Right Atrial Tachycardia

[JW24]

I am 36 yo female, no known cardiac disease, with PMHx of allergy-related asthma and benign PVCs.  



1/02 - Had EPS and RF Ablation for SVT - Dx was Right Atrial Tachycardia.My EP doctor said he was unable to ablate at a higher temp. because the signal causing the arrhythmia was too close to the phrenic nerve. After the ablation he was unable to reproduce the ATach again and felt it was successful. However, 2 hrs postop I had an episode, and then another 2 days later, so restarted on Atenolol 12.5mg BID. Tried Cardizem once for a few days - felt awful and still had ATach. EP wanted me to try flecainide, but I was too scared (I am a nurse - aware of s/e of anti-arrhythmics)and opted for Atenolol. No further episodes for months, so EP doctor suggested it was possible that scar tissue had grown enough to block the signal found previously. So he said I could wean down or even try to d/c Atenolol.Got to 12.5mg/day, then had 2 episodes, so am back to 18.75mg/day.  This has wreaked havoc in my life - causing me great anxiety, fears of death, and panic disorder. I have 2 small children and want to return to work. I recently read of ATach pts.using the new Non-Contact Mapping system having success with subsequent ablations. My questions:

1.What is your experience with Right ATach?

2.Would I at all be a candidate for a second ablation in light of the position of the signal near the phrenic nerve?

3.Should I seek other surgical opinions(live in southern CA), if so - where?

4.Do I just need to learn to live with this/long-term medication?

5.What if no medication?

6.Support grp?

[CCF-M.D.-RCJ]

jw24,



Sorry to read of your troubles. I'll answer your questions in order.



(1) I am a general cardiologist, and so have experience treating Atach with medications. Your situation requires expert consultation from an electrophysiologist at a major medical center.



(2,3) I do not know if a second ablation procedure would be possible.  I suspect that the only way to know would be to undergo a second EPS with mapping.  If a site could be found, and was not thought to be in a dangerous location, then a second ablation could be possible.  If you are interested in staying in California for a second opinion, then try UCSF, Scripps Clinic, or UCLA.  If interested in coming to the Cleveland Clinic, then start with Dr Natale, Saliba, or Schweikert.



(4,5) I certainly am not going to tell you to just live with it; especially given the limited amount of information about your symptoms that you provided.  If you had infrequent spells, that lasted seconds to minutes, and were associated with minimal symptoms; then yea live with it.  Otherwise, attempts at therapy make sense.



(6) A support group makes good sense to me. Perhaps our readers/commenters can provide some information or other chat rooms they have found of interest?



Hope that helps. Good luck.

[CLM]

Hi!  I have some of your same sit. and live in your area:  if you are interested you could contact me at ***@****  I am especially interested in your ep and where you had your ablation done in our area.  (I also opted not to do tambocor for similar reasons, but on "bad" days get tempted.)

[dande4]

Hi,



I also suffer from atrial tachycardia or I guess PAT. I always wondered if we born with this electrical problem, how come it does not effect most of us until later on in life and why can't it go dormant again?



I'm still trying to get a good answer from my Dr...



Hope you are feeling better!

[JW24]

Thanks for your msg.  My doc said we are born with this, and that usually some type of trigger gets it going.  I don't know if they really know, but the most challenging part is learning to live with it (if you can't have it surgically cured).  Have you had an EP study?  Are you on medication?  Or do you just deal with the episodes? Hope you are well!

[jdm]

I have posted previously about my atrial tach.  It is caused by extended periods of aerobic exercise, alcohol, caffeine, and , of all things, eating a meal.  The docs finally stopped telling me to ignore it when my resting pulse would run 125 for hours following a moderate 6-8 mile hike for which I was in perfect shape.  My rhythm is normal sinus but inapprop. fast.



I am using attenolol and it controls the tach though I am not yet exercising at pulse rates above 100.  Like you, I am VERY sensitive to attenolol.  I know people who can take 50 mg once a day for BP and not even notice it.  25 mg. at one time floors me.  Confusion, panic, low pulse 55-58, cold etc.  So I take 1/4 of a 25 mg tab 4 times a day and am experimenting with using a bit more as I increase exercise.  They say this is OK.  



How are you able to precisely control the dose?  I find it difficult to cut the tabs.



I am taking ativan now since they tell me I developed , over a number of harrowing years, a conversion reaction from all the stress of the inappropriate tach.  episodes.  Being very sensitive to drugs I am taking very little  .5mg 3x/day and sometimes 4x.  Whether placebo or for real it seems to help me avoid panic over higher heart rates when I exercise.  



