Advice Needed: 24 Years old Athlete with AFIB (CANADA)

Hello, I am a 24 year old male living in Vancouver BC, Canada. I have had symptomatic paroxysmal a-fib since 2022, and I am a professional weight lifter and boxer, so you can imagine how much it has affected my athletic career. (Exercise is a big afib/PAC trigger for me). I feel that each time I get an episode now, it lengthens every time greatly. I fear that my next episode will last over 12-24 hours and progress my Afib into persistent, which will be harder to treat with ablations/drug therapy. Should I put a stop to my athletic activities and all known triggers until I get my ablation or treatment/management sorted first? To continue engaging in exercises and athletic workouts from doing none at all and affecting quality of life in order to prevent triggering episodes and progressing the Afib? It has destroyed my life and I am in dire need of help to seek a cure for my a-fib while it is still somewhat early. I wonder if I am ever able to go back to sports in my life as that truly means the world to me. I am aware that medications at this age is not very feasible, so I am looking for the "cure" with ablation. I feel like my ability to live life and enjoy life has already ended. My progression now is PAC's everyday, and Afib Episodes a few times per month. It used to be every year, to every few months, to every month, to now few episodes per month, all not lasting over 12 hours yet.

ABLATION DOCTOR:
As I live in Vancouver, I am considering Dr. Jason Andrade or Dr. Atul Verma since he is still within Canada and I can use my health insurance. But I wonder if I should consider going overseas to get the ablation done by the BEST POSSIBLE doctor in the whole world, even if I have to pay for it. I am so young and I want the best chance possible to not have repeats or an ablation failure that might make things even worse (complications/developing new arythmias). I know that Dr. Natalie from USA and the Bordeaux Group is very known for the success as proven on A-fib stories. However, given my age and financial circumstances, I am worried I may not be able to handle the financial burden of getting an ablation done by Dr.Natale or at Bordeaux. Since my A-fib is somewhat early (episodes not lasting over 12 hours yet) should I take a gamble on Dr Atul Verma or Dr Jason Andrade, since it is most likely an easier procedure with just PVI isolation needs? Or should I not put a price on health and just throw all my money/house debt to pay for Dr.Natale/Bordeaux for a better quality PVI, and maybe early isolate potential other trigger sources, as well as ensuring quality and durable lesions that will last a long time? I did also hear that maybe Dr. Atul Verma was taking a break from ablations and doing more leadership/research roles, as well as using Pulsed Field so I do not know if he is rusty with using other energy sources now (RF/Cryo) or if he is rusty in general. I had heard Pulsed Field is more for safety and efficiency, but not as good as RF/Cryo for efficacy.

GENERAL QUESTION TO ALL:
Just a weird question, and I am sorry to ask. I have a fiancee and sexual activity was a big trigger to my PAC’s, leading to Afib, so I had completely stopped having any sexual activity, fearing it will worsen my disease. This has greatly affected my relationship with my fiancee and we are just in our early 20’s… Can I take any advice whether to continue on and ignore the effects for my Afib in order to maintain a healthy and normal relationship? Or completely abstain from it, leading to a very poor quality of life and potentially her leaving me. After an ablation, if it is successful and I am in NSR, am I able to get back into these activities that trigger PAC's/Afib? Triggers such as sexual activity, athletic sports, heavy exertions, all of which are usually "Triggers", does Ablation make those "Triggers" no longer "Triggers"? so I won't have to worry about any physical limitations or avoiding my known "Triggers"? I feel palpitations and potential A fib episodes with daily life and certain triggers such as sudden exertions/sudden heart rate spikes and more prevalent at night time such as jumping out of bed to go the washroom at night (most of my afib episodes), even stretching in bed at night, weight lifting, sexual activity, running up the stairs, suddenly lifting a heavy object, getting woken from alarm clocks, excessive talking or with stress exerts my heart (lightheaded/faint/ palpitations), holding my breath, deep breaths, anything that suddenly spikes the heart rate especially if it's in a low resting heart rate at night or at the least, will give me palpitations.

CURE:
Also, since my A-fib is in the early stages of paroxysmal. I was wondering if I get the ablation, how long would I be cured for? Would I be able to live A-fib free until I am 80+ years old? Or will this eventually come back in my mid ages/later ages. How long has it been since ablation completely cured you? Should I even dive straight into ablation? Or try medication first? As you might imagine, heart surgery at this age is insanely scary if there are complications/risks, But then again, delaying treatment and having it develop into persistent Afib increasing the chances of stroke/heart attacks is worse. I am overwhelmed by the disease and the many decisions and I do not know if I should get an ablation due to the potential risks and the chance that Afib may come back regardless. I heard medications can be more dangerous than ablation and or the AFIB itself.

