How long to wait to treat persistant Afib

The Dear Wife has had paroxysmal afib for about ten years. She would have symptoms (pain/discomfort) about 10-15% of the time. Her measured burden (by Holter) was 3%. However lately ( 4-5 months) she has had many more episodes (as detected by smart watch) - albeit without any overt symptoms.

Over the past several months she and I have met with her cardiologist and he he put her on a 14 day monitor, to see if a cardioversion or medication change was appropriate. The results were 100% burden.

Following these Holter results (100% burden) he scheduled her for a cardiac stress test that was completed last week, the interpreted results of the cardiac stress test was "normal" and the afib continued.

Through his nurse, his advise is to schedule an office visit with an electrophysiologist (team mate). That appointment is now eight weeks away.

She will continue to take her Multaq and Warfrin (that she has been on for approx 10 years)

So, my question is: Should she just relax and wait for this scheduled appt, OR should she be more aggressive and insist on being seen earlier?

Obviously my concern is does persistant (but pain-free) AFIB cause damage to the heart while we wait ,

My non-medical opinion:

Taking a rhythm med, like Multaq is pointless while you are in persistent afib.

While sooner is better, a couple months probably won't change the equation much.

The quick change that could be made would be to get an ECV (electro cardioversion) and change rhythm meds (Multaq is the weakest). Whether you could get them to do that is another question. If her afib heart rate is low (<100 BPM) and she's not bothered by the afib, there is an option to not treat further and just live with it and continue with the warfarin anticoagulation. If she is in persistent afib for a material amount of time, it will be more difficult to successfully ablate and using a top tier ablating EP would be prudent, if she chooses to go that route.

There's no harm in waiting as long as her resting heart rate remains under 100. Besides, good luck with insisting on a sooner date. Almost all medical specialists in every field are booked solid for months due to the 2-year COVID backlog. I would recommend relaxing and waiting.

However, if she's persistent now I would question who the EP is who will do the procedure and how much experience they have doing ablations for persistent afib. Ablations for persistent afib are extremely difficult and have a miserable success rate on the order of 40%. However, that's the success rate for all EPs in general. There is a small handful of EPs in the US who have much higher success rates, upwards of 80%. If you've been on this forum long you've probably seen the name Andrea Natale. He would be the #1 example of such an EP and he's exactly who I would be booking the procedure with if I were your wife. An excellent second choice is Pasquale Santangeli at Cleveland Clinic.

Has an MRI or echo-cardiogram shown substantial enlargement of the left atrium? If it is quite enlarged, many EPs will opt not to do any mechanical treatment such as catheter ablation. I'm unsure of her exact circumstances, but someone like Natale might be quite amenable to treating your wife.

Quote
Taking a rhythm med, like Multaq is pointless while you are in persistent afib.

I just completed a 14 Day Zio Monitor and it shows i'm in AFIB 100% of the time. It also showed I have 0 Isolated 0 Couplet and 0 Triplet Ectopics from SVE/PACs. It also showed I have 1.2%, or 18,603 from VE/PVC's. If i'm understanding this correctly, I don't really have any PAC's, but do have 1% PVC's, and have a 100% Afib burden. I figured that on the Afib, I've been persistent or long standing persistent for at least a couple of years. With that said, I am on Sotalol and Diltiazem. Are you saying that you don't believe that either the Sotalol or Diltiazem or both don't help if I'm in Afib 100% of the time?



Edited 1 time(s). Last edit at 03/07/2024 01:17AM by cornerbax.

The sotalol is unnecessary. If it's needed for rate control, your EP can just up the dose of diltiazem or substitute metoprolol. Sotalol is a pretty heavy hitter and I would get off it since it's not fulfilling its purpose, which is to prevent afib.

Quote
The sotalol is unnecessary. If it's needed for rate control, your EP can just up the dose of diltiazem or substitute metoprolol. Sotalol is a pretty heavy hitter and I would get off it since it's not fulfilling its purpose, which is to prevent afib.

You are an Encyclopedia of Medical Info, Carey, thank you again! I know when I was in the hospital being monitored for 3
days before Administering Sotalol to check the QTC Interval, it was a process. Would I need to wean off the Sotalol?
I was originally on Flecainide and then Propafenone, and BOTH caused significant AFLUTTER which caused my heart
to shoot up to 200BPM and where I was pale and sweating profusely. The doctors figured out it was the Type 1C
medications,so that is where Sotalol and then Diltiazem came in. I have not had any known issues on either, but as you
stated, I have been in AFIB nearly 100% of the time. Should I wean off the Sotalol? I've been taking 120MG 2x a day
since April.



