Rythmol or ablation for atrial fibrillation?

[DQ]

I had been suffering with PAC's for the past 6 years.  I had pretty much adapted them, and wasn't letting them bother me much.  Suddenly about 3 weeks ago I had a bout of a-fib after having a stressful week.  Converted on my own own in about 36 hours.  My doctor sent me to a cardiologist and he put me on Rythmol. (thankfully no side effects) I've had no a-fib bouts since.  However my PAC's have increased.  I'm suspecting that it may be anxiety about having gone into A-fib.  Something to adjust to again. I noticed that when I take Klonapin they settle down.

My question:  Can Rythmol increase PAC's? or more probaby the anxiety?

I think the A-fib is due to a hot-spot and the PAC's are a trigger.  My cardiologist thinks the same.

Would it be worthwhile to consider an Ablation procedure?  
What is the prospect of success? long-term cure?  Especially when my cardiologist says that after awhile patients get used to certain drugs and we have to try other ones.

My cardiologist says ablation is an option, but seems to think of it as a last resort.  Do you think it has to be a last resort?

[CCF-M.D.-CRC]

Dear DQ,
No, Rhythmol should actually decrease PACs.  What I suspect is happening is that your heartrate may be a bit slower on the rhythmol so you may notice it more when you do have a PAC.  You are correct that PACs are thought to be the triggers for afib.  This was first described in 1998 by Haissaguerre in the New England J of Medicine (1998;339:659-66). Yes, I would definitely consider an ablation to treat the PACs and afib.   In our hands the success rate is currently around 80% cure.  However, if medications are working well and you and your cardiologist want to wait on ablation then this is reasonable also.

[Dr. Erik]

I am in the same boat as you. I have had pac's and pvc's for years and then one night last Oct. I had a four hour episode of A-Fib. my doctor put me on Cardizem along with Toprol wich I was already taking. My doctor does't seem to think I need an EP study,though I would having interested in having one. I would like to cure the A-Fib rather than take the mediation and live in fear of having anothr attack. Now every time I have pac's and pvc's I get anxiety about going into A-Fib again. I also take a Magnesium supplement because my Magnesium level was ver low at the time of my A-Fib.

[arthur]

I had bouts of AF / PACs.  The AF was cured using an rf ablation procedure.  Get an EP to check you out and provide you with the details regarding the procedure and the risks involved.

[Dr. Erik]

You actually had an RF Ablation procedure and it cured your AF?
That is great. I'm just curious, where did you have it done. Did the doctor say that the scar tissue left from the ablation could cause problems down the road? I would greatly appreciate it if you could go into detail about your case. I am strongly considering asking about this procedure. Thank you!

[arthur]

2.8 years ago I had my first AF bout (lasting 18 hours). That year I proceeded to have about 6 more such bouts of what is called PAF, paroxysmal AF.  Along with those came a background noise of PACs (0-6/min).  After consulting 4 cardiologists, I was referred to Dr. Francis Marchlinksi (Univ of Penn Hosp) who had published extensively in the area of arrhythmias.  My problem was diagnosed as PAF originating from a pulmonary vein focal source (ie, a spot or two in the cardiac tissue making up the pulmonary vein attachment to the back of the heart...this is actually a pretty common source of unwanted electrical activity).

It is possible to ablate such foci and this procedure has become quite standardized these days.  At the time, Marchlinksi had done about 60+ such procedures (for PAF) and was batting a 70% success rate (on the first ablation...if you count a follow-up ablation, his success rate was about 85%), and a 0% complication rate.  He was very conservative in his approach, using just enough energy and ablating only the focus responsible for the problem...this accounts for his 0% complication rate.  

So I had only one focus burned, no complications, and now I have no AF ... but do have some PACs (due to the remaining foci) which may be treatable in the near future by the same procedure, since the techniques have become quicker and cleaner (and safer).