ANY DANGERS OF ABLATION?
I also want to ask about ablations, since it is still a relatively new and still developing medical technology and mostly performed on older adults, and its effects over the long term "40-60 years after ablation" are not too well studied yet. Should I be concerned of the adverse events that may come later on in my life due to ablation at such a young age? As it is still invasive, and living with lesions, scarring, vessel narrowing on my heart, complications for the rest of my life at such a young age is one of my concerns as well as I could not find any information on what may happen later in life, although it proves very effective in getting rid of Afib even if only temporarily. Also, many studies of ablation successes show patients Afib free for 1-3 years but unfortunately I could not find much data in patients being Afib free for say, over 15 years. I am wondering if the potential risks of the ablation surgery itself is more concerning. Given that being Afib-free from ablation may not be permanent and I may eventually develop Afib again later on? I also read many scary stories of ablations causing patients to be worse and develop new arrythmias which is my biggest fear. (to get even more symptomatic than right now would be hell) I just wanted to ask for some advice, since my case is relatively new and I am otherwise healthy, do you think it would be okay for me to trust a general EP in Canada such as “Dr. Atul Verma” or “Dr. Jason Andrade” to perform my ablation? Or would it be absolutely necessary to ensure it is the absolute best EP in the world? My choice of the best doctors I have narrowed down are 1.Dr. Natale, 2. Dr Jais from Bordeaux. 3. Dr. Atul Verma, 4. Dr. Jason Andrade.

WHAT SHOULD I DO FOR EPISODES FOR THE MEANTIME BEFORE ABLATION?
I just have one last question, If I happen to have my next Afib episode that lasts longer than usual,, and I head to the Emergency Room, since I experienced many ER doctors offering different options (electrical/chemical), and they often lead the decision up to me in the end, could I ask you what you would suggest? Electrical or Chemical?, and if Chemical, what would be your choice of drug and dosage? The ER doctors recommended a different drug every time leading me to be hesitant of trust in the drug's safety and efficacy due to the lack of a consistent choice. They recommended sotalol at one time, and propafenone the other time. I would feel much more at ease and more willing to try a cardioversion method if recommended by an experienced Afib patient such as yourself, due to the low but potential side effects of cardioversion such as developing new arrhythmias, or having a stroke. What should I do before the ablation to have less frequent/duration of episodes? I panic everytime. I am afraid of medication. I have also tried many natural remedies but to no real avail to reversing my progression of Afib (magnesium, meditation, diet, light exercise, lifestyle changes)

I thank you for all the work you have all done, and the empathy you all continue to show to the rest of the world suffering from this insidious disease, Atrial Fibrillation. Thank you for taking the time to read this. Have a great rest of your day.

I have a chart below that I am trying to fill out regarding the information of the ablators I am debating to help me make a decision. Would anyone know the answer to some of them by any chance?

Kind Regards

JASON ANDRADE:
1. Time Frame = 10-14 months
2. Ablations Per Year =
3. Total Ablations =
4. What Energy Source = Cryo
5. Yearly Breaks =
6. Mortality/Complications Rate =
7. Afib Recurrence During/After Blanking Period Failure Rate =
8. Afib Free Lasting Over 5 Years Success Rate =

ATUL VERMA:
1. Time Frame =
2. Ablations Per Year =
3. Total Ablations = 8000+ ablations
4. What Energy Source = RF
5. Yearly Breaks =
6. Mortality/Complications Rate =
7. Afib Recurrence During/After Blanking Period Failure Rate =
8. Afib Free Lasting Over 5 Years Success Rate =

PIERRE JAIS:
1. Time Frame =
2. Ablations Per Year =
3. Total Ablations =
4. What Energy Source =
5. Yearly Breaks =
6. Mortality/Complications Rate =
7. Afib Recurrence During/After Blanking Period Failure Rate =
8. Afib Free Lasting Over 5 Years Success Rate =
9: Price =

ANDREA NATALE:
1. Time Frame: 4-6 months
2. Ablations Per Year: 624/year @Los Robos + 324/year @Texas
3. Total Ablations: 12,000+ ablations
4. What Energy Source: RF
5. Yearly Breaks: 2-3 weeks longest break
6. Mortality/Complications Rate: very low
7. Afib Recurrence After Blanking Period Failure Rate: ?
8. Afib Free Lasting Over 5 Years Success Rate: 85%+
9. Price: - 35000-50000 USD
10. Pulse Field Trial: Criteria: Paroxysmal, Drug Failed, Not Free



Edited 9 time(s). Last edit at 12/11/2023 01:21PM by Brian.

If you decide to use Dr. Natale, I would suggest using his Texas location. He personally told me his state of the art equipment is better and he has multiple staff ( NPs) so you have seamless care when someone is on away on vacation.

Hi Brian, your research and analysis is impressive and that sets you up for good therapeutic outcomes. If it would be easy for you to be prescribed a “pill in the pocket,” that might be an interim step to get you out of this miserable cycle. Flecainide is the most common one—no more than 200 mg if you are under 154 lbs. no more than 300 is you are over. And if that doesn’t work, you might consider a low daily dose until you can get a more permanent treatment like ablation. Re: ablation, how about getting in a trial for pulsed field ablation? I don’t have up-to-date info on who is participating right now, but some of the best, like Natale and Vivek Reddy at Mt Sinai have been.

As far as long-term, given your age, there are bound to be major treatment developments that may be less invasive, so finding a treatment that will keep your Afib controlled for the next decade or so might be a good way to frame it.

Hi Brian,

Does the afib happen during the exercise or after? I ask to see if your exercise trigger tends to be adrenergic or vagal (parasympathetic). For more description go to [learn.afibbers.org] and click on "Are there different types of LAF?"

Per Daisy's comment on flecainide on-demand, here is the original paper. Both flec and propafenone are used in this way. I've used flec this way for over 19 years.