Edited 2 time(s). Last edit at 10/19/2023 04:57PM by cornerbax.

How long have you been on sotalol? If it's months, not years, you can just stop. It's a beta blocker, so if you've been on it for years your body has learned to compensate by over-producing adrenaline, so you should probably taper off or you'll be overwhelmed by the excess adrenaline.

If your doctors concluded the type 1c antiarrhythmics were the cause and you stopped them, then I don't see why you should continue taking it. But talk to your EP. Maybe there's something here I don't know, but it's definitely a drug I would not stay on any longer than I needed to.

Quote
How long have you been on sotalol? If it's months, not years, you can just stop. It's a beta blocker, so if you've been on it for years your body has learned to compensate by over-producing adrenaline, so you should probably taper off or you'll be overwhelmed by the excess adrenaline.

If your doctors concluded the type 1c antiarrhythmics were the cause and you stopped them, then I don't see why you should continue taking it. But talk to your EP. Maybe there's something here I don't know, but it's definitely a drug I would not stay on any longer than I needed to.

I think I'm misunderstanding one aspect of your post. You said "if doctor's concluded the type 1C medications were
the cause"...I know you know this so maybe i'm misunderstanding, but Sotalol is a class 3 drug. Felcainide and
Propafenone within 2 days of taking them shot my heart to nearly 200bpm, this was back in January when I was
prescribed those medications. They took me off Flecainide after I told my Cardiologist of the high heart rate, sweating,
etc, and they somehow STARTED me on Propafenone which is ALSO mind boggling. When I changed Cardiologists,
they were suprised they put me on Propafenone as it's in the same class as Flecainide.

At any rate, I haven't been on either since they were stopped and I was started on Sotalol and Diltiazem. I haven't had
ANY known side effects since February on either of those, but I have been in AFIB every time i've checked (countless)
on my Kardia,or smart watch. Once or twice I think I showed Bigeminy, but it was short lived and AFib immediately
returned. I will talk to my Doctor tomorrow and will stop Sotalol because it doesn't make sense to keep taking such
a powerful drug when it hasn't done what it was intended to do in the first place. Thanks, Carey!



Edited 2 time(s). Last edit at 10/19/2023 08:40PM by cornerbax.

Yes, I know sotalol is a completely different class of antiarrhythmic, but it's still an antiarrhythmic and I can't see any reason why you're on one at all. I'm just erring on the side of caution and suggesting you run the idea of stopping it past your EP because I'm not entirely sure what the doctor had in mind by putting you on it in the first place. Seems kind of an odd thing to do, which suggests maybe there's something I don't know?

Back in January when my heart rate shot up to nearly 200bpm and I had the worst symptoms I've Ever had I rushed to the ER. They took me in immediately. Because this was the second time this happened they admitted me. They did all kinds of tests and couldn't find anything that would cause the issues I had so the hospital EP was certain it was from the reaction I had to the type 1C Anti arrhythmics. He immediately stopped them and because I didn't want to be Cardioverted at the time he prescribed sotalol. They monitored me for 3 days but my heart rate was still over 100 regularly and that's when the EP prescribed Diltiazem. I've been on both medications since the beginning of the year and sought out a highly respected EP at Cedars Sinai. He told me to continue to take those Medications which I have. He mentioned an ablation and I said I wanted to lose weight eat clean and use my cpap machine for Sleep Apnea.

Fast forward to current I have lost 45lbs my sleep apnea is gone as my AHI number from the last 90 days was 2.8. You have to be over 5 to be classified as Obstructive Sleep Apnea. I found out I was just over 5 at the beginning so I never had bad Apnea. At any rate, my recent appt with my EP came up he told me nice job on the things I worked hard on and the Sleep Apnea not an issue but I still have AFIB.

He then said to continue on the medications as he didn't know if I ever converted to NSR or not. He prescribed the Zio for two weeks which I just recently finished. The Zio shows 100% AFIB 0 pacs and 1.2% PVCs. My EP is supposed to follow up with me any time to go over those results and I'm thinking at that time he would likely stop the Sotalol?

In a summary, I'm thinking he kept me on the Sotalol because he didn't know definitively if I ever converted to NSR due to the Sotalol? We definitely know now that I don't and the Kardia is really exceptional as it never said NSR all this time either.

