Apprehension about taking pill-in-pocket

Looks like my AF is going to be more frequent. My last episode was three weeks ago and, this morning, I went into afib upon awakening. Very disappointing. I've been given propafenone to take but when I was first given it in the ER, I really did not like the feeling it gave me--actually made me lightheaded and felt like my heart had stopped just before I converted. I didn't take it at home for the last episode but they gave it to me in the ER and I converted to flutter and then a bit later to sinus rhythm, this time without the sense of the heart stopping. I've now been in AF for six hours--pretty slow rate, blood pressure is 88/66. I'm trying to convince myself to take the propafenone because I sure don't want to go to the ER. Anyone have any encouraging words???

Laura

I currently take propafenone 300mg TID and it keeping me in NSR, and for me has been the least toxic medication of the 4 antiarrythmics I have tried. I do understand your hesitancy to take the meds, as side effects can be unpleasant. I took propafenone two years ago and it failed; I currently have a pacemaker, and take a very high dose of Verapamil (720mg/day) now with the backup of the pacemaker and I seem to be tolerating the meds better. Why? I'm not sure, but I am grateful.

Laura you said, "I've now been in AF for six hours--pretty slow rate, blood pressure is 88/66." Were you describing your heart rate, "pretty slow rate?" The blood pressure is not real high and the pulse is within norm. When I have been in afib, my blood pressure was really high, and my heart rate was over 160 bpm.

If the medication you have at home worked in the hospital, it seems that you would be safe using it at home, just because of the stress of being in a hospital.

I made up my mind that the only way I would go back to the ER would be if I couldn't covert after 36 hours. I actually rode out my last episode in June of 2006 and it converted in 6 hours. I increased some of my supplements, relaxed with soft music and when I got up to go walk my dog, I converted. I think the danger point (blood clot possibilities) for LAF's is 48 hours, so it appears you have several hours before you really reach any danger point. However, that is your call as only you know how you feel and what you should do, all of us are different. I will be thinking of you, please let us know what you decide and what happens. Sharon

Not that this should influence you, but one note is that in the PIP studies, the sooner you take the meds the higher the probability of conversion success.

That being said, my first use of flecainide as a PIP med was to successfully end a 2.5 month episode.

I wouldn't tell you to take a different dose than what has been prescribed. However with PIP flec., some have been prescribed to take a dose smaller than the full loading dose and wait. If they don't convert within a period of time, they take another dose.

For example, if a loading dose of flec is 200 mg for a person <70kg, then they might take 50 mg or 100 mg now, then another 50 or 100 mg in 10 hours if they've not converted. This might be a topic of conversation between you and your doctor, as this protocol might minimize the bad feelings you have. It also may lower the success factor. It is an individual thing.

George

Thanks everyone for your observations and thoughts. Gee, this just drives me nuts, and I haven't even had more than 3 or 4 episodes a year since I was first diagnosed in 2000. I know there are those of you who would love to have as few episodes. At the moment, my BP is 108/71, heart rate is 81, although I doubt my monitor is picking up everything. Usually my BP is quite high in AF, but that's mostly when I've gone to the ER--talk about "white coat hypertension"!! I realize the PIP works best when used early on, but on both occasions that I did take it, I had been in AF for 36+ hours. I'm considering hanging on for 24 hours and see if I convert on my own; if not, then I'll try to work up my courage and take the propafenone. Wouldn't you know, my husband is gone all week and I'm babysitting a standard poodle in addition to my own two--too many dogs for a 71-year-old to handle!

Thanks everyone for your help.

Laura

Laura, curl up with the dogs, a big pitcher of water, a good book or movie and just relax. Who knows what could happen with that formula. Of course you have to be the one to decide what you want to do with medication, I know you will make the right decision for you personally. Sharon

I used flecainide on demand for four years until my corrective surgery.
I wouldn't hesitate to try it.

What I don't understand is why you would need to go to the ER if you don't use it. Are you high risk for stroke?? do you have other health problems that indicate going to the ER to deal with an afib episode?? If not, seems like an overreaction to me. In four years and close to one hundred episodes I never went to the ER.

