed with WPW or long QT syndrome?

I also don't think you need to be calling an ambulance for afib, even with a rate of 184. Nobody dies of afib. They die of strokes because they didn't get proper care for afib, but not afib itself. Which makes me wonder, are you receiving proper care? Are you seeing an EP? If so, why don't you have a PIP solution in your pocket?

If you aren't familiar, PIP = "Pill in Pocket" meaning a rhythm med to take on demand that can convert you back to NSR. Here is the 2004 paper on the topic. In your case, with high afib heart rates, this could also mean a rate control med, such as a beta blocker, to slow your afib heart rate down and perhaps mitigate symptoms.

Per Carey's comment, are you on an oral anticoagulant med? What is your CHA2DS2-VASc score? Here is a reference to score it (ignore the point for being female, if you are female).

My blood pressure is low. The hospital actually put me in the ICU with my last afib episode. I cannot take beta blockers. I do have diltiazem to pop but it doesn't stop the episode. (Yes I know about PIP). Diltiazem also lowers bp. I have been told to always call an ambulance. It is very infrequent but dramatic when it happens.

My QTc was 504 last time. I have been told it is "borderline" long and that I should avoid zofran and other meds that lengthen it. I know that "borderline" is a bit controversial.

I declined an anticoagulant in 2015. One doc wanted me on, and one doc didn't. The doc who wanted me on now says I was right and that they may be overmedicating people.

My last episode lasted 7 hours and the hospital did an echo to check for clots. Usually I convert within 5 hours, often sooner.

This last episode ended pretty quickly but my heart feels wobbly and my Kardia just shows PVC's. Not concerned.

I just wanted to know if afib caused longer QT interval. I know that the reverse is true and I saw one study that suggested afib could lengthen it during an attack- which would be good news.

I feel as if the responses here are a bit dismissive. I am not a hypochondriac. I have many health issues that I won't go into. If anyone knows if an afib episode temporarily lengthens QT interval, let me know. Otherwise I have the situation well in hand.

ps One reason for this question is decisions on what meds to take, including zithromax. Cardiologist cannot see me until November.



Edited 3 time(s). Last edit at 09/04/2023 12:28PM by windyshores.

Of course prolonged high HR can be dangerous depending on how long and other symptoms you may have like shortness of breath, near fainting spells or fainting spells, chest pain etc. Not to be taken lightly if it persists for long periods, as I have discovered.

I'm sorry you feel that the answers were dismissive. I assure you none of us intended to be, nor do we think you're a hypochondriac. It's just that you provided very little information so I was asking questions. (I still don't know if you're male or female, which is highly relevant to any discussion about QT.)

The short answer is no, afib does not widen QT.

@Carey you wrote this: " I also don't think you need to be calling an ambulance for afib, even with a rate of 184."

Every doctor and every EMT or paramedic has told me to absolutely call an ambulance when I have these episodes. I have asked repeatedly. Clearly , my situation is different from yours. Last post here.

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windyshores
@Carey you wrote this: " I also don't think you need to be calling an ambulance for afib, even with a rate of 184."

Every doctor and every EMT or paramedic has told me to absolutely call an ambulance when I have these episodes. I have asked repeatedly. Clearly , my situation is different from yours. Last post here.

My situation was similar to yours. Everyone is different and I was thanked by the triage nurses when arriving by ambulance as they also suggested.

Clearly it is. I guess you have other issues going on that you don't want to reveal, and that's of course your right, but a shame you feel the need to leave on an angry note. You could have just asked google instead.

(I'm a former EMT, by the way.)

WindyShores has been posting for over 5 years. I always was interested in her posts. Any questions about chads scores etc was disclosed in prior posts. Fyi she is 72 with a chads1. She has GERD. No structural problem with heart and was advised by this forum years ago to call 911.

“ The problem is the tachycardia in terms of calling an ambulance. My symptoms are kind of dramatic.”

Take care WS! I wish you the best. Continue using your own good judgment when you feel it’s necessary to use an ambulance. Only you know your body and how AFib affects you.

In my afib journey I remembered being told by the ER to always call 911 and I was in the ER almost nightly with 187-189 hr until I started on flecainide and had a successful 15+ break. I also fainted a lot from my symptoms and while I was in the ER with my tachycardia, I got my roadmap scalp stitched as well.