Does any of this make more sense Carey?



Edited 2 time(s). Last edit at 03/07/2024 01:18AM by cornerbax.

Cornerback:
Congrats on your weight loss and sleep apnea improvement! I am so surprised why you wouldn’t refused an ecv at Cedar Sinai and be done with it instead of suffering with high hr as high as 200 and your worst symptoms and 3 days at that hospital.

I only was converted once unsuccessfully at Cedars and it was a cluster mess. I was assigned a diaper girl resident and she was so scared to place the pad near my chest that she placed it by my navel and refused to move it. I was obviously not successfully converted that time. What’s the odds you would get the same resident as me? You could had been assigned a knowledgeable person.

For me when I was very symptomatic around 200hr I just asked to be ecv and get back to nsr and leave. I hate sleeping in the ER ward for up to 3 days with curtains separating unisex patients. I was ecv 54 times —hospital record of ecvs— but it’s included 12 during ablations —8 ecv during my third ablation (unsuccessful to break the afib-I woke up in 190 for days), 4 ecv during my first ablation and 4 ER ecvs were “re-dos” after the initial didn’t work so they increased the joules…so that made it 38 ER visits since 2004 that was successful at the first attempt. Everyone is different but flutter sometimes needs an ecv because drugs are not as successful. Were you in flutter at 200hr?

Quote
cornerbax
Does any of this make more sense Carey?

Yes, and you shouldn't have refused the cardioversion. I would go back to the EP and ask for it now since you're still on sotalol. Cardioversion is a safe, effective procedure that takes only minutes.

And then, successful or not, I would contact one of the two EPs I recommended and ask to schedule an ablation with them. It will probably take a couple of months to get in.

@Susan,

It was flutter not afib at the high rates and within about an hour I converted to a normal rate on my own. Because this happened twice, I went to my local hospital which isn't Cedars-Sinai. I had pretty bad experiences there which is why I sought out Cedars. I refused the ecv because I heard and read NSR often doesn't last long and you often times need multiple ecvs. I also wanted to know more about my condition and was told
I wasn't in critical condition where anything had to be done right at that immediate moment.

@Carey,

Remember my Afib has been classified by a Cedars-Sinai Cardiologist and Cedars EP as Valvular Afib and directly a result from my Severe Mitral Regurgitation. I am likely having the Robotic Mitral Valve Repair done within 3 months. You are saying I should get an ECV and an ablation and not the Mitral Valve Repair first?



Edited 1 time(s). Last edit at 03/07/2024 01:20AM by cornerbax.

To recap from the original post it would seem that the advice/thoughts are:
1) continue her present meds ( 75 mg metopropanol BID & 400 mg Multaq BID)
2) observe for cardiac pain/discomfort
3) watch her recorded heart rate via Fitbit for extended periods of "resting" ventricular rate in excess of 100 bpm (Fitbit records the average
of the previous 5 minutes)
4) relax the anxiety, while waiting out the upcoming visit EP visit.

IF she begins to have pain or if the Fitbit shows a persistant heart rate of > 100 for several hours, then she should contact her cardiologist.

Do I have that essentially correct? THIS is my primary concern

Other reactions to the prior comments:

She has seen the local EP, so is not a "new" patient, however he is gung-ho about doing an ablation and she is hesitant to have "portions of her heart burned away". I can actually appreciate that because the afib first appeared immediately after she had a cardiac cath and two stents implanted ten or so years ago. She associates poking around her heart tissue with a catheter as having instigated a conduction problem that evidenced itself in the afib "birth". Other GP's in our area have suggested that the local cardio & EP group are pushing patient towards ablation to justify/pay for the specialized hospital apparatus. Fortunately for us we are only about 90 miles from Cleveland Clinic, so if an ablation is unavoidable, that's where we we will go.

BTW, for the same reason (poking around in her heart) she is not inclined to consider the Watchman procedure, that seems to be even more invasive (boring a hole through the atrial septum).

Our Kardia 6L mobile, only reports "Possible Afib", rather than a declarative "Atrial Fib Detected". I am assuming that the Kardia evaluates the relative inconsistancy of the R-R interval throughout the recorded ECG as the chief indicator. Her R-R interval is chaotic. Is my understanding correct?

Lastly, I'm perplexed by the comment that MULTAQ is ineffective,. And I'm wondering if that assessment is given in the context of an Afib prevention tool or using MULTAQ to arrest an afib episode. If it is ineffective to prevent, what is the purpose of prescribing it to my wife for the past ten years (lots of $ spent for an ineffective drug?)

