Just Diagnosed with A-Fib and Still Out of Rythm

I’m a 53 year old male being treated for sleep apnea (CPAP), hypertension (Diovan/HCT and Verapamil) and high cholesterol (Pravastatin).  They all seem to be fairly under control now – although BP averages around 155/88 and pulse 55.

In the past couple of years I had experienced occasional irregular heartbeats.  Had an echocardiogram 2 years ago and didn’t show any problems (at least none that were brought to my attention.)  Within the last 30 days, I’ve had three episodes of irregular rhythm lasting from 8 to 14 hours. The first may have been triggered by caffeine, the other two unknown (perhaps apnea related as I was experimenting with a new mask.)  I wore a holter monitor last week, but did not experience any issues that I could detect.  Results are still not in.

Sunday I started irregular rhythm (episode 3) and was able to catch it this time on EKG Monday morning.  Dr. diagnosed it as atrial fibrillation and put me on 250 mcg of Digoxin.  I’m scheduled for a follow-up on Thursday. My heart is still out of rhythm and it’s now been about 50 hours.  My questions are:

1.  Should I be concerned that I’ve remained out of rhythm for this long and am I increasing my risk of a clot/stroke?

2. Is Digoxin the correct first step I should be taking at this stage?  I’ve read that Digoxin has perhaps fallen out of favor as a drug of choice for a-fib issues.  Not to mention I’ve read there are interaction issues with Verapamil.  (Dr. is aware I’m on Verapamil, but did not change the dose.)

3.  How long should I wait to consider chemical or electrical cardioversion?

Thanks.  (I’m located on the MA/RI line.)

[Michael J. McWilliams, M.D.]

I don't think you need to worry.  After a discussion with your physician, you should probably be on aspirin or coumadin depending on your risk factors for stroke. If you have ever had a stroke that is thought to be embolic, you should be on coumadin.  The other risk factors are hypertension, heart failure, age greater than 75 and diabetes.  It is sometimes a difficult decision so you should talk to your doctor.  Your personal history plus these risk factors will help decide you decide if coumadin is the right choice for you.

Beta blockers and/ or calcium channel blockers are often first line for atrial fib rate control.  Digoxin is sometimes used for additional rate control.  Dig and verapamil can be used together with caution.

If you have symptoms with your atrial fib despite rate control, cardioversion is a good option.  Since you have been in Af for over 48 hours, you will need coumadin for a cardioversion.

If you have more frequent AF, there are decent medications that can help reduce the frequency.  The medications choice is based on your heart function, renal function, etc.

There are very good options for AF treatment in Boston if you think you need a second opinion.  

I hope this helps.