Edited 2 time(s). Last edit at 09/04/2023 10:07PM by susan.d.

Of course they're going to tell you that. They almost have no choice. You've perhaps heard the acronym CYA?

If a patient asked me as an EMT, I would say the same because I wouldn't want to hear my words thrown back in my face two years later by their survivors when they died at home because "That EMT told me I didn't need to call 911." You have no idea how many patients I've advised to go to the ER who deep down I didn't think really needed to. But I'm not functioning in the role of a licensed medical provider here, so I feel free to offer more honest advice and not tell people what the insurance company thinks but what I actually think.

And, Susan, for you to talk about calling 911 is kind of absurd. You've taken Uber to the ER many times expressly against my advice. Some people need to call 911 and some don't. You're one who almost always does and maybe WS is too, but I'm not going to read someone's entire post history to figure out which they are. I don't understand the angry reaction to simple questions.

Not apples to apples. 911 yes to get me to any close ER to see any random cardiologist or EP who doesn’t know my history before ablations. But since my ablations 911 wouldn’t drive me obviously 30 minutes out of the way to a hospital where I had my Ep (Natale) who I trusted. Not all hospitals are linked to read other hospitals histories and I prefer an EP I trust no matter the distance even if it meant taking a Lyft.

So yes I took Ubers or Lyfts to Dr Natale’s hospital where either he was in town or his NP was possibly available and told the drivers there is an extra $20 to get me there. And they did in no time.

The possibility of you dying en route in the back of an Uber isn't a very good justification for choosing hospitals against sincere, knowledgeable advice. Any ER can intervene in a life-threatening emergency and then stabilize you and have you transferred to the facility of your choice.

But that's all beside the point. My standard advice to someone with uncomplicated afib would not be to call 911 for an afib episode. My advice would be relax on the couch, take a PIP if you've got one, put on a good movie or something, chill, and wait for it to end. Like I said, nobody dies of afib directly. Unless you have other issues, an afib episode is not life threatening.

FWIW, I can see both sides of this, and probably both of you can as well. You've both been in that anxious state, truly uncomfortable, demurring, wondering if this is the time to get to an ER....you both know the feeling as well as I do. I have never called an ambulance because I felt like I had time and that there was no imminent danger...just anxiety and wishing fervently for my heart to kick itself back into NSR. But I HAVE driven myself or been driven to the local ER when I simply couldn't stand it any longer and felt like I was going to be awake all night. I don't sleep well, or long enough really, so one bad night puts me into a tail spin.

One time, after the inevitable reversion, and this in deference to Carey, I was sheepish and said aloud that I had taken up a lot of resources for nothing...another three hours at home and I'd have been in precisely the same newly reverted state. The nurse said it was absolutely the right thing to do..to get to the ER, and to not second-guess myself that way, not about my heart. Still, the story has been the same, whether cardioverted or just waiting it out on a gurney, once in a busy hallway and not in a cubicle; inside of six hours the missus and I slink back home and heave a sigh as we walk into the front door to let our Italian greyhound out for a pee.

Leaving aside one's dread, or ability to withstand the uncertainty and the feeling that one is possibly going to remain in AF this time...for once...there is that big hammer called history. If one has a history of needing interventions, especially if they have time-limited the unwanted cardiac behavior, then a person naturally wants to avail themselves of the same effect and outcome, and that means wanting to get to an ER. If a person can't drive for one reason or another, then a taxi or an ambulance is the way to go.

So, I can personally sympathize with these stories, but I also see, with the rational eye, Carey's point that hurrying to an ER is most often not necessary. Swallow a pill, chillax, and let the usual turn of events happen. Go for a walk, read a book as best you can, but relax and it will be all right.

Quote
gloaming
So, I can personally sympathize with these stories, but I also see, with the rational eye, Carey's point that hurrying to an ER is most often not necessary. Swallow a pill, chillax, and let the usual turn of events happen. Go for a walk, read a book as best you can, but relax and it will be all right.

Everybody can have a different situation. I went to the ER (driving myself - my ski patroller friends tell me you'll never see a patroller on a sled - that isn't for practice - unless they are unconscious. I'm pretty much in the same category) on episode #1 because I had no idea what was going on. I picked up the afib (only knowing it was very unusual) with a stethoscope while taking my blood pressure. It sounded very odd. Threw on a heart rate monitor with a 5 second average display and wondered what was happening to my rate as I was very fit and mild exertion, like walking up stairs, pushed it to 150+.