Quote
Searching9
IF she begins to have pain or if the Fitbit shows a persistant heart rate of > 100 for several hours, then she should contact her cardiologist.

She has seen the local EP, so is not a "new" patient, however he is gung-ho about doing an ablation and she is hesitant to have "portions of her heart burned away". I can actually appreciate that because the afib first appeared immediately after she had a cardiac cath and two stents implanted ten or so years ago. She associates poking around her heart tissue with a catheter as having instigated a conduction problem that evidenced itself in the afib "birth". Other GP's in our area have suggested that the local cardio & EP group are pushing patient towards ablation to justify/pay for the specialized hospital apparatus. Fortunately for us we are only about 90 miles from Cleveland Clinic, so if an ablation is unavoidable, that's where we we will go.

BTW, for the same reason (poking around in her heart) she is not inclined to consider the Watchman procedure, that seems to be even more invasive (boring a hole through the atrial septum).

Our Kardia 6L mobile, only reports "Possible Afib", rather than a declarative "Atrial Fib Detected". I am assuming that the Kardia evaluates the relative inconsistancy of the R-R interval throughout the recorded ECG as the chief indicator. Her R-R interval is chaotic. Is my understanding correct?

Lastly, I'm perplexed by the comment that MULTAQ is ineffective,. And I'm wondering if that assessment is given in the context of an Afib prevention tool or using MULTAQ to arrest an afib episode. If it is ineffective to prevent, what is the purpose of prescribing it to my wife for the past ten years (lots of $ spent for an ineffective drug?)

Let me respond to a few of your points:

I have a Fitbit and a Kardia and the Fitbit often shows my HR as 10 - 15 points lower than the Kardia. The Kardia is much more accurate. You will get a much more definitive “diagnosis” on the Kardia if you subscribe to their Advanced Determination program. I am grandfathered in. It shows 6 possible rhythms as well as normal sinus rhythm and does display Atrial Fibrillation rather than possible Atrial Fibrillation.

About Multaq: it is the least effective antiarrythmic though it can do a decent job in preventing (rather than stopping) Afib for some patients. I took it for a year and it was pretty good at prevention for the first four months but then I got more and more episodes. Since your wife now has 100% burden it is not likely a useful drug for her right now.

I have never heard that poking around in the heart could cause Afib, though I am not the expert here. As I understand it, there has to be a substrate for Afib to occur – in other words tissue with abnormal electrical properties. During and ablation, portions of your heart are not burned away, rather specific lines are drawn “corralling” the abnormal tissue where abnormal electrical properties generating the Afib arise.. During an ablation it is necessary to make a tiny puncture in the atrial wall in order to access the left atrium where the Afib is happening. This is also necessary in order to place a Watchman but these holes heal in a matter of months and this can be verified through echocardiograms. My atrial wall has been punctured several times and is fully healed.

Quote
cornerbax
You are saying I should get an ECV and an ablation and not the mitral valve repair done first?

No, what I said was go ahead and do the ECV. It probably won't work for long, but it's worth a shot since you're on sotalol already. If it does last, stick with the sotalol but otherwise dump it because it's doing nothing for you and it's a big hitter. It's unlikely to stop your afib on its own, but it may prevent it if you stop it with ECV.

Do the valve repair first no matter what you do with the ECV and sotalol. After that, schedule an ablation with Natale or Santangeli.

So the order of steps is:

1) ECV
2) Stop sotalol if not successful
3) Valve repair
4) Ablation

Quote
Searching9
Lastly, I'm perplexed by the comment that MULTAQ is ineffective,. And I'm wondering if that assessment is given in the context of an Afib prevention tool or using MULTAQ to arrest an afib episode. If it is ineffective to prevent, what is the purpose of prescribing it to my wife for the past ten years (lots of $ spent for an ineffective drug?)

I agree with almost everything Daisy said. I don't know who said Multaq is ineffective but that's an overstatement. It's not ineffective at preventing afib, but it is the "weakest" of all the antiarrhythmics.

What I disagree with slightly is that afib can't happen without the substrate. Actually, it can. It can be brought on temporarily by binge drinking ("Holiday Heart Syndrome"), by low potassium levels, and by serious illness or injury, including major surgery. But afib of that sort goes away once the underlying electrolyte levels are corrected or the inflammation from the illness/injury is resolved.