Having the ablation done at a large, experienced center (such as the Cleveland Heart Clinic) is probably the safest avenue to take.  My most recent discussion with Marchlinksi's people indicates they have the success rate up near 85% on the first ablation (similar to CHC).  The major potential complications to look out for and discuss with your EP are PV stenosis (when the vein swells and blocks flow) and thrombi (blood clots that could change your life or kill you).

I was 53 when all this took place.  I have a very active lifestyle (play competitive soccer) and that lifstyle was important enough for me to pursue the ablation route.  Hope this helps your decision making.

-Arthur

[Dr. Erik]

Thanks for the information Arthur!

[ubersax]

I've had fairly frequent PACs for about 3 years now and I've always wondered if AFib would follow somewhere down the line. I was just wondering how different AFib felt from PACs?  I expect that it must feel totally different and is fairly easy to distinguish from your everday run of the mill PACs. Anyone have any comments?

[cyn123]

Hello everyone,  im a 32 yr old female who had  RF with Ablation and it was the best thing i ever did.  I was so nervous at first to get it done, but to live with the tachcardia, which went up to 200 beats for hours at end, only put me into a state of panic every time .  My MD told me i was to young to live like that.  He was right.  Had it done at YALE NEW HAVEN,  CONN.  BY DR Batsford.   As an RN myself,  i could not of picked a better Doc.

[tjmat]

art,
Last June I was diagnosed with A-fib.  Was given Sotolol(not exactly what a 40 year male old needs), then flecainide and Digoxin (too strong)  Verapamil and Flecainide were better but none of the meds solved the A-fib.

So, last week I had a Pulmonary Vein Ablation.  So far so good, I feel like a new man.  I would definitely suggest looking into it.  My main reasons were my intolerance to the medicine and my fear of another stroke.  Unfortunately, my first Doctor did not prescribe aspirin or coumadin and I had a stroke after the first diagnosis.  

Good Luck.

BTW, I had my ablation at Mass General in Boston.  Rather not give the Doctor name but he was excellent and they have a great EP center there.

[dodgybeats]

Like ubersax, I am also wondering what the difference between many PACs and A-fib feels like, if someone out there can enlighten us that would be much appreciated.  I have rare bouts of PACs where my heart rate feels irregular and rapid and I've often wondered if this is A-fib although my cardio thinks its probably just salvos of PACs.  Also, has any one ever heard of hereditary A-fib? my grandfather died of a stroke caused by a-fib and my brother from cardiomyopathy, possibly induced by years of a-fib.  Thanks for any info
Penelope

[arthur]

I am sure your cardio/doc can provide a list of symptoms re. the difference between AFib and PACs.  There may be some slight differences between people...some feel everything, some feel almost nothing.  Here's what I felt.

Isolated PACs are pretty much the classical thump in the chest...generally produced as a result of the heart's ventricle pushing up an extra load of blood due to the premature atrial beat which was inefficient in filling up the atrium in the prior cycle.  If you're running or exercising, these thumps can feel almost painful.  PACs are generally imbedded in a normal, regular  sinus rhythm, so if you're paying attention to your pulse, you will generally feel what seems to be a skip in the normal rhythm.
If you're really paying attention (eg, using a finger against your temple) then you might actually notice the premature beat (it's a lot weaker than the normal one).  When getting a lot of these PACs (I get up to 4-6/min on bad days), it sometimes makes you wonder if it is AFib...however, if the other beats are steady and equally spaced, then it's likely nothing but a flurry of PACs.

Afib can feel like a bunch of PACs, but here the normal steady background sinus rhythm is gone.  Instead, the apparent sinus rhythm feels quite irregular...very few beats that seem regularly spaced, there are pauses, there are short runs of tachycardia...all due to the atria firing off at a high rate and the ventricle kicking in when it can.  Often AFib is a form of tachycardia resulting in a high heart rate (100-200 bpm)...in my case, it was usually quite slow (50-100 bpm) and extremely irregular (pauses up to 2+ seconds).  Also, in my case, I could feel distinctly different types of beats..shallow fast ones, dramatic slow ones.