However that experience taught me, that for me, afib was not a trip to the ER.

I can also relate to both approaches too a highly symptomatic a fib episode. The first time I did not have any idea what was going on but my heart rate monitor was showing 180 to 190 and I felt absolutely terrible.. So I drove myself to urgent care, not willing to take that extra step and call an ambulance for the first time ever. The urgent care was not open yet so I knocked on the glass door until someone showed up and just held up my heart rate monitor for them to see and they let me in….Then they called an ambulance! When it happened two weeks later, this time I called an ambulance as I did not yet have a cardiologist and thus had no means to treat it at home. After I was established with a cardiologist and an EP, I took medication at home and waited it out.

I am just going to say this one time. I cannot just pop a pill. I have low blood pressure. EMT's gave me diltiazem and my bp was 60/30. The teaching hospital put me in the ICU. That doesn't seem to argue for staying on the couch.

I am tiny and it feels like big fish flopping around. I remain calm. I don't get anxious, in fact paramedics comment on this. The whole thing is familiar if infrequent. I get chest and left arm pain, short of breath, and very faint. Heart rate fluctuates and can reach 190. My EKG has a few other things going on (depressions) and my troponin goes up. I also have QTc interval up to 504 but fast heart rate can indeed affect that measurement and who knows which formula the local hospital is using.

I was an EMT too. In the city.

I have just gone two years and three months without a significant episode. I had one that I resolved myself (drove myself to the hospital parking lot just in case). I can tell when I need 911. I have been drinking low sodium V-8 and discovered GI triggers, mainly gas in the chest area that responds to gas X. I resolved that one episode by reaching for Gas X, not diltiazem, and sitting up straight. (Because my torso is tiny and I have several spinal fractures, I don't think there is room in there and gas presses on my heart. Position matters too.)

Noone I know wants to call 911. I hate the commotion and attention and am known to drive to the police station and have them call. I have been told in no uncertain terms not to do that.

I give health advice on other health forums and occasionally slip and write in the patronizing tone that Carey used here. I apologize when that happens.

editing to add that of course I will go on anticoagulants if I have episodes more often; I have read a great study on short term (one month) anticoagulation for someone like me if an episode exceeds 5 hours; wish that would go into practice. In the meantime, once the female point was removed from the CHADS score, I not longer met the criteria for anticoagulation so it is a good thing I declined.



Edited 1 time(s). Last edit at 09/05/2023 03:38AM by windyshores.

I apologize for using a patronizing tone.

It does sound like you have a complex history. Okay, you can't use a BP lowering drug, but how about antiarrhythmics? You have an EP and all that?

Not everyone can use a PIP. Everyone is different but obviously I’m not alone with pip being an option -there are others who need the ER. I had a flecainide overdose and fought for my life so what are my options? So sitting it out watching a Netflix movie isn’t an option because I was usually in angina and half out of it. Once I arrived in the ER by Lyft (yes that was a bad call) and they started to prep me in the hallway being gurney quickly to a room for an ECV within minutes-stating I didn’t appear to be looking good and they zapped me as fast as they could and I was transferred back in the icu. What would had been the outcome if I chilled at home? Nobody knows so first instinct to go to the ER is a good call if in doubt.

Some ERs may unfortunately have a doctor on call who believes there is nothing wrong with living in Afib and won’t bother treating Afib and send me home with stable 180 flutter. Dr Natale hospital where he has attending privileges knew me by my frequent visits. The nurses were my advocates. Once a young dr told me to go home and I refused. He then took away my blankets and chair claiming he was removing all comfort. I laid down for an hour until a familiar nurse woke me up and said he talked to the dr and they would either chemical treat or ECV. That ER doctor apologized stating (after nurses were giving him my history and recommended a cardizem push would work) and he was too harsh on me. Any random hospitals wouldn’t know my history like the nurses who had treated me knowing what dose of cardizem push works to how much joules I need to convert.

A random ER by ambulance one may not find a familiar face who will be your advocate when one is too out of it to speak up. But you are right-Lyft isn’t safe but I had nobody to take me to my hospital of choice.