@ Daisy
Thank you for your remarks. As I hopefully said previously my present principle concern at the moment is what to do while awaiting the office visit with the EP.
Previously we had been told that if her AFIB was persistent for 12 hours or longer she should go to the emergency room. This advice was given by her cardiologist and prior to a ZIO determination that she was in AFIB 100% of the two week monitor.

Following that advice, she should have gone to the hospital as soon as the ZIO results were available. However, I suspect that the Cardio intended: if you are in pain or that your heart is racing for >12 hours, go to the hospital ER.

In other (clearer terms), if no pain OR heart is not racing..........no immediate action is needed, regardless of Kardia "diagnosis" of AFIB.

Now, regarding Kardia. Yesterday (at rest) she did a 60 second record and Kardia reported "possible Afib". It also reported a heart rate of 74 bpm (during that 60 second observation), however if you look at the R-R intervals, they vary between .32 and .92 ms (or 187 bpm 62 bpm).Simultanously her Fitbit reported a 5 minute average of 73 during the Kardia observation.

So I'm inclined to use the Fitbit as the first line device to detect that she is in a sustained heart rate in excess of 100 (while at rest) and use that as guidance about seeking immediate ER care. Does that seem reasonable?

Believe the Kardia, not the Fitbit. Like almost all sports heart rate monitors, they do very poorly with the irregular rhythm of afib. And why calculate (probably inaccurate) R-R intervals when you have an FDA-approved device that accurately tells you what the rate is?

Afib with a rate under 100 doesn't warrant a hospital visit. A rate over 100 but under, say, 150 warrants a prescription for a rate control drug such as metoprolol or diltiazem, but still no hospital visit unless she finds it intolerable or has other symptoms such as shortness of breath, chest pain, fainting, etc.

@ Carey, Why use the Fitbit as the first device? I actually have found that the Fitbit is essentially as accurate as the Kardia rate determinations.
In the example I gave above, Kardia reported a HR of 74 (over 60 seconds) and the Fitbit reported HR of 73 (over 300 seconds) , with the Fitbit observation period overlapping the Kardia.
But more to the point is that the Fitbit is recording 24/7 while the Kardia is only reporting when it is applied. So consequently one could "see" an extended period of elevated HR overnight (during sleep) ..... did I mention that my wife does not report any pain or discomfort - so nothing to awaken her......

"And why calculate (probably inaccurate) R-R intervals when you have an FDA-approved device that accurately tells you what the rate is?"
Why examine the R-R intervals? , because that's what her cardio looks at when he sees her ECG in office. As he put it to us: 'chaotic irregularity of R-R'. Is my measurement of the Kardia R-R interval rates completely accurate, probably not, but the degree of inaccuracy should be the same for each successive R-R (limited by my ability to clearly distinguish between 17.0 mm and17.5 mm on the Kardia printout. The rest is just straight math.

In case I didn't mention it above, she is also on metoprolol 75 mg BID for the past couple of years.

Thanks for your interest, and I don't want to come across as argumentative, but the Fitbit (for us) has been a surprising useful, albeit a simplistic tool. (BTW, I have no stock in Google !)
.

Is her cardiologist an EP? Every EP I've ever met can identify afib by simply glancing at a rhythm strip (so can I). There's rarely any need to look at R-R because it's just going to confirm what the strip says.

Sorry, but I admit to being badly biased against Fitbits because my wife has had one for years and I think they're the biggest piece of overpriced crap ever made. They also have the world's worst warranty claims department. Trust me I know this because I've replaced hers 5 times now in less then 5 years and have given up even trying to make warranty claims. It takes weeks for them to even respond to a claim and then they spend days arguing about it, demanding more information and proof. If I wanted overnight monitoring, I'd get an Apple Watch. Pricey but FDA approved, therefore proven accurate, and vastly better build quality and software.

Quote
Searching9
"And why calculate (probably inaccurate) R-R intervals when you have an FDA-approved device that accurately tells you what the rate is?"
Why examine the R-R intervals? , because that's what her cardio looks at when he sees her ECG in office. As he put it to us: 'chaotic irregularity of R-R'. Is my measurement of the Kardia R-R interval rates completely accurate, probably not, but the degree of inaccuracy should be the same for each successive R-R (limited by my ability to clearly distinguish between 17.0 mm and17.5 mm on the Kardia printout. The rest is just straight math.

Yes, the Kardia looks at RR interval variability. As Daisy points out, Kardia won't give you a definitive answer and will say "possible Afib" unless you are a subscriber.