Exercise was my path to afib as well, over 19 years ago (at age 49). My afib progressed to a 2.5 month episode after 2 months of paroxysmal afib. The EP wanted me to stay out of rhythm, but I offered a plan B that he accepted. Briefly, my plan included changing my training, magnesium, potassium & taurine supplements and on-demand flec to convert if I went out of rhythm. I also later learned that limiting calcium intake was good for my afib.

For me, exercise was a vagal trigger, happening after I'd settled down, sometimes with a material delay between the exercise & the afib. My trigger was the product of duration times intensity. Empirically I found out that using what the cyclists call "Zone 2" as my limit for long duration activity made exercise not a trigger. I could and can do short duration very high intensity like Tabatas on a fan bike without issue. I do absolute max effort for the 20 seconds hard portion of each rep. Though you can get technical with Zone 2, I generally use nasal breathing as my limit for long duration activity. As long as I can easily nasal breathe, I am fine.

I'd vote for Verma. As I recall, he trained with Natale. You are not long standing persistent so he would likely do well for you & not cause financial distress. I don't think in your case the extra expenditure would be necessary.

My son-in-law presented with afib at age 30 (now 37) & he's generally followed these suggestions, including PIP or on-demand flecainide and is doing well. He's in the military, so has to maintain fitness, but trains with a Z2 limit on long duration activities.

I'm happy to answer further questions.

Brian, I am on the mid-Island. My EP was Dr. Paul Novak at Pulse Cardiology. He's very good, but if he agreed to see you, it would be four months, and if he agreed to perform the procedure, it would be another four months. Unless you have an emergency need, such as flutter whose onset is unknown, and if it looks like you might have been in flutter for some time, you would get an ablation inside of two weeks. But again, if an emergency.

Secondly, catheter ablation does not 'cure' AF. It controls it, dams or stockades it, and otherwise prevents it from happening. But the sad truth is that your heart is still electrically disordered, and if you could somehow undo the fibrosis caused by the ablation procedure, your heart would immediately be predisposed to returning to AF, or actually start the ectopy right away. So, your best bet is to regulate the AF to the extent possible with learning the triggers, which are individual, and using medication such as metoprolol and flecainide or propafenone. Then, as or when your AF evolves to the point where it really impacts your quality of life, you should be ablated. In fact, you should get in line for an ablation sooner rather than later because the more advanced the disorder the harder it is to manage, especially to ablate.

Your case appears to be adrenergic. In order to exert yourself as a pro weight lifter, you need a lot of 'oomph'. That comes from adrenaline, and it appears that your heart doesn't like being bullied by the effort that the adrenaline requires of it. So, that should answer your question about continuing to do what you have been doing. I had to stop running until I was seen by a cardiologist and put on metoprolol. Even then, it was slower run-walking. I have never returned to long distance running because my first AF episode happened about 8 km into a 10 km maintenance run.

[Edited] - In the second para, I forgot to go on and to say that ablation is almost necessary over medication because medication will lose efficacy more quickly. I mean that drugs might do for now, maybe even really well (did for me), but as you become more anxious, more adrenergic, you'll get more ectopy, and it will move toward persistent and then permanent AF. Get in line with a great EP long before then.



Edited 1 time(s). Last edit at 12/08/2023 10:28PM by gloaming.

Hey Brian- I feel your pain....really. Exercise/activity has been my life... running, tri, martial arts. At 64 yrs my competitive time is passed. But I do what I can to still enjoy moving. You should read "The Haywire Heart"...how I learned that this is an athletes problem.

You should probably try medication first to see if there is a way to continue without much progression of the afib now. Frequency of events seems more critical to progressive than duration of event. My first event lasted 24hrs, but I had only 1 more in 3 yrs. Then they began to be more frequent... progressed faster. If meds don't seem to slow things, I would suggest ablation...it is more successful the sooner. But ablation is not certain:

I had ablation 2 months ago. I paid to travel to Austin to get Natale....it was worth it over the uncertain docs in the big hospital in my city. He is good and the hospital is good and his team is good. Despite that, he acknowledged that he didn't get one ectopic site - I will have to have a second procedure to resolve the atrial tachycardia that now I have daily. Some folks are good for 5-10 yrs after ablation. Some have 2-3 ablations and remain with afib.

As said above, there is no cure - afib is always eventually progressive. The game seems to me to be slow it down the best way possible to give you a good life. Every person's case is different and the future is unknowable. I am sorry you have to experience this now - young. You might have been hit by a car or have cancer. This is real life. You will be fine.

There is good advice on this forum...but everyone is different and you have no choice but to try and figure out what works for your body.
Let me know if you want to talk about it.

good luck. -Sven

Quote
Swhanson
I had ablation 2 months ago. I paid to travel to Austin to get Natale....it was worth it over the uncertain docs in the big hospital in my city. He is good and the hospital is good and his team is good. Despite that, he acknowledged that he didn't get one ectopic site - I will have to have a second procedure to resolve the atrial tachycardia that now I have daily. Some folks are good for 5-10 yrs after ablation. Some have 2-3 ablations and remain with afib.

