Re: Tachy-Brady Cardia

Posted By David Young on October 29, 1998 at 05:47:40:

In Reply to: Re: Tachy-Brady Cardia posted by CCF CARDIO MD-APS on October 28, 1998 at 18:57:40:






My father, 66, has been recently diagnosed for paroxysmal atrial fibrillation
and first degree AV block with pauses from 2.5 - 3.2 seconds.  However, he
has no symptoms at all.  He has been exercising regularly, jogging on the
treadmill at least 2-3 times a week, for the past thirty years.  He has
history for high blood pressure and prostate enlarge (recent PSA 2.05 ng/ml)
for the past five years and on medication {Cardura & Zestril
(switched to Cozaar one month ago)} ever since.  
Some doctors recommend him to put permanent pacemaker right away and treat
AF with Cordarone (with and without) Warfarin, others recommend him to stay
in intensive care unit to try different dosages of Cordarone and if the
heart beat become too slow they will finally put the permanent pacemaker
for him.
We are very confused and having hard time to decide the best treatment for
him.  The most important point is he feels perfectly fine at the moment and
incline to be administered with Cordarone with the hope to do away with the
pacemaker.



_____


: Dear David,
Firstly, the paroxysmal atrial fibrillation needs to be addressed, because a fair amount
of atrial fibrillation with an abnormal atrial size poses a significant stroke risk for the patient and
a 66 yo with p.atrial fib. intermixed with bradycardic episodes is only going to get worse not better REGARDLESS
of medications.  Many patients with atrial fibrillation 'feel fine' and never even know the heart rate is abnormal.
Discuss the risk of stroke with your father's physicians and your father, and this might make the whold Cordarone issue
clear up so to speak.  Unfortunately, cordarone is noteworthy for slowing the heart rate and may make what is already a
deteriorating conduction system in your father's heart, worse in that he requires a pacemaker.  As you may already know,
it is highly unlikely that any patient with Tachy-brady syndrome will go more than a few years or so without eventually
requiring a pacemaker.  So if you follow my line of thought, getting a pacemaker a few years early so that
one can use cordarone keep the atrial fibrillation away (such that the risk of
stroke is diminished) is a small price to pay to avoid a potentially life altering event like stroke.
If your father simply had the bradycardia and pauses, not the a. fib, then a pacemaker would not be indicated
until he became symptomatic from the pauses and bradycardia.  But this is not the case, and having to treat
a patient with tachy-brady syndrome is not straightforward for anyone (doctor or patient) until you consider the risks
of doing and not doing each of the necessary steps to treat the syndrome.  I hope this
information has been helpful, please feel free to write back with any further questions.
Information provided in the heart forum is intended for general medical informational purposes only,
actual diagnosis and treatment can only be made by your physician(s).
Thank you very much for your direct and clear answer, I have come across an article
in American Heart Association that in some patients with tachycardia-bradycardia
syndrome, pindolol, a b-adrenegic blocker with intrinsic sympathomimetic activity,
may provide rate control without the need for permanent pacing.  
Do you think my father should try this medicine as I have difficulty to convince
him to put permanent pacemaker right away without letting him try the pharmacological
therapy first?
Are there any risks if my father choose to be on anticoagulation drugs such as
Warfarin without addressing paroxysmal atrial fibrillation and without permanent
pacemaker?  Do your agree with this treatment?
In the end, if my father need the implantation of permanent pacemaker then what
type of pacemaker, single chamber, dual chamber, rate responsive etc. and after
the pacemaker has been implanted which therapies to proceed to prevent stroke,
anticoagulation or antiarrhythmic therapies.