Hi Laura,
I experience the same sensation as you do, when converting. It is really very unpleasant! I take sotalol and a little metoprolol to convert and I have 100% success rate so far. The dizziness, or a wave of high pressure in the head comes in about half of the conversions. Sometimes I get it without converting. So far I have converted more than 200 times. I have thought a lot about what is going on and I have a theory:

As you might know there are ectopic foci where the pulmonary veins attach to the left atria. The location of the foci is confirmed by the success of pulmonary vein isolation or ablation. Vagal afibbers seems to have a problem with bradycardia induced dispersion of repolarization. We get into AF at rest, after exercise or after a meal, when the heart rate goes down.
See:
[www.medscape.com]

User name: alfrida
Password: carlotto

Bradycardia induced dispersion of repolarization means, that the refractory period is not getting longer synchronized all over the myocardium in the atria, when the heart rate goes down. Locally or regionally there are parts of the atria where the refractory period is shorter than what it should be. This conditions can set up the possibility of AF. Normally the contractions from ectopic foci are overrun by overdrive suppression or the contractions is stopped by running into surrounding myocytes that are in their refractory state and are not ready to contract.
When you take the antiarrhythmic pill the refractory period is reinstated, prolonged, by potassium blocking, this is true also for Class I drugs, like propafenone , but is more accentuated by amiodartone and sotalol and especially tikosyn. When the refractory prolongation is getting long enough to have any effect, also contractions initiated by the SA node are affected: e.g. normal contractions are not getting through. I can feel this very clear by putting a finger on my neck under the ear. I have regular SA initiated contractions that feel stronger than the small contractions from ectopic foci. Just before conversion my heart is at its lowest pumping capacity, e.g. contractions initiated by the SA-node are partially blocked by myocytes in the refractory status and finally the blockage is total for a couple of SA-beats, that's when I feel all dizzy and on my way to faint, and then suddenly the SA initiated beats starts again and due to the reinstated refractory period, contractions from the ectopic foci are blocked by override suppression.

The only consolation I can give you is that the heart has not really stopped, the SA node is working and the beats will start again. I hate this, but it is worth it to get back to NSR again.

I hope, I am getting through with this rather complicated explanation. Any ideas to better explain what is going on are welcome.

Effective Refractory Period: [cvphysiology.com]
Ectopic foci: [cvphysiology.com]
Overdrive suppression: [cvphysiology.com]

Kerry,

My cardiologist has said to go to the ER after 48 hours. I'm on a daily aspirin but they usually give me a shot of Lovenox in the ER. Other than controlled hypertension, I don't have any risk factors for stroke other than my "advancing age" :-)

Thanks for your help, Kerry.

Gunnar,

As always, you are so generous with your knowledge. I appreciate your taking the time to post this information, and even though I don't understand it all, it helped me to feel a little more confident. I will take Sharon's advice tonight, snuggle with my dogs, and hopefully convert by morning. If not, I'm going to take some nattokinase and the propafenone and see what happens.

Thanks again for your help.

Laura

Thanks so much Sharon,

As I told Gunnar, I'm going to take your advice and see if I convert during the night. If not, I've got some nattokinase (I do worry about clots) which I'll take and the propafenone. I just dislike taking any medication and I probably read way too much about all the horrible things that can happen.

Thanks for being so supportive.

Laura

@ Laura

I am surprized at your low pulse rate. Are you feeling lots of skipped and or irregular beats? If so, maybe your BP monitor cannot detect all the beats and is giving you an innaccurately low reading of your pulse rate. In any case, I hope you are OK now and the AF is gone.


@Gunnar:

Thanks for the really interesting explanation of the relationship between bradycardia and AF. I never had bradycardia or AF UNTIL I was put on a beta blocker for suspected low level labile hypertension. Even at the lowest possible dose (25mg bid) my pulse rate ranges from about 47 to 53 bpm. I suspect the beta-blockers might be contributing to my occasional bouts of AF -even though they are prescribed for AF as well as hypertension.

@ all:

This is really a great group; I thank you and especially Hans for all the support and valuable information to be found here.

Sharon wrote:
"I made up my mind that the only way I would go back to the ER would be if I couldn't covert after 36 hours."

How on earth can one convince any ER doctor that you are at 36 hours of being in AF? They are not going to believe you..."you are not qualified to know if you are in NSR or AF"...or so I've been told.

I've tried numerous times in the past to convince a doctor that I knew the exact hour I went into AF. In the past I never waited...I would go into AF and immediately get to the ER. Only one time out of 5 did a doctor believe me enough to cardioconvert. A second doctor refused until I signed a paper saying the hosptal would not be liable if I had a stroke.

So please educate me...what can one say or do to convince an ER physician to cardioconvert? That's the reason I walk around with a portable EKG machine and take regular strips every 48 hours...I need the "proof' that I was in Af.

Perhaps it depends how symptomatic you are. I have never had a problem, 5 electrical conversions and perhaps I have been there 10 more times and converted at the hospital during waiting for conversion.