I am a year out from my ablation with Natale and I certainly agree about how good he, his hospital and team are. Still, when I went back to get a watchman (needed because he had to isolate my LAA) he did 10 more minutes of ablating to catch a couple of spots that had been causing a high resting heart rate, not really tachycardia. Right off the table my heart rate had dropped 20 points back to my previous level. But he had told me before the initial ablation that I was very likely to need a touchup because my case was complicated. So, very true that nothing is certain but you greatly increase your odds of good outcomes by going to top tier EPs.

Thank you everyone for the replies.

GENERAL QUESTION TO ALL:
Just a weird question, and I am sorry to ask. I have a fiancee and sexual activity was a big trigger to my PAC’s, leading to Afib, so I had completely stopped having any sexual activity, fearing it will worsen my disease. This has greatly affected my relationship with my fiancee and we are just in our early 20’s… Can I take any advice whether to continue on and ignore the effects for my Afib in order to maintain a healthy and normal relationship? Or completely abstain from it, leading to a very poor quality of life and potentially her leaving me. After an ablation, if it is successful and I am in NSR, am I able to get back into these activities that trigger PAC's/Afib? Triggers such as sexual activity, athletic sports, heavy exertions, all of which are usually "Triggers", does Ablation make those "Triggers" no longer "Triggers"? so I won't have to worry about any physical limitations or avoiding my known "Triggers"? I feel palpitations and potential A fib episodes with daily life and certain triggers such as sudden exertions/sudden heart rate spikes and more prevalent at night time such as jumping out of bed to go the washroom at night (most of my afib episodes), even stretching in bed at night, weight lifting, sexual activity, running up the stairs, suddenly lifting a heavy object, getting woken from alarm clocks, excessive talking or with stress exerts my heart (lightheaded/faint/ palpitations), holding my breath, deep breaths, anything that suddenly spikes the heart rate especially if it's in a low resting heart rate at night or at the least, will give me palpitations.

REPLYING TO DAISY:
-Would a pill in the pocket be more harmful or would electric cardioversion/ chemical cardioversion at the hospital? I know all of them have very small risks but I just want to know which would be the most safe for the long run for every episode I have. My current EP has prescribed Flecanide with Diltiazem but I am not taking it yet because I am contemplating doing ablation as a first line treatment before diving into medication. Given that medication does not slow the progression down, but ablation may actually stop it from progressing and halt the disease course from becoming persistent much more effectively.
I have thought of pulsed field ablation but it is such a new technology and we do not know if it is as effective in duration compared to RF/Cryo. We also don’t know the potential side effects from the new technology even though it says it is more safe for the esophagus and heart tissues. If I were to, would it be a free clinical trial in the USA? And thank you for the insight on ablation with Dr.Natale. So even if Dr.Natale is the best, he may not have a PERFECT ablation every time, and may need a repeat. As I definitely do not have the financial ability to pay for 2 ablations with him.

REPLYING TO GEORGE:
When I exercise, I do not get sent into Afib, but if I exert on harder rep during exercise, I have a lot of PAC’s (its like my heart telling me its going on overdrive). Then if I exert too much, that night of, or after the workout, I will very likely have an episode. Lighter workouts without any PAC’s have a less chance of having an episode. It is hard to say, but my triggers are usually at night. It is usually when im about to sleep in bed, and I suddenly get up. That transition in laying resting heart rate to a sudden standing/walking heart rate VERY OFTEN sends me straight to Afib. So I believe it gets triggers with heart rate spikes. Some similar episodes would be when I was laying on the floor stretching, and I suddenly jumped up to stand up. Or when I suddenly ran up the stairs. Or when I picked up and lifted a heavy portable air conditioner. Weirdly, when I exercise and have a brief warmup, I can still lift light weights and do a light workout. However, after some recent episodes now I almost have an episode the night of/ or after the of day I workout every time. So now I just stopped exercising completely. I think based off what I read on the "Are there different types of LAF?", mine seems to be more Vagal, as it happens at night, and doesnt necessarily happen DURING exercise, but afterwards or the night of. Although it may be a bit of both/mixed (mostly vagal, partly adrenergic. Would a pill in the pocket be more harmful or would electric cardioversion/ chemical cardioversion at the hospital? I know all of them have very small risks but I just want to know which would be the most safe for the long run for every episode I have. I could change my training to a lighter form, and up my intakes of supplements such as magnesium but I really would love to go back into competitive weight lifting/boxing. Where I am exerting over 100% of my abilities haha. I miss lifting super heavy weights and releasing my all on the punching bag. As you mentioned, your trigger was teh product of duration times intensity which I think is similar to mine, because if I exercised for 30 min, most likely I won’t have an episode that night, compared to if I trained for 3 hours that day. Or maybe a light workout for 2 hours would be less likely than a VERY intense 1 hour workout. I follow the nasal breathing limit as well as I never want to over exert in fear of triggering an episode these days.

Is Dr Verma the best in Canada? Did you also get an ablation done by him is that why you vote him? Do you know anything about Dr. Jason Andrade? I had heard a story from “Lorraine” of some negative times post ablation and I am so scared that might happen to me.

May I ask, your son in law being in the military. If hes on on-demand flacainide, does that mean exercises/exertions do not trigger his episodes? And he can mainly go about the day doing ANYTHING with no physical restraints, and his episodes are random so he just needs to take the pill to convert?