As to measuring, in these two graphs, I show RR heart rate vs. time graphs. A lot of PAC's can "fool" Kardia sometimes. As your cardio says, afib is chaotic irregularity of R-R. Whereas lots of PAC's do have beat to beat variability but there is regularity as well. Your measurement skills are sufficient.
[www.afibbers.org]
[www.afibbers.org]

A lot of PACs might fool the Kardia's afib detection algorithms, but they don't affect its rate counting and that's the thing she's monitoring. They do fool every other sports-quality device I've ever used, but I admit I've never tried a Fitbit, and if you read my previous post you know I never will.

@ Searching9,

I do apologize, I did not intend to hijack this thread. When I read the aspect on medications it correlated
with the exact question/issue I have. I hope you have gotten all the information and help you were looking
for with your questions.

@Carey,

Quote
No, what I said was go ahead and do the ECV. It probably won't work for long, but it's worth a shot since you're on sotalol already. If it does last, stick with the sotalol but otherwise dump it because it's doing nothing for you and it's a big hitter. It's unlikely to stop your afib on its own, but it may prevent it if you stop it with ECV.

Do the valve repair first no matter what you do with the ECV and sotalol. After that, schedule an ablation with Natale or Santangeli.

So the order of steps is:

1) ECV
2) Stop sotalol if not successful
3) Valve repair
4) Ablation

Got it and understood. I will consult my EP on the ECV and follow the steps. My EP did mention he strongly believes
my AFIB is a direct result of my Severe Mitral Regurgitation so he may tell me that even if I did convert, the likelihood is
it wouldn't be long before going back into AFIB. Either way, I will absolutely consult. I think from all of your great responses
as well as others, the Mitral Valve Repair Surgery is a must and sooner than later.

With that said, I do have one last question on this matter regarding Sotalol. I know it is a heavy hitter as you mentioned
but I do remember reading that suddenly stopping Sotalol can lead to worse Arrhythmias. Do you think that will be the case
since i've taken it for around 6 months or so? Also, do you think Sotalol is doing anything at all for my RATE? I honestly
don't think it is. As I mentioned, the 3 days I was in the hospital and on 240mg of Sotalol at 120mg doses twice a day, my
heart rate was still around 100+, which is why the EP started me on Diltiazaem. I'm on 240MG of Diltiazem which seems
to be working fine, i'm sure my weight loss has helped too.

I'm just curious if you think I could experience those worse arrhythmias from stopping Sotalol cold turkey and what do you
think it's Rate Control is worth? Anything?

Quote
cornerbax
I'm just curious if you think I could experience those worse arrhythmias from stopping Sotalol cold turkey and what do you
think it's Rate Control is worth? Anything?

I've stopped it twice and did so cold turkey both times. No problems. Check with your EP but I don't think you have anything to worry about after only six months, but you can always taper off if it worries you. I think people tend to think they have to taper a lot more drugs than they actually do.

And yeah, it's a beta blocker so it does have some rate limiting qualities, but I think they're relatively weak compared to diltiazem and other beta blockers like metoprolol.

Quote
I've stopped it twice and did so cold turkey both times. No problems. Check with your EP but I don't think you have anything to worry about after only six months, but you can always taper off if it worries you. I think people tend to think they have to taper a lot more drugs than they actually do.

And yeah, it's a beta blocker so it does have some rate limiting qualities, but I think they're relatively weak compared to diltiazem and other beta blockers like metoprolol.

I hear you and you are right, Diltiazem had a greater affect on my Heart Rate than did Sotalol. I'm curious, why did
you stop Sotalol the first time? And why did you get back on Sotalol (how long after you stopped the 1st time)
and stop again a 2nd time?

Quote
Carey
A lot of PACs might fool the Kardia's afib detection algorithms, but they don't affect its rate counting and that's the thing she's monitoring. They do fool every other sports-quality device I've ever used, but I admit I've never tried a Fitbit, and if you read my previous post you know I never will.

My wife has used a fitbit, but she doesn't have any rhythm issues. I've never used one, but I have used devices that use plethysmography for beat detection (I understand the fitbit does use an optical sensor). I don't know about PAC's, but afib certainly seems to fool them on rate. Vastly different (lower) than recording beat to beat using an ECG quality chest strap (& I can record for many hours as well) when I run them in parallel. What I've noticed about plethysmography is that in afib, not only is the RR beat length randomly random, but looking at beat amplitude on a plethysmograph display, there is a lot of amplitude variability as well. I can feel this in my pulse with my fingers as well. It is low beat amplitude that seems to fool the sensor.

