Chronic afib treatment

Thanks for taking my question.

I am a 64 yr old male in good health generally (6' 5", 260 lbs). I currently take HCTZ, cardizem and altace for high BP as well as ryhtmol and coumadin for afib.

I've had afib off and on for over 30 years, eventually becoming persistent for several months in 2002. Two cardioversons at that time and taking rythmol has kept me in normal sinus rhythm since--- except for day long episodes every two months or so that self-converted. Unfortunately, the latest episode, following a particularly stressful time, has been ongoing for the last 2 weeks. Looks like this one won't spontaneously cardiovert.

As I see it, here are my choices:

(1) schedule a cardioversion and perhaps increase my rythmol dosage or even try another antiarrhythmic (rhythm control approach).

2) try rate control -- i.e, stop taking the rythmol and just live with the continuous afib the rest of my life, perhaps taking a beta blocker to lower heart rate. I'm been told by my cardiologist that I'm a good candidate for this approach since I'm largely asymptomatic with a heart rate averaging less than 80 when in afib. The afib doesn't appear to affect my active lifestyle.

(3) have an ablation. This option is complicated by an enlarged left atrium (5.2 cm).

Any recommendations? Have I overlooked other promising options? What are my chances with an ablation? If I opt for rate control, will my atria enlarge further leading to more problems (I have mild mitral valve regurgitation).

Thanks in advance

Tony

[Forum-M.D.-MM]

Hi Tony,
You have thought this out pretty well.  Regarding the three options you listed, if the rhythmol worked to successfully keep you out of atrial fibrillation for a long time, my first approach would be to cardiovert you again and see how long you stay out of atrial fibrillation.  The goal of antiarrhythmic medications is to decrease the number of episodes or the duration of episodes, it is not a cure.  I think keeping you out of atrial fibrillation and two cardioversions a year is a good choice for some people.  Another option is to try a different medication like dofetilide (Tikosyn) or sotalol, I prefer Tikosyn in most people.

An ablation is an option if you really do not like the atrial fibrillation, but the fact that you are asymptomatic makes this a less attractive option.  There are risks to the procedure, as I am sure you know, and I prefer to have significant symptoms before proceeding with an ablation.  It is possible to have an ablation without severe symptoms, but I would want to make sure you and your family understands the risks involved.

You last comment about persistent atrial fibrillation causing more atrial enlargement and more heart disease long term is what a lot of us think happens long term, but it is important to acknowledge that the data is not all there to support that yet.

The best predictor for a successful ablation is the absence of atrial scar.  Currently the only way to know this is to actually do the ablation.  Therefore we can't use this data to quote a success rate pre-procedure.  It is true that enlarged atriums are more likely to have scarring, but we do lots of ablations with atriums your size with good success rates (70-90% depending on other factors like ejection fraction).

I hope this answers your questions.  Thanks for posting.

[va_tony]

Forum-M.D.-MM

Thanks again for taking time out of your busy schedule to share your views on how I might deal with my afib. Your answers were very helpful to me and confirm my own thoughts that an attempt to restore normal sinus rhythm by cardioversion and meds is a logical way to proceed in my case. Your comments are much appreciated.

Regards

Tony

[EchoTech]

I would go with the cardioversion to see how long your normal rate will hold.  Drug therapy would be my second choiice.  Wouldn't really chase after the ablation in your situation myself, but that's just me

[va_tony]

My afib is chronic so the cardioversion won't hold long without a drug.  With rythmol, it's held these past 5 years. I'm used to taking an antiarrhythmic, so at this point it's no big deal.  I agree with you about avaoiding an ablation.

[PikaPika88]

Tony, good on you that you got a chance to ask a question.  I also have mild mitral valve regurgitation + moderate tricuspid valve regurgitation.  I bet that is the doctor who inteprete the echo again in "attenuation artefact".

[randall 335]

My afib would not respond to cardioversion or ablation.
For the past 10 years have been on amiodarone.
I know about the side effects you can encounter,but so far have been okay.

I don't know anything about rythmol,maybe that is a better medicine,with less chance of lasting side effects?`
Also,I am allergic to coumadin,so take a 81 mg of aspirin.