Carey

You said the following I also don't think you need to be calling an ambulance for afib, even with a rate of 184. Nobody dies of afib. They die of strokes because they didn't get proper care for afib, but not afib itself. Which makes me wonder, are you receiving proper care? Are you seeing an EP? If so, why don't you have a PIP solution in your pocket?

As you probably know I have had AF episodes for about 20 years, they were not too often and I always converted. I am now in permanent AF for about the last 3 years, I took and take Zeralto everyday for those 3 years, but it did not stop me from having a stroke this past May 30th. I have a tingling/some weakness in my right foot./hand/arm.. I am taking exercises for it, I do most of the work I always have done, but the numbness/tingling are still the same.

Liz

Sorry to hear about the stroke. But I'm not sure I understand your point. Signs of a stroke are always reason to call an ambulance. Even if you think you can drive there faster, going by ambulance means there will be no delays at triage and you'll be taken to the hospital best equipped to handle strokes. The ER will know you're coming and will be pre-prepared. You'll go right into the stroke program without having to wait for someone to do a workup, and with brain tissue, time is everything.

Carey:

If I didn't have AF, I would not have had a stroke. I had an Ep, took a blood thinner when in permanent AF, exercised, I have always ate quite well, no junk food, raised a lot of my veggies/fruit. I never had an ablation, so maybe that would have helped me. However, I know of a few people that have had ablations and still got a stroke. So, the whole point being is we need more knowledge about AF, it can and does lead to problems.

L

Quote
Elizabeth
If I didn't have AF, I would not have had a stroke.

Maybe.

I've been asked many times why I continue taking a half-dose of Eliquis despite being afib-free for 6 years and having a Watchman device. The short answer is afib isn't the only cause of strokes.

But I certainly agree that we need more knowledge about AF.

Here are some quotes from a few studies on oral anticoagulants. "Warfarin reduces stroke risk by 64% and mortality by 26%" "Low-dose new oral anticoagulant regimens showed similar overall reductions in stroke or systemic embolic events to warfarin (1·03, 0·84-1·27; p=0·74), and a more favourable bleeding profile (0·65, 0·43-1·00; p=0·05), but significantly more ischaemic strokes (1·28, 1·02-1·60; p=0·045)."

My interpretation is that these drugs produce a very significant risk reduction in ischemic strokes, but NOT 100%. The NOACs have less bleeding. I didn't pull up the detail, however my understanding is that these risk reductions apply to the risks after considering a subject's CHA2DS2–VASc score. Hence it makes sense to lower CHA2DS2–VASc as much as possible, if possible.

Detail:

Source: [pubmed.ncbi.nlm.nih.gov]
Findings: 42,411 participants received a new oral anticoagulant and 29,272 participants received warfarin. New oral anticoagulants significantly reduced stroke or systemic embolic events by 19% compared with warfarin (RR 0·81, 95% CI 0·73-0·91; p<0·0001), mainly driven by a reduction in haemorrhagic stroke (0·49, 0·38-0·64; p<0·0001). New oral anticoagulants also significantly reduced all-cause mortality (0·90, 0·85-0·95; p=0·0003) and intracranial haemorrhage (0·48, 0·39-0·59; p<0·0001), but increased gastrointestinal bleeding (1·25, 1·01-1·55; p=0·04). We noted no heterogeneity for stroke or systemic embolic events in important subgroups, but there was a greater relative reduction in major bleeding with new oral anticoagulants when the centre-based time in therapeutic range was less than 66% than when it was 66% or more (0·69, 0·59-0·81 vs 0·93, 0·76-1·13; p for interaction 0·022). Low-dose new oral anticoagulant regimens showed similar overall reductions in stroke or systemic embolic events to warfarin (1·03, 0·84-1·27; p=0·74), and a more favourable bleeding profile (0·65, 0·43-1·00; p=0·05), but significantly more ischaemic strokes (1·28, 1·02-1·60; p=0·045).

Source: [academic.oup.com]
10.1.4 Stroke prevention therapies
10.1.4.1 Vitamin K antagonists

Compared with control or placebo, vitamin K antagonist (VKA) therapy (mostly warfarin) reduces stroke risk by 64% and mortality by 26%,412 and is still used in many AF patients worldwide. VKAs are currently the only treatment with established safety in AF patients with rheumatic mitral valve disease and/or an artificial heart valve.

