AFIB, What To Do Now?

[Berob99]

I am a 42 yo male in excellent health, diagnosed with AFIB in March after a 2-month mystery virus (fever, flu-like symptoms). Ultrasound, stress test, and cardiac cath were all normal/negative. Bystolic and flec worked great but switched to propaf due to side effects (tremoring, anxiety).  NSR most of the time.  Saw EP for 2nd opinion and dose was increased last Tues to 225 mg 3x day + 25 mg metop ER 2x day.  Thurs, I went into AFIB and have been in it since, my longest episode ever. Most prior episodes have have lasted minutes to 36 hrs max and have never been debilitating.  This is different - heart rate is higher (115 vs. 90ish on bp machine), constantly light-headed, and even the most moderate levels of exertion leave me gasping for air and extremely dizzy to the point that I almost passed out on an easy bike ride with my 4-year old and while mowing a flat lawn at the slowest speed possible. There are times it feels like I'm almost in rythm but my heart is still racing and Ifeels like its coming out of my chest. Called the EP for a consult and EKG to confirm my arrythmia as AFIB (instead of something else triggered by the meds?) but was told by his nurse that my options were to go to an ablation consult or to go to the hospital for solatol or "tecan..." (sp?).  I'm frightened and want to talk to someone.  I assume it will take weeks to get the ablation consult and without the ability to have a diaglogue with my EP (seen him just once), I don't know how to make the decision he's offering me.  I also want to know if there are any prudent options for getting me out of this episode.  For example, I've heard about a modified pill-in-the-pocket approach where I could take an extra dose of prop 3 hours after my last dose to try to kick me back in rhythm, or how about a cardioversion?  Does this mean prop won't work any more?  I just want your feedback adn guidance on where to go from here.  BTW, I'm in Raleigh.  

[try2002]

I was a very healthy 35 yo, thin, when I had my first episode of afib with heart rate almost 200. Went to ED in ambulance. It was awful. EP always wanted to cardiovert me but I always refused. Instead then he gave me Verapamil IV, some dig, twice in ED.  It took hours, but I eventually converted on my own. Ended up on Inderal prn for premature beats which usually preceded afib, and could also take it for  anxiety/stress prn. After 2 trips to ED, I swore I would never go back!

Long story short- now if I go into afib I just take 2 or 3 Inderals, 80 mg pills. I will convert within a very short time, usually as soon as the Inderal addresses the tachycardia. Voila! No trip to ED, no cardioversions. But I also am very careful to get plenty of potassium, magnesium and calcium. Sodium and the typical American diet are very bad for this condition as it leaches out the other electrolytes.  I take no regular meds, by the way, still, 20 yrs later.

[Michael J. McWilliams, M.D.]

I do both cardioversions and ablations.  I haven't done an atrial fib ablation since I started here in Wilmington because we didn't have an intracardiac echo machine yet.  It is set to arrive here in the next two weeks.  I will start doing left sided ablation (atrial fib, left sided atrial tach and atrial flutter) next month.

A consult now could be for either.  If you wanted to come here for a cardioversion, I would have come fasting so we could do the cardioversion in the afternoon with a TEE.  You could start taking coumadin before you came so you wouldn't have to stay in the hospital or go home with shots of heparin.  Hopefully you have a doctor in Raleigh that can manage coumadin for you -- usually managed by primary care doctors.  


We can usually get office records in a few days.
My office number is 910-341-3417.

[Berob99]

Thanks kat4.  I saw my original cardiologist today and he diagnosed my current problem as atrial flutter.  Furthermore, he scheduled a flutter ablation for Friday.  He says they could cardiovert and try to treat it with meds, but they ususally find it to be difficult to control with meds and very recurrent.  He says the ablation should solve the issue for all and return me to the good old days when I just had AFIB!  Thanks again.

[kat4]

Hi,

I think the doctors do not monitor the responses in a thread, so you would probably have to send him another question directly for him to see it.

You could phone his office and ask to speak to a nurse to get info.

Here is what I can say (remember I am not a medical person) about your questions:

If afib has lasted longer than a day and the person is not on Coumadin, then they either have to go on Coumadin for some time (a month?) or have the TEE.  If the TEE finds no clots, I believe the cardioversion can be done right away.

I don't think people usually have to be in the hospital as an inpatient for a cardioversion.  They do have to for three days to go on Tikosyn.

I believe a regular cardiologist can set up a cardioversion, an EP is not needed.

To avoid a delay in getting records, I have sometimes picked them up at a doctor's office and taken them to the new doctor/specialist.  You have the legal right to a copy of your records, if someone gets sticky about this.

[Berob99]

Thank you, Dr. McWilliams.  Just a few follow-up questions.  Since you are in this area, who would you recommend I see for an ablation consult?  The only name I've gotten so far is someone in Chapel Hill.  Also, do both the cardioversion scenarios you mention above (#1 and #3) require a hospital stay and the coumadin with the TEE / cardioversion?  In scenario #2 where you suggest a low dose of flec, are you assuming a cardioversion first or are you hoping that the flec will convert me?  Finally, if I'm willing to come to Wilmington, how long would I have to wait to see you and what would my visit be for (consult, cardioversion, etc.).  I know that it can take a while to get records sent over.  Thank you again for your time.