[va_tony]

Rythmol is a sodium channel blocker and has far fewer side effects than amiodarone... but amiodarone is more effective at actually keeping you out of afib.  So it's a trade-off. Fortunately for me, the rythmol worked great for 5 years.  We'll see what happens when I get another cardioversion.

You say your electrical cardioversion attempts and ablation didn't work, but since you are now taking amiodarone on a regular basis, I assume the amiodarone chemically converted you and you are now mostly in normal sinus rhythm.

[EchoTech]

Sorry I didn't make it clear
cardioversion + continuing drug therapy = 1st choice
drug therapy alone = 2nd choice

I am confident that you will make the best decision for yourself.  

good night and good luck.

[randall 335]

Thanks for the info.
I am going to look into this drug.Will discuss it with my doctor.
I worry about the amio-but afib is no fun either.

God Bless-Randall

[browntrout]

My cardiologist mentioned the possibility of "ablation"
for me for AFib. Unfortunately we didn't have time to discuss the procedure, but he did mention I was not a candidate for cardioversion.(Meds don't seem to help) In one of your notes you mentioned:

An ablation is an option if you really do not like the atrial fibrillation, but the fact that you are asymptomatic makes this a less attractive option. There are risks to the procedure, as I am sure you know, and I prefer to have significant symptoms before proceeding with an ablation. It is possible to have an ablation without severe symptoms, but I would want to make sure you and your family understands the risks involved.

I presently take Coreg and Pacerone. I cannot take coumadin. My EF is around 31% and I've had a St Jude pacemaker since September 11th, 2006, and I had a CABG in November 1997.

Can you enumerate some of the risks me and my family should consider ... and be aware of? I have another appt with my cardiologist the latter part of March. Thanks for any information you can give to me. BJ

[supdav]

Has anyone tried myofascial trigger point therapy? It has been working for my Afib. Once a Dr shows you the key point(s) and some simple stretches of the chest muscles the afib stops and one feels much better overall. I had some severe afib, basically incapacitating.

[knightrider]

It took awhile and I found ya.Where's everyone hidding.About a week ago,I got out of the hospital.I was having another episode where my B/P hit an all time low and pulse 200.They shocked me and I was a wake for that and it put me on the right track.I had an angiogram and I just had a small blockage 30/35.
I was shipped out to Little Rock Hospital (Arkansas).More test as Electrophysiology Study.There they found I have Ventricular Tachycardia.I ended up getting Implantable Cardioverter Defibrillator ( ICD ).Man,I've gone through hell.Acouple years ago they thought I had an AFIB and that ended up to be my Pacemarker since I was Pacemarker depended.Oh yea,one more thing.I'm on MEXILETINE 150mg 3 times a day for starters to get me in tone.

[va_tony]

Sorry to hear that you've had such a hard time lately.  Hopefully, your vt is now under control with the mexiletine. If not, the ICD will shock you out of it (not pleasant I hear).

I have been posting over on the medhelp patient-to-patient support forum. Pika, Iireneo and scouser costa rica are over there as well. Also, we still post on HCOL (as do a lot of the old regulars).  You can't enter the board through the iVillage/HCOL home page because they removed the links but you can still get in through the back door so to speak. They have disabled the board. If you still have the arrhythmia board on your favorites you can enter.  If you are asked to log-on and you do and it bounces you to the iVillage/HCOL home, just try again to enter using your favorites (the log-on should have given you a cookie to get in). If you don't have it marked, just google va_tony and the 3rd and 4th results are links to the board. Sue, Vienna, Pika, Denise, Ireneo, etc. are still there.

Regards

Tony

[knightrider]

   Between the 14th and the 15th of March,( 20hrs ) I was zap twice.To make a long story short.I got to my cardio and he checked out ICD and it was OK.They doubled my meds were as 300 MG of MEXILETINE 3 times a day.The shock wasn't that bad.  I believe after getting  this ICD,I got PALPITATIONS.It comes and goes but just thinking about it when it startes,that when the shock comes.So far,I been OK . When I feel  it coming,I think of something else and fight it.