PACs seldom result in symptoms, whereas, if you have AFib, it's likely you will feel lightheaded and extremely weak.  Climbing a couple of stairs may require taking a time out to catch your breath...all because the heart's not pumping efficiently.

All of this is, of course, my personal experience and my personal opinion...In either event, if you suspect a rash of PACs or a bout of AFib, you should consult your doc or cardio, as there are plenty of non-invasive tests to diagnose what exactly it is you are feeling.  

-Arthur

[DQ]

Thanks to everyone for your input.

The last description of the difference of PAC's and A-fib is right on.  When I got up in the morning with A-fib I knew it was different.  My heart would race for a while than slow down, then race for awhile then slow down.  I was already on 25mg of atenolol so it wasn't extremely fast, but fast enough I knew something was different.

For those who are sufferers of PAC's I can understand your feelings of fear.  After my A-fib incident I was filled with anxiety that my PAC's would go into A-fib. My suggestion that if you are concerned about A-fib that you ask your doctor to put you on a 48 heart monitor.  It's really not a big deal.

Something that I have always had to keep in mind is that PAC's are not harmful.  They are really not skipped beats but extra beats.  The harm comes when the area where the PAC originates gets so hot that it becomes a trigger to A-fib.  I got my A-fib incidence after a very stressful week.

How does it get "hot"?  Lots of reasons, but the NUMBER ONE culprit is stress.  Too much adrenalin in the system.

It has been my finding that if I am having bouts of PAC's it is like my body telling me to slow down.  I am running on adrenalin.  To calm things down I take Clonazipam for awhile and cut down on my schedule.  Tough to do when you are self-employed, but it is the only way I can get relief and get on top of them.

Also we have to remember tha paroxymol A-fib is not as bad as chronic A-fib.   But as my doctor has stated, "If you are young you want to take coumadin.  The risk of not taking it far outways the risk of taking it.  You don't want to get a stroke at age 46.  That would be far worse."

[debra21784]

DQ,
Applause to your doc for recommending you go on Coumadin.He is absolutely right you don't want a stroke at 46 ( been there and done that at 46 )Even without chronic Afib and Par.Afib the risk of stroke is there.It only takes one run for it to occur.I had an ablatation done unfortunately it was after the stroke because my doc didn't pay attention.Wish the ablatation was prior .Stay on the Coumadin but get the ablatation done.

[Jennie]

I've been taking Rythmol(along with atenolol and lanoxin) for my afib for about 2 yrs.  Unfortunately it is not working aa well now, and I have episodes about five times a month. My doctor suggested I change to sotolol.  I'd like to know what other peoples' experiences have been with the latter medicaion. Has it worked well?  I'm rather hesitant in starting it.

[Tiffany54]

To Authur and all with PACs and A-Fib,
I was going to try to ask a question of the Doc, but Aurthur you provided the answer I need.
I have mitral stenosis and aortic insufficiency.  My doctor has always been afraid of my going into A-fib because he says the geometry of my heart is so off, I would not be able to tolerate it.  Last night I had an episode of arrhythmias that I had never had before.  It was EXACTLY as you described, with hard slow beats, painful that felt as if the top half of my heart was being pulled to the left side. Then my heart would race, go back into that rhythm and repeat.  I was able to get a BP during the episodes, it was low, but my HR said 97. However the hard beats I was feeling were no where near 97? I was going to ask if it was A-fib, but from what you described, it sounds exactly what was going on.  I also had this earlier in the week and almost blacked out, my legs simply gave way.  
DQ, I agree with the stress trigger.  This week I had to fire an employee and now they are sueing the company.....Gee, do you think that might have something to do with it???

[kristilb77]

i had a radio frequency ablation done back in 1995.  to me, it was the worst thing i had ever experienced.  i was allergic to the dye that they used. and to top itoff, they didn't fix my problem. i have taken nadalol since 1997.  the cardiologist just switched me to betapace(sotalol) and it didn't work.  i am now taking toprol along with tambocor.  now i am 24 years old.  they first found my arrythmia in 1994. i never knew i had it.  now i can tell if i don't take my medication.