If @Searching9's wife is on metoprolol 75 mg BID, she likely does have a slower rate and the fitbit may do better in this situation.

Quote
GeorgeN
If @Searching9's wife is on metoprolol 75 mg BID, she likely does have a slower rate and the fitbit may do better in this situation.

Good point; I'm sure it does. And yes, you can easily feel afib with your fingers. I can pretty much diagnose it with nothing more than palpating a 15-second radial pulse. Irregularly irregular rhythm and varying beat intensity = afib. Nothing else fits that profile.

@Carey, In answer to your question, my wife's cardio is not an EP.
As to the Fitbit, no need to apologize for any bias. I've come to be relatively trusting of the Heart Rate as a preliminary tool as it has been a reasonable predictor of heart rate over a 5 minute span. For a closer look I'd be much more confident with the Kardia.

As to some of the other Fitbit functions, the ONLY thing that I have confidence is the time. I have no confidence in the "steps" or other fitness parameters or the sleep stages (that I consider to be voodoo). So yeah, I hear you and understand the bias. (now with Google having bought Fitbit I anticipate further neglect to "fix" Fitbit products or software, so as to push people to the Google Pixel product line. It's called killing the competition)


BTW, I've just recently discovered that the Kardia recording length can be altered to achieve a strip as short as 30 seconds or to as long as 5 minutes. However the "determinations" are only based on the first 30 seconds .

The other disconnect for me is that the HR, (measured by the Kardia or smart watch) doesn't indicate what the atrial rate is. If the atria is polarizing/depolarizing at 200/sec, but the vast majority of those "signals" never get to the ventricle level the ventricular rate does not tell us anything about how hard the atria are working and how long they are working at high rates.

Your wife needs to find an EP. Really, it matters. A lot.

Quote
Searching9
The other disconnect for me is that the HR, (measured by the Kardia or smart watch) doesn't indicate what the atrial rate is. If the atria is polarizing/depolarizing at 200/sec, but the vast majority of those "signals" never get to the ventricle level the ventricular rate does not tell us anything about how hard the atria are working and how long they are working at high rates.

Member susan.d had an AV node ablation and her ventricular rate is dependent on a pacemaker. The pacemaker does record the atrial rate and can be interrogated for that information. She has said she can "feel" when her atrial rate is high and commonly has symptoms during these periods. Decades ago, this was a fairly common procedure, but is now rarely used, typically only when other approaches have failed (which is Susan's case).

@ Carey,
Dear wife does have an EP, and is an established patient with him. After it was apparent ( inferred from Fitbit and reinforced by Kardia) that the frequency of her afib episodes had increased dramatically, the cardio prescribed the ZIO monitor (which confirmed her 100% burden) and then subsequent chem induced stress test. Presumably this was all in preparation for dear wife's next routine visit with her EP. At this point her EP visit is now 2 months away, and I'm hopeful that the EP has reviewed the ZIO and Stress test and is sufficiently prepared to see her in late December.

My current concern is focused on the impact of waiting and doing nothing, while her atria is now fibrillating apparently constantly. (Doing nothing is probably misleading, she is continuing her multaq , metoprolol, warfrin that she has been taking for the past 10 years. What would be more accurate would be "doing nothing new")

When she and I met with him a year ago, he was really gung-ho to do an ablation when her burden was 3%. Now that the burden is 100% I anticipate that he will be even more ardent.

Based on some of the recommendations you've made in the past, about an EP's effectiveness record and the number of ablation procedures performed, we are pondering seriously about transferring her case to Cleveland Clinic, and starting over with a (hopefully) more experienced EP. But to do so, will no doubt, incur another waiting period, probably well beyond the current schedule of an office visit in late December.

So that's the basis for my initial question, is waiting a problem? If persistent (but pain-free) atrial fibrillation can wait for an extended period of time (many months) without adverse conditions, we may well chuck the local EP and travel to Cleveland, effectively "starting over".

BTW, her 14 day ZIO reported no PACs, no PVCs, and 1 VT @ average 128, max 138, that lasted <20 sec.

Cleveland Clinic is a good choice but don't just call their main line and ask for an EP. You'll get the next EP in rotation, and you'll have no idea what their experience level is until you meet them. Ask specifically for a consult with Dr. Santangeli.