You must be very unlucky with your doctors (or I am very lucky with mine). He knows that I am so symptomatic with AF that I do actually know the minute it starts and the minute it ends. He trusts me to stay at home until an attack approaches 40 hours and then go to the hospital. This has never failed and I have always converted at around 40 hours or gone in to see him - and converted just a bit later on after I get there! I know I have been a long long time without an attack now but I would still treat it the same way,and I know he would still take my word for what time it started and finished!

Susan, you said, "How on earth can one convince any ER doctor that you are at 36 hours of being in AF? They are not going to believe you..."you are not qualified to know if you are in NSR or AF"...or so I've been told."

Susan, I think we have to have a pro-active relationship with our doctors, we will never know the ER doctors personally. My EP knows my decision on how I am approaching afib naturally and he supports what I want to do. On my last checkup he said he would see me in a year. I am coming up on my yearly checkup and I intend to present him with written information on all I have done this past year, so he will have knowledge of my approach to afib. I believe he will be glad but skeptical that what I have done is what has helped. He will probably say, Sharon, that is all good, but afib will come back, maybe in a year, maybe tomorrow. That is the approach of all doctors who deal with afib and thats okay, it is still my body and my personal decision on how I take care of it

I would assume that if I am taking a pro-active approach that would include keeping him as my primary heart doctor in the loop when I go into afib. I would call his office and let him know I am waiting the 36 hours. Then if I need to go to the ER, he will be aware of what is going on when the ER doctor calls him. If it is during regular office hours when I reach the 36 hours I would call again and see if he wants me to come to his office or the ER. I think it is vital that you keep your EP informed and to have a relationship with him/her that will allow that.

I always intend to have my body under my control as much as possible, but I also know I may need medical intervention some day. Sharon

Hi everyone,

Just for the record, I converted to NSR about 7:00 last evening, so that was approximately 13 hours in afib. I had walked the dogs a mile and a half, came home, drank some LSV8, took 1000 mg of taurine and 0.5 mg of Ativan, and about an hour later converted, thank goodness.

The longest I have gone without an episode is 18 months; after that an average of 3 episodes a year; but now I've already had 4 so far this year. Hard to figure out triggers--there doesn't seem to be any one thing that's constant.

Anyway, for today, I don't need to address the propafenone issue. I have a scheduled followup with my cardiologist on Friday so I can discuss it in more detail with him.

Thanks to all of you for sharing your knowledge and providing support.

Laura

When I would go into AF I would be very symptomatic so I knew exactly when it started. I just have problems with the ER....or in fact, 4 different ERs. One in NY [Mt. Sinai] has a policy that they don't convert. period...only cardiologists do that. My Mt. Sinai cardiologist told me never to go to the ER because "its an evil place"...and knows the hospital policy of them only converting if it is life threatening or if a cardiologist does it. That wouldn't be a problem because I have an active relationship with my NY cardiologist...I email him during the year and he knows who I am and knows my desire to remain in NSR...so if I am in NY and go into AF I can be assured he will do the cardioconvertion.

My concern is that I live in CA and rarely visit NY except to visit and babysit my grandchild. Three ERs in different hospitals in CA have in the past gave me problems. I do have a cardiologist who was the one who wants the proof so the ER can convert. Now since I have my AfibAlert I have peace of mind...finally have the darn proof necessary for the day that my AF will return.

Those of you who had no problems convincing an ER doctor to cardioconvert has my admiration.

Okay, so it is your cardiologist who wants the proof, sounds like he might want you to go to the ER when it starts so the medical staff can observe and do what is needed. Does he have confidence in the AfibAlert? (whatever that is - I am not familiar)

When I first had afib in 2005, the ER doctor wanted to convert me and I refused because I didn't want anyone stopping and starting my heart, I didn't even know what that was and it scared me. I had only been in afib less than two hours when they wanted to convert, looking back I know it was too premature on their part. When I refused the convert, they started medication drip and the minute the medication hit my blood I converted. Since I have been on this board almost two years I would not be so scared of a conversion because I understand it now and the need for it sometimes. I would still try medication first I think. Sharon

Sharon, I believe it was the hospital in addition to the cardiologist wanted proof as a liability in case I wasn't sure when my AF actually started to avoid lawsuits in case i stroked out.

I don't convert easily with drugs. I was in the ER when my first AF started and they started me on blood thinners and tried for three days to convert with drugs...after 72 hours they gave up and cardioconverted me.

Of course I too don't like someone to stop and start my heart but I have had been zapped two separate times with no problems.

Susan, I remember what I said to the ER doctor when he was telling me what he wanted to do. I said firmly, "God started this heart of mine and he will be the one to stop it, not man!" They looked at me strange, but they didn't push the cardioversion anymore. I know a lot more now and would still be cautious, but also know the dangers of being in afib too long. Sharon