So far I have not considered ablation as long as this therapy allows me to live somewhat normally.  I just wanted to share that you are not alone in having profound and frightening side effects to what they say are low doses of attenolol.  But it is wonderful to be able to eat a meal and not have my resting pulse go from 68 to 100 or 110 for hours for no apparent reason.



ps.  from age 21 to about 36 I was addicted to running, biking, and things like mountaineering.  A very high aerobic guy.  Now I am 52.  I have seen some posts that suggest that physical changes to the heart as a result of extreme levels of aerobic conditioning might cause ectopic atrial pacing sites to develop.



None of the docs here have any opinion of this possibility and tell me to exercise as much as I can for the sake of my heart.  They also found slight insufficiency in aortic and pulm. valves in echo but tell me it is very very slight and not to worry.  Of course, I worry given my history.  



Perhaps this was caused by all the exercise.  Like 18 hours on a climb at 150 + pulse rate and feeling GREAT.  Maybe I did it to myself?  



Good luck, I know I am rambling and , as a medical person yourself, you know a lot more than I about the subject.  But our human reaction to the symptoms and side effects of drugs made me want to comment.  John

[JW24]

Thank you for your message - it always helps knowing you are not alone with this frightening condition.



As far as the atenolol goes, I use a pill cutter to cut it in half, then cut the half into quarters (sometimes it's not exact, but I do the best I can.)  I, like you, am very senstitive to small amounts of this medicine.  I may have to go back to 12.5mg twice/day, but I'm trying to hold at approx. 18.75mg/day (12.5 in the morning, 6.25 at night)for now.  



I guess one of the hardest things was the disappointment that I still have the ATach and that the surgery was not successful.  I spoke with my EP yesterday and he said he would be happy to try it again, but that the area he found the focus was close to the phrenic nerve and he really wanted to be sure not to damamge the nerve, which I appreciate.  So, I may (for peace of mind that I have exhausted all options) get a second opinion from someone who does the non-contact mapping.  Besides the panic/anxiety, I still have a hard time with "you're going to have to live with this".  I can't believe how crippling this has been and I just want to function normally again.  I guess that will happen with time.



I really appreciate your feedback.  Exercise is definitely not the culprit in my case, but very well could be in yours.  I too am fearful of the tachycardia when exercising.  My doc said it's okay to exercise, but now that my HR has been so low for awhile, anything 100 or above freaks me out.  How about you?  Have you been cleared for exercise?  Tell me more about your episodes - how long are they - what are your symptoms, etc. How did you get diagnosed with atrial tachycardia as opposed to AV nodal re-entrant tachycardia and some of the other SVTs?



Don't mean to ramble - your post just got my mind going.  Thanks again!

[jdm]

My tachycardia is not "episodic" in the sense that it just "happens".   So far it has never just happened unless prior exercise or eating was involved.  The anxiety condition has triggered high pulse rates in the past due to adrenaline dump but it is not the tach condition itself.  



Like you I can no longer emotionally tolerate knowing or perceiving that my pulse is over 95 or 100.  I spent over a decade and a half aerobically exercising at rates of 140 to 175 or higher with no problem.  



This is where the ativan comes in and also TIME and predictability so that I can trust that the tach is actually controlled.  Have I been cleared for exercise? Well, my HMO cardiologist told me to get all the exercise I could.  That is the extent of the advice...no warnings I guess are present.  



He sees basically nothing wrong with me that is life threatening.  It is a matter of my "accepting" the condition.  The attenolol is prescribed by my HMO GP and NOT the cardiologist.  



They have not suggested or offered an EP study.  I am certain, though, that I could not emotionally tolerate anything invasive at this time without general anesthetic.  They have shown no interest in finding out the source or exact nature of the inappropriate pacing of my heart in some circumstances.  I don't know what AV nodal re-entrant tach is but will find out.  



I spent my career in computers and electronics and I find myself capable of understanding just about anything related to heart problems if I take the time.  



My episodes are caused by exercise.  The duration and degree of pulse elevation is always directly proportional to the duration and degree of aerobic exercise preceeding the episode.  Without attenolol if I take my evening walk ( I live in a hilly area at some elevation ) of one hour results are much different.  I will run a pulse of 85 to 105 which is totally appropriate for my condition and demands of the walk.  



Without attenolol my pulse will stay at 85-90 for several hours and then gradually go down to my ( non attenolol ) healthy rate of 66 to 68.  This is NOT tachycardia by definition.  The problem is if I want to do MORE.  



A moderate hike of 2-6 hours with a sustained pulse of 95 to 120 will result in a pulse rate of 110 or 115 for 2 to 4 hours then very gradually coming down.  A really strenuous aerobic session can result in rates of 125 plus for 3 or 4 hours even as I sleep