REPLYING TO GLOAMING:
I am afraid I may have/ or develop flutter. Do you know how flutter feels compared to A-fib/ or PAC’s? Or how it looks on the ECG? And yes that is why I am hoping for an EP that can do a very durable lesion that will last the longest if possible. Should I do the ablation first before meds to prevent the AF to evolve? Also, after your ablation, did you go back to long distance running? I understand that between waiting for treatment, pausing on it is best to prevent it from getting worse. But after the ablation, when you are kept out of Afib, were you able to exercising back at your best without Afib?

REPLYING TO SHWANSON:
Thank you for the reply and empathy. I am a fellow martial artist haha and was in the prime of my competitive time sadly. Should I do an ablation to hopefully stay A-fib free so I can continue with my athletic career? Would I even ever be able to go back into athletic competitions? Or do I have to take it light and never compete for the rest of my life?. Even if the ablation helps me stay A-fib free? And the frequency has been progressing to now a few episodes per month. It used to be every year, then every few months, to every month, to now few times per month. All never lasting over 12 hours. Can I ask if that ablation is what made you have that atrial tachycardia? Or did it have it before the ablation already and he just did not ablate that area? And in terms of slowing down progression, I am avoiding exercise, all triggers, getting up slowly, but all these affect my quality of life so I really want to have a “STOP” to my afib even if only temporary. Maybe that is from an ablation?



Edited 1 time(s). Last edit at 12/09/2023 01:40AM by Brian.

Hi Brian,

First, on Verma. I've never had an ablation (and I live in the US), but have been on this board for 19.5 years, so am relating what I recall. Here is a search on the terms Verma ablation, so you can see what others have said.

On flec vs ECV in the hospital. I've never had an ECV and I've used flec as PIP for 19 years. My use has generally been infrequent, but have taken it chronically for a few periods of time. I don't see your choice as meds or ablation. You can use meds while getting your ducks in a row for an ablation. As I mentioned, my afib went to a 2.5 month episode quickly. It started 2.5 months after my first episode. I used PIP flec to convert it and it was the first time I used flec (the EP wanted me to schedule an ECV and prescribed the flec to be used PIP after the ECV, I just tried the flec to see what would happen. It worked, but took 20 hours the first time - normally a couple of hours after that).

Flec has given me the freedom to find out what my limits are, with respect to triggering afib. If I cross the line, I just take the flec and convert. For example, I have a 100 gallon (380 l) stock tank in my backyard. I use it as an ice bath in the winter. I have to break ice to get in most days. I usually sit in it early in the morning, then go inside, warm up a bit and exercise. The other day, I did Tabatas on the fan bike. That was fine, but lead to a vagal trigger shortly after the session. What I mean about finding limits, a couple of days later I repeated, but I'd hypothesized that if I did a 20 minute warm up at Zone 2, as well as a long cool down, I could do the Tabata session without issue. So I executed my plan without fear that I would go into afib as I knew I could just take some flec and convert if I did. Turns out my hypothesis was correct. I will say I've used the ice bath many times followed by milder exercise without issue (the fan bike Tabatas are brutal), and I've done the Tabatas without the ice bath before many times as well, without issue.

My experience has been figuring out how to get my overall metabolism such that fewer things are likely to trigger afib. During my 2.5 month episode, I hypothesized that electrolytes could help. I'd gone to the ER when I had my first episode and my serum potassium was 3.1 Eq/L. I also was getting fasciculations of my eye lids during the long episode a indication of a potential low magnesium level. Hence I hypothesized that supplementing with both would help. I did an intracellular ExaTest (harder to come by, but an RBC mag test is a reasonable proxy) for the magnesium (serum levels of magnesium can be OK and you can still be low on an intracellular test). My Mg level was very low. So I started supplementing magnesium to bowel tolerance. I also supplemented with potassium but later learned I should consume it in small quantities over the day as a bolus will be immediately excreted by healthy kidneys (people should only supplement with electrolytes if they have normal kidney function). So I would put 2 tsp of potassium citrate powder in a liter of water and consume over the day - my version of timed release. I also added in 1/2 tsp of taurine powder. This and limiting long duration endurance exercise to a Zone 2 level worked very well and I would only have a couple of episodes a year after that (before my 2.5 month episode, I was getting 6-9 hour episodes every 10 or so days). This went along very well. Then 11 years ago, my wife wanted a divorce. My normally good control went downhill a lot. I thought it was divorce stress, but after a year or so hypothesized it might be the extra calcium in the brie cheese I was stress eating. As I ate a low carb/keto diet, I thought the brie would be a free pass. Turns out this hypothesis that the cheese was the issue (and I assume the calcium in the cheese) as when I quit the cheese, it was like flipping a switch and my control went back to pre divorce levels (good).

During the cheese time, many things were triggers that had not been before. This included the time immediately after sexual orgasm. When sex was a trigger, I could feel the PAC's starting and normally changing position, like sitting up or standing up and moving around would stop the PACs and ward off an episode. I never stopped having sex and fortunately my partner (now wife) was understanding. Subsequent to quitting the cheese, sex is not a trigger.

In 2021, I had an association with afib and C19 vaxxes. I got 3 mRNA and 1 old style C19 vax that year and also had 15 episodes (a lot for me). I started taking 50 mg flec/day, which worked and kept me out of afib for the most part. I dropped it to 25 mg/day after two months and that worked as well. I tried unsuccessfully to get off flec completely a number of times (when I'd stop, I'd have an unprovoked episode in 3 or 4 days). I then hypothesized that if I was far enough in time away from a vax, I could stop the flec. I had my last booster in Oct 2022 and successfully stopped the 25 mg/day flec in June 2023.