[kat4]

Hi, Berob99,

It sounds like Dr. McWilliams really came thru for you with the names of doctors who might help.  I hope you can get an appointment with one of them, or drive the two hours to Wilmington to see him.

[Michael J. McWilliams, M.D.]

It definitely sounds like the propafenone is not helping.
There are two cardiologists there in  Raleigh named Chris Gring and Ben Atkinson.  They are not EPs but are Cleveland Clinic trained cardiologists that can give you  down to earth advice on how to treat it.  They are with Wake Med.
I think their office number is 919-359-0322.  They work out of Clayton and are part of Wake Med.  You could also come to Wilmington but that is two hours away.

You options are:
1. Cardioversion on propafenone and see how long normal rhythm lasts
2. Try low dose flecainide 50 mg po twice per day if that wasn't tried.
3. Cardioversions with Tikosyn or Sotalol Load
4. It sounds like you are a good candidate for an atrial fib ablation as well, but that does take some time to schedule usually.

If you have been in a fib greater than 48 hours, you would need coumadin with a TEE / cardioversion.

I agree that waiting until October is not reasonable if you are that symptomatic.

You need an EKG to know for sure what rhythm you are in.

I hope this helps.

[Berob99]

Thanks for your feedback, and I'll try to repsond to several of the issues you raise. 1) Bystolic and metoprolol (generic of Toprol) are both beta blockers and it doesn't appear that either alone would keep me in nsr.  The flecainide worked great at 100 mg 2x per day but became less effective when I cut the dose to 50 mg 2x per day and then had to quit altogether with the side effects of tremoring, anxiety, and an over-hyped central nervous system.  I should note those side effects went away within a few days of stopping the flecainide.  After 2 days of being on nothing by the beta blocker (bystolic), my afib returned and that's when I was put on Rythmol (generic is propafenone).  2) The reason the cardilogist did the cath was because I was complaining of chest tightness and "aches" that started in conjunction with the AFIB and, in spite of the negative stress test, he wanted to put the topic of "plumbing problems" to rest.  3) I am not on Coumadin but do take an 81 mg aspirin per day, which both the cardiologist and the EP have indicated they thought was sufficient.  Of course, I've also never been in AFIB for 5 days before either.  4) I, too, have wondered if my current symptoms of being lightheaded, dizzy, rapid heartbeat, "afib" are indeed afib or perhaps symptoms of a new arrythmia caused by the recently increased dose of propafenone (rythmol).  Again, other than being aware of a rapid heartbeat, I've never had symptoms during an AFIB episode.  That's why I thought for sure that when I called my EP today he'd at a minimum do an EKG to make sure what we're dealing with.  5) Don't want to have to go the emergency room if at all possible.  I went once before and they acted like I wasting their time.  Seems like that's what my doctor (cardiologist or EP) should be for, but my EP said today he couldn't see me until October, which is simply unconscionable to me since something is clearly going on.  Hope this helps and again, I appreciate your input.  I simply want to find a doctor who is accessibile and will listen and care.  As anyone who is dealing with this knows, there is far more too it than the physical manifestation of problem.  There is the psychological toll it takes, and it's pretty tough to deal with when you can't even go on a bike ride with your 4-year old.  Thanks again.

[kat4]

p.s.  Maybe the Rhythmol is causing this, I hope so, then you could get rid of it by switching meds.

I think the med the nurse mentioned is Tikosyn, which does have to be started in the hospital.

If I were you, one thing I'd ask about is trying just a beta blocker.  Or reverting to the Flecainide and a beta blocker and seeing if a lower dose would work or if the side effects would go away with time.

It does often take some monkeying around with meds and dosages to get afib stabilized.  That's why you need a caring doctor.

[kat4]

Berob99,

I am just a layperson, so take my advice as worth nothing.

I have had occasional afib for eight years.  My first cardiologist wanted to put me on a serious heart med, Rhythmol, which is what I think you mean by propaf, but my long time internist intervened and I wound up going to another cardiologist who put me on just a beta blocker, Toprol, which I am still on, although the dosage has increased over the years.

To my knowledge, beta blockers do not cause tremoring or anxiety, in fact, they reduce anxiety.

I wonder why your doc did a cardiac cath, which is a somewhat risky procedure.  Perhaps you had some risk factors like very high cholesterol?  In the afib group I am in (P_Atrial_FibSupport on yahoo), I can't recall anyone having a cardiac cath because of an afib diagnosis.

I am trying to say, I wonder if your EP is too aggressive.

It also sounds like your EP is not very responsive.  EPs are specialists.  I am guessing you might be better off with a regular cardiologist, and if I were you, I would ask your family doctor to recommend one who would see you promptly so you can get some relief from whatever is going on.  Your family doctor might also be able to do an ekg him or herself and get some info.

Are you on aspirin or Coumadin for blood thinning?  With afib episodes over a day long, you probably should be.

You might also think about an ER visit if your regular doc can't help, but those seem to be a mixed bag.  If you get a good cardiologist there, you're in luck, and they can decide about a cardioversion.  Sometimes they are understandably very rushed however.  

I think trying to see a regular cardiologist promptly is your best bet, just imho.  Also keeping your family doctor in the loop.