The continuing atrial rate for a few more months isn't a problem. All that matters now is that the ventricular rate stays under 100 at rest and she's religious about taking the anticoagulant. Since she's already on Multaq I would ask for a cardioversion. If that works, it's possible the Multaq will keep her in NSR for a while. But without the cardioversion there's really no good reason to keep taking it. It's not doing anything for her.

Quote
cornerbax
I hear you and you are right, Diltiazem had a greater affect on my Heart Rate than did Sotalol. I'm curious, why did
you stop Sotalol the first time? And why did you get back on Sotalol (how long after you stopped the 1st time)
and stop again a 2nd time?

It wasn't working for me so I stopped it to switch to Tikosyn. I had stopped it once before a year or so previously, but don' recall why. The second time was during a period of time when I was dealing with flutter, not afib, and we couldn't find any drug that would prevent or stop it until I went to Tikosyn, which is even a heavier hitter.

Quote
Carey
Ask specifically for a consult with Dr. Santangeli.

This is really important! Wherever you go make sure you’re seeing the top EP. The outcomes are very different depending on experience. And, the scheduling doesn’t go by strictly first come first serve – they will look at the patient’s overall situation and risk and take the more at risk patients first. Most of us who have had ablations with top EPs waited several months during which we had a pretty high burden. But, in my case for instance (I saw Natale), they were keeping an eye on me by prescribing a monitor and then asking for regular Kardia strips—I wasn’t just in the wilderness. So, getting a top EP trumps getting in faster with a less experienced person.



Edited 1 time(s). Last edit at 10/21/2023 11:57AM by Daisy.

Quote
Daisy
So, getting a top EP trumps getting in faster with a less experienced person.

This can't be repeated too many times. Any EP who can do an ablation within 2 weeks isn't the EP you want.

Quote
Carey

I'm just curious if you think I could experience those worse arrhythmias from stopping Sotalol cold turkey and what do you
think it's Rate Control is worth? Anything?

I've stopped it twice and did so cold turkey both times. No problems. Check with your EP but I don't think you have anything to worry about after only six months, but you can always taper off if it worries you. I think people tend to think they have to taper a lot more drugs than they actually do.

And yeah, it's a beta blocker so it does have some rate limiting qualities, but I think they're relatively weak compared to diltiazem and other beta blockers like metoprolol.

Obviously everyone is different but when I had ablation #3, I was on sotalol for less than a year and I was told by N’s EP to wean off slowly for 5 days. I was scheduled for ablation #4 a few months later and was instructed the same. Wean off for 5 days. Unfortunately once I was completely weaned off, my ablation was cancelled because of a GI bleed and Dr Natale, being safe, suggested I save the slot and get an emergency watchman so I could stop Eliquis 24 hours after the procedure to give me time for a colonoscopy and to stop my GI bleed.

However a different EP performed ablation #4 because dr N was out of town and my flutter was uncontrollable @<200 and couldn’t wait and the new EP just stopped my sotalol cold turkey after the av node ablation and I had no iatrogenic side effects.

I’m sure it may be safe to not wean. Ask your EP what’s his opinion for you since everyone is different based on situation.

The short answer is most probably "no" as long as her rate is controlled.

And since she's not in long-term persistent (one year or more) the odds of a future intervention -- ablation or medical -- should be about the same as with someone with paroxysmal afib.

No doubt the ep will offer her an ablation. And so long as the ep is in a top- fated cardiac hospital and has a high throughput, a basic PVI (rf or cryo) is probably all that is necessary. Alternatively, they can try and restore normal rhythm with cardioversion and/or use some sort of anti-arrhythmic med strategy.

Jim

Thanks to all in this thread. I did stop Sotalol Cold Turkey last week and for a few days I had palpitations. Not bad, but I can feel them. One of the things I am happy with is even with my Severe Regurgitation and Afib I RARELY have palpitations. My Zio Monitor for 14 days actually showed almost no PVC's and showed a burden of about 1% of PACs. After stopping Sotalol cold turkey I had some palpitations but they weren't very bad,
I could just feel them throughout the day and at night. This lasted about 3 days and for the last day i've had virtually none. My Heart rate with no palpitations is the same as it was when I was taking Sotalol. It looks like the 240mg of Diltiazem is doing its job, where Sotalol wasn't. Thanks to all for the info here.



Edited 1 time(s). Last edit at 03/07/2024 01:21AM by cornerbax.

I'm sure we're all happy to see your results. Good job!