One lifting protocol, which has efficacy and might not be a trigger for you is Doug McGuff MD's "Body by Science" Basically it is a super slow, one set to failure approach. You use a weight that is continuously under load with ish 10 second concentric and eccentric reps, where positive failure will occur in 60-90 seconds. I commonly use a static variant "Timed Static Contractions" or TSC. In my case, I do 90 second TSC's where the first 30 seconds is subjectively at 50% effort, then next 30 is at 70-75% effort and the last 30 is 100% or as "hard as you dare." Of course it is really the perceived effort that is increasing, not the actual force as your muscles keep getting weaker as time goes on as it is a continuous load. I have a device with a load cell that Bluetooths the data to a phone app, so I can see a graph of my force output as well as store the data at the end.

"May I ask, your son in law being in the military. If he's on on-demand flecainide, does that mean exercises/exertions do not trigger his episodes? And he can mainly go about the day doing ANYTHING with no physical restraints, and his episodes are random so he just needs to take the pill to convert?" My son in law generally follows my suggestion to endurance train at Zone 2 levels. He also does a lot of isometrics for resistance training. For him stress, some food and alcohol are triggers as well. He's a senior officer, so depending on his assignment, stress can be a big deal. When he has less stressful assignments, this trigger is much better. I had him track his episodes some years ago and he found that alcohol was a big trigger, so now drinks only very moderately. I don't recall exactly, but I know that overeating can also be a trigger. He's been doing this now for 7 or so years and controlling it pretty well, so we don't chat about it much. He does have to maintain his fitness, but with my suggestions on exercise, this doesn't seem to be an issue for him. He's not in combat arms, so it is easier to follow my suggestions.

Even at 68, I maintain my fitness as well. I have a 36 year old son who has been in the nursing home, bedridden with a brain cancer diagnosis. I go visit him 4 or more times per week. He was in the army and did two tours in Afghanistan. I was riding up the elevator a few days ago and a couple of staff asked me if I was going to visit and named my son. I said yes. I did not recognize these women, but they'd obviously recognized me. Then one asked me if I was an army buddy and if we'd served together. I laughed and said, "no, I'm his dad." When I later related this to my daughter (also a senior officer in the military), she said, "Well you definitely have the build of an army spec ops guy," I can do most things I want. I rock climb & have no difficulty carrying a 70# (32kg) pack up steep approach trails in a canyon at 7500' (2300m) & am commonly the guy who leads the routes. I can alpine ski hard all day fasted off piste at 12-13,000' (3700-3900m). I don't skin up and ski down, like my 37 year old friend. The skin up part would violate my Zone 2 rule.

Not that what works for me will for you, we are all different. I try to look at my situation holistically and figure out what I'm doing that makes triggers likely to be triggers (i.e. the electrolytes). The number one thing I try to do is to always pay attention.



Edited 1 time(s). Last edit at 12/09/2023 08:01AM by GeorgeN.

Expanding my thoughts on Verma vs. Natale. With Verma, you are getting a very good EP. This should be good for your index (first) ablation, which may be all it takes. Natale normally reserves work on isolating the left atrial appendage (LAA) till ablation #2 as LAA isolation has a 60% risk of requiring lifetime anticoagulation or placement of a Watchman device (or similar) - LAA isolation isn't the only thing he may do in ablation #2.. If you went to Verma, you could be "one and done." If you needed a second ablation and perhaps LAA isolation, then that would be the time to consider Natale. I don't know anything about Verma's skill/experience with LAA isolation. To me, this is the most financially prudent course and is not imprudent for health outcome.

Quote
GeorgeN
Natale normally reserves work on isolating the left atrial appendage (LAA) till ablation #2 as LAA isolation has a 60% risk of requiring lifetime anticoagulation or placement of a Watchman device (or similar) - LAA isolation isn't the only thing he may do in ablation #2..

True, though he isolated my LAA on my index ablation because I had both Afib and Aflutter and he couldn’t eliminate all the arrhythmias without isolating the LAA. I think his approach is to do whatever is necessary to get you into stable NSR.

Quote
Brian
REPLYING TO DAISY:
-Would a pill in the pocket be more harmful or would electric cardioversion/ chemical cardioversion at the hospital? I know all of them have very small risks but I just want to know which would be the most safe for the long run for every episode I have. My current EP has prescribed Flecanide with Diltiazem but I am not taking it yet because I am contemplating doing ablation as a first line treatment before diving into medication. Given that medication does not slow the progression down, but ablation may actually stop it from progressing and halt the disease course from becoming persistent much more effectively.
I have thought of pulsed field ablation but it is such a new technology and we do not know if it is as effective in duration compared to RF/Cryo. We also don’t know the potential side effects from the new technology even though it says it is more safe for the esophagus and heart tissues. If I were to, would it be a free clinical trial in the USA? And thank you for the insight on ablation with Dr.Natale. So even if Dr.Natale is the best, he may not have a PERFECT ablation every time, and may need a repeat. As I definitely do not have the financial ability to pay for 2 ablations with him.