The use of VKAs is limited by the narrow therapeutic interval, necessitating frequent international normalized ratio (INR) monitoring and dose adjustments.413 At adequate time in therapeutic range [(TTR) >70%], VKAs are effective and relatively safe drugs. Quality of VKA management (quantified using the TTR based on the Rosendaal method, or the percentage of INRs in range) correlates with haemorrhagic and thrombo-embolic rates.414 At high TTR values, the efficacy of VKAs in stroke prevention may be similar to NOACs, whereas the relative safety benefit with NOACs is less affected by TTR, with consistently lower serious bleeding rates (e.g. ICH) seen with NOACs compared with warfarin, notwithstanding that the absolute difference is small.415,416

Numerous factors (including genetics, concomitant drugs, etc.) influence the intensity of VKA anticoagulant effect; the more common ones have been used to derive and validate the SAMe-TT2R2 {Sex [female], Age [<60 years], Medical history of ≥2 comorbidities [hypertension, diabetes mellitus, CAD/myocardial infarction, peripheral artery disease (PAD), HF, previous stroke, pulmonary disease, and hepatic or renal disease], Treatment [interacting drugs, e.g. amiodarone], Tobacco use, Race [non-Caucasian]} score,417 which can help to identify patients who are less likely to achieve a good TTR on VKA therapy (score >2) and would do better with a NOAC. If such patients with SAMe-TT2R2>2 are prescribed a VKA, greater efforts to improve TTR, such as more intense regular reviews, education/counselling, and frequent INR monitoring are needed or, more conveniently, the use of a NOAC should be reconsidered.418
10.1.4.2 Non-vitamin K antagonist oral anticoagulants

In four pivotal RCTs, apixaban, dabigatran, edoxaban, and rivaroxaban have shown non-inferiority to warfarin in the prevention of stroke/systemic embolism.419–422 In a meta-analysis of these RCTs, NOACs were associated with a 19% significant stroke/systemic embolism risk reduction, a 51% reduction in haemorrhagic stroke,423 and similar ischaemic stroke risk reduction compared with VKAs, but NOACs were associated with a significant 10% reduction in all-cause mortality (Supplementary Table 8). There was a non-significant 14% reduction in major bleeding risk, significant 52% reduction in ICH, and 25% increase in gastrointestinal bleeding with NOACs vs. warfarin.423

The major bleeding relative risk reduction with NOACs was significantly greater when INR control was poor (i.e. centre-based TTR<66%). A meta-analysis of the five NOAC trials [RE-LY (Randomized Evaluation of Long Term Anticoagulant Therapy), ROCKET-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation), J-ROCKET AF, ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), and ENGAGE AF TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48)] showed that, compared with warfarin, standard-dose NOACs were more effective and safer in Asians than in non-Asians.424 In the AVERROES [Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment] trial of AF patients who refused or were deemed ineligible for VKA therapy, apixaban 5 mg b.i.d. (twice a day) significantly reduced the risk of stroke/systemic embolism with no significant difference in major bleeding or ICH compared with aspirin.425

Post-marketing observational data on the effectiveness and safety of dabigatran,426,427 rivaroxaban,428,429 apixaban,430 and edoxaban431 vs. warfarin show general consistency with the respective RCT. Given the compelling evidence about NOACs, AF patients should be informed of this treatment option.

Persistence to NOAC therapy is generally higher than to VKAs, being facilitated by a better pharmacokinetic profile of NOACs432 (Supplementary Table 9) and favourable safety and efficacy, especially amongst vulnerable patients including the elderly, those with renal dysfunction or previous stroke, and so on.433 Whereas patients with end-stage renal dysfunction were excluded from the pivotal RCTs, reduced dose regimens of rivaroxaban, edoxaban, and apixaban are feasible options for severe CKD [creatinine clearance (CrCl) 15 − 30 mL/min using the Cockcroft-Gault equation].434,435 Considering that inappropriate dose reductions are frequent in clinical practice,436 thus increasing the risks of stroke/systemic embolism, hospitalization, and death, but without decreasing bleeding risk,437 NOAC therapy should be optimized based on the efficacy and safety profile of each NOAC in different patient subgroups (Table 11). ,



Edited 1 time(s). Last edit at 09/07/2023 12:45PM by GeorgeN.