[pjstrk]

Hi everyone, I read with great interest all of your comments.
Although I'm looking for direction and possible answers.  My husband went into afib two weeks ago on Monday April 8th. He was admitted and put on 5mg coumadin, 1mg mavik, 100 mg atenolol twice a day, 25mg hctz and was released on April 10.  They said it would be to dangerous to convert him as they thought he was in afib more than 24 hours.  On Friday April 12 he had what they called a mild stroke and thought he through a clot, he was admitted and put on 100mg lovenox injections every 12 hours, 7mg coumadin, 25 mg digoxin 25 hctz, 81mg aspirin, 100mg atenolol 2mg mavik they released him sunday April 14 Monday the 15th he had another mild stroke and was admitted and released on Tuesday April 16th with 100.4 temp diareha, vomiting, and they had taken off two units of blood to raise his protime.  Wednesday he had a minor stroke and when I called they said oh just watch him.  Thursday April 18th he had a appointment with a neurologist at 1:00 P.M. he stroked again at 8:45 A.M. and this time unlike the others when he would get his speech back and use on his right side in a matter of an hour or so, he still couldn't talk or use his right side when he saw the neurologist and was direct admitted again.  His ct scan showed the stroke in the left lucanar.  So they said it wasn't caused by throwing a clot but instead by high BP. Meds this time are 75mg atenolol twice a day, 1 mg mavik, 325mg aspirin, 5mg coumadin M,W,F 6 mg coumadin on S,Su,T,& Th. He has still yet to be seen by a cardiologist as this hospital doesn't have one on staff and the one at the clinic doesn't have practice rights at this hospital.  I asked to have him transferred and they said it wasn't necessary, that they couldn't convert him or do a heart cath to look at the aetrial valve which they say is causing the problem until he is stable for 3 weeks after the last stroke.  I'm at my wits end, they released him again yesterday April 22nd. I can't sleep, I'm worried I will miss another stroke and or worse.  Anybody with advice or that may have had the same condition please reply back.  Thank you
Pam

[KLB]

I would like to know what "ablation" is and whether it would be a possiblity for me. I have atrial fribrlation and it limits the amount of exercise I can do without feeling short of breath. I am okay if I stop and rest for a few minutes but if try to exert myself ( steady waling for ten minutes or sometimes less) I get short of breath. Please comment.

[TJH]

Jeannie's experience is opposite to mine.  I was on Sotalol.  Because it made me too fatigued, I switched to Rythmol.  The switch itself was frightening.  After being on the new drug for about 24 hours, my heart went wild causing a rapid visit to the emergency room.  After about two hours it started to return to normal.  The Rythmol (675 mg) worked great after that for about a year.  It then suddenly stopped working and I went into a-fib about every day for a period of hours (ALWAYS in the middle of the night.  My doctor increased my dosage to 825 mg and added a dosage of Lenoxin (which I subsequently stopped). I have been in sinus rythem since.  I am strongly considering ablation because, once again, I am constantly fatigued.

[pam2]

I have had A-fib for the past 5 years.  I am now 55.  To my knowledge, I do not have episodes of PACs or PVCS.  My episodes were originally about 2 weeks apart, lasting about 1-2 hours, converting on their own.  Several years ago I gave up caffeine, alcohol, and went on what was basically a "Sugar Busters" diet.  Something in this mix of treatments allowed me to go 6-8 months between episodes for the last few years.  Recently, however, I've had 3 in a 6-week period, the last one going on for 12 hours.  I have been told that I'm a good candidate for ablation since I'm not yet chronic, and my cardiologist recommends Cleveland Clinic.  All comments and explanations as to what to expect from the surgery would be appreciated.  Also, I have never been put on coumadin, as my episodes have not lasted 24 hours.  Obviously, some of you have been given different instructions.  Also, once on coumadin, do you stay on it or can you go off after a certain period of time post A-fib episode.

Thanks for any information.