Hospital conversion would be either electrical which would mean a dose of Propofol to briefly knock you out, or usually Diltiazem as a push or IV which is not nearly as reliable. Sometimes they might use Flecainide though we hear about Diltiazem and sometimes Sotolol more often. Hard to say about the level of “harm” — it might come down to individual reaction the different drugs—but all are considered safe. Some get a bit of a burn from the electrodes but that seems to be uncommon. Using Flecainide as a pill in the pocket or daily if the one-time pocket dose isn’t working, is considered safe, particularly if you keep the dose on the lower end. Flecainide side-effects seem to be dose dependent. If you take Flecainide it it is recommended that you take Diltiazem or a Beta Blocker a half hour beforehand to guard against the rare effect of one-to-one conduction between the atria and the ventricles. Also, genetics can be involved. For instance genetic testing showing that I should be given about half the normal dose. Medication DOES seem to slow down the progression simply by preventing episodes as every episode adds to your predisposition to have the next one. “Afib begets Afib.” So you are reducing long-term consequences through any means that prevents episodes. Thus many will use medications until they can be scheduled for an ablation.

Though pulsed field ablation is still in trials (will probably be approved next year) everything is looking good so far. Because there is no heat involved, less cardiac tissue is affected. I believe that if you were in a trial it would be cost-free, though that would certainly be something to check. There would likely be more followup though.

As far as whether an ablation would allow you to engage in exercise or other lifestyle patterns that are now triggers, probably yes as far as triggering the areas that were ablated by a skillful EP, BUT continuing at the same level would be likely to cause tissue changes in other areas that would generate new arrhythmias. GeorgeN has worked with this a lot to continue exercise in ways that have proved safe for him. Lots to consider!

P.S. A few of us here who have had hospital conversions with Diltiazem found that a push, over about 10 minutes, was much more effective than an IV. The push allows them to give a bigger dose with pauses to monitor your BP and HR. It is a balance to give enough but not so much as to lower them too much.



Edited 1 time(s). Last edit at 12/09/2023 02:26PM by Daisy.

[pubmed.ncbi.nlm.nih.gov]

Brian: "...REPLYING TO GLOAMING:
I am afraid I may have/ or develop flutter. Do you know how flutter feels compared to A-fib/ or PAC’s? Or how it looks on the ECG? And yes that is why I am hoping for an EP that can do a very durable lesion that will last the longest if possible. Should I do the ablation first before meds to prevent the AF to evolve? Also, after your ablation, did you go back to long distance running? I understand that between waiting for treatment, pausing on it is best to prevent it from getting worse. But after the ablation, when you are kept out of Afib, were you able to exercising back at your best without Afib?.."

I know of myself and one other case. I had flutter at one point and felt like it was AF. A friend had an unknown onset of flutter that was only found when he went to his GP for another problem. It was deemed an urgent case and he had an ablation about week later at Royal Jubilee in Victoria. My brother-in-law also has AF, not flutter as far as I know, and he didn't know about it. So, it seems this disorder, in all its manifestations, greatly alarms some and is innocuous to others who can't even feel it when it's happening. Doesn't matter if it's AF or FL.

You can google 'ecg showing flutter' and many examples will pop up. Look at at least two so you get the range of appearance.

I can't honestly answer the 'ablation first or medication first' question. My cardiologist didn't tell me much, bless his wrinkled little...and I do mean little...heart. I had to read and find out that this is a progressive disorder, and that the statin he put me on, fearing ischemic heart disease with diagnostics not yet in hand, prevents the body from synthesizing the exceedingly important CoQ10 enzyme which is essential for heart function. So, long story short, as I said earlier in my reply to you, I did quite well for almost three years. Then the disorder began to act up more frequently and with longer durations in AF. At that point, now three years in, my tiny-hearted cardiologist asked me if he had ever mentioned seeing an EP to me. GGrrrrr!. I knew what an EP was, and what a good one could do for any AF or flutter sufferer, and told him that I was happy to hear him mention the possible referral.

Ever since having AF come on during a run, I have been reluctant to return to that level of demand on my heart. I now walk briskly, including up hills, or I alternate run-walk if things feel right and are going well. I also include a substantial set of stairs on a bluff about 100 feet high, and the rising path beyond it that climbs another 140 feet. I do this at a reasonable pace, being north of 70, but my HR is always 140 or so when I plod out the last of the stairs, and then I plod up the rest of the path, often stopping once for 30 seconds to keep control of my HR. So, nope, no more running, and I now use an ebike. On 'eco' setting for lowest level of assist.

My cardiologist said that my heart was 'irritable'. It turns out that I had developed severe sleep apnea in recent years, and it was probably the stress of dealing with hyypoxia all night long that put my otherwise very fit heart over the edge. I don't feel it is any better, even after the ablation, and even with very well controlled apnea (I use a CPAP machine religioiusly). My lovely and faithful heart is now cranky and disordered, and I don't feel it's wise to try to pick up where I left off six years ago. That bus has already stopped and left the next station.



Edited 2 time(s). Last edit at 12/09/2023 02:33PM by gloaming.

Respecting post ablation tachy...yes it was happening prior to ablation. I would have a mix of afib/flutter/tachy. The ablation resolved all but the tachy which is coming (presumably) from the one site not addressed in ablation. Note: prior to ablation, I had PACS continuously, about one every couple seconds...for years. Gone with ablation. There is reason to believe that with the second ablation, I will remain in NSR. How long? Dunno. Will I be susceptible to arrhythmia after? Probably more than the average joe. I am hoping that I get 5 years before it catches up with me again. If I get 10, I celebrate big time.

Brian:

How much do you weigh, and how is your blood pressure? Also when in AFIB, what is your HR like? Can you slow it down (rate control) if need be?

I agree with what Gloaming eluded to, in that a combined approach to managing this will give you a much better chance for positive outcome, that just Ablation alone. Several of us like me and George never got Ablations, but found out how to manage and minimize it.

I also agree with GeorgeN's talk about continuing activity, but finding the limits that actually induce AFIB.

I would do research into Weight lifting related to straining the heart. Overhead presses in particular cause "Atrial Stretch", one of the things that precipitates AFIB onset.

Maybe back off the heavy weight training for now and try to Box without exerting yourself as much. Boxing puts way more of a load on the heart than it looks like. You would need to tell you ever your training with you may need to let up, as you have a heart condition. Compared to general exercise, or even other sports, it's way harder in boxing to let up, as the other guy would hit you or knock you out. This is what happened to me, so I'm not just theorizing here.

I have to be careful with my diet. I can eat NO carbs, sugar or salt. I would suggest keeping a journal and eating only meat and green vegetables and when you fall off the wagon (which I do and that's how I learned about my diet triggers) and have an episode, write it down. May I strongly suggest keeping a paper journal and not a computer journal.

"I was in NSR until I ate X," are the kinds of notes I keep by date. I have a long list of forbidden foods.

Thank you all so much for your replies and advice!

Replying to The Anti Fib

I'm 6 feet tall and weigh 180lbs and am/was pretty athletic so I am not overweight. Blood Pressure is around 120/80, can be 140/80 if stressed. When im in Afib, when im sitting or laying down my heart rate is around 90-110. If I suddenly get up it jumps to 170-200. Then it stables back to around 140-160 if im walking. I have not tried any rate control or any antiarrythmic medications yet. I usually just lay down to keep my heart rate low and I would suddenly get up and sprint to shock my heart so much into the 200bpm, and that often sends me back to NSR hahaha. I think the shock of the transition as well as when the heart rate being super fast is usually a more "normal" rhythm , without as much pauses or delays, resembling NSR but super fast, which sends me back to NSR.

I want to consider a combined approach but I had heard that long term use of these medications lead to side effects, and in general these medications make you feel ill. Also, these medications are said to not be effective after a while. Whereas ablation may "get rid" of Afib for a temporary time. And could possibly stop progression altogether during this time you are staying A-fib free.

I want to continue all my activities but unfortunately weightlifting, and boxing requires so much exertion that I experience an Afib episode the night of every time I have a workout that day. Thank you for the advice on overhead presses.

I am backing off weight lfiting for now, until I decide which doctor to get an ablation done by. During the waiting period I will get back into activites and maybe "light" weight lifting. Hopefully I can do back to "heavy" weight lifting after my ablation if it goes well. Boxing will have to be after my ablation if it goes well too, as it is almost impossible to box in any way given my heart rate will be so exerted it will pretty much guarantee an episode afterwards. Same with heavy weight lifting



Edited 2 time(s). Last edit at 12/11/2023 01:36PM by Brian.

Brian:

"I want to consider a combined approach but I had heard that long term use of these medications lead to side effects, and in general these medications make you feel ill. Also, these medications are said to not be effective after a while"

When i said that I meant things like trigger avoidance, electrolyte balancing, diet, lifestyle and exercise modification, stress management, etc.

Personnally I don't take the drugs unless I have an episode, then I use rate control drugs, and Flecainide to help convert out. Then when in NSR, stop the drugs.

Also, I am wondering if you are calling bouts of Ectopy (premature atrial contractions, palpitations) as being AFIB? You can be in NSR, and still have so many PAC's that it make your HR feel very irregular. This is common in many people when they change body position. I do believe you have AFIB episodes, I am just wondering if when you are describing your situation, you are lumping the Ectopic bouts in with the actual AFIB?

If my HR was that high in AFIB, I would take something for rate control. My symptoms from AFIB, are minimal if I keep my AFIB HR down close to my normal NSR HR. A calcium channel blocker like Diltiazem along with a low dose a cardio-selective beta blocker has worked for many of us, while producing minimal sedation and legarthy.

Brian,

Your situation reminds me of my own, here’s my advice: get on flecainide 200mg a day (under EP guidance) and get your life back. Don’t wait months (or years) with frequent daily episodes — your heart is being remodeled. You have a lifetime to adjust/reduce meds and get an ablation, right now flec is your best shot at stopping the cycle cold in its tracks.

Afib begets afib!

Rel- Do you take metoprolol or other bblocker as well or Flec only? thanks.

Metoprolol 50mg, Flec 200mg.

Originally on Metoprolol alone, it did nothing for my SVT+afib episodes. Then added Flec 100mg (50mg twice daily) which restored my life. I cannot tell you how much burden the daily SVT (plus threat of afib) was placing on me, all of which disappeared within days of starting Flec. Unfortunately, 5 months later had a breakthrough afib episode.

I was arranging PFA ablation with Dr Natale but decided to up the Flec to 200mg (100mg twice daily) and it’s been NSR for 17 months.