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Breakthrough tachycardia (SVT's?) while on fecainide/ditialzem

Have been taking flecainide 50 mg 2x/day and diltiazem 120 mg ER 1x/day for 13 months for AFib/flutter...no episodes during this time. On Sunday 6/14/2020 had tachycardia (sinus rhythm) starting at 125 bpm. Took metoprolol and 1/2 flecainide and it dissipated in about 4 hours. Don't know what to expect now. Scared and anxious. Does anyone know anything about this? I don see my electrophysiologist until July 21st. Any response would be so much appreciated!!!
2 Responses
20748650 tn?1521032211
COMMUNITY LEADER
Hmm well.. how did you know it was sinus rhythm / Sinus Tachycardia?

I know there’s a lot of different home monitoring systems now. Some of them I feel seem to work, others I’ve seen aren’t necessarily as effective, others I’m simply not to sure about (ie Apple Watch).

Signal acquisition/waveform generation varies as does the actual algorithms that determine a rhythm. I have a little pocket unit at home myself that I’ll occasionally use on a rainy day. The model is several (3-5 years) old and is capable of generally acquiring an ugly waveform which I can interpret (beyond just identifying QRS) manually about 50% of the time. The success of the units interpretation of rhythm is only correct maybe 25% of the time.

Point being that even with technology coming as far as it has in just 3-5 years; I’m fairly certain that ECG quality is still far from perfect and automatic device interpretation is probably not quite 100% yet.

—That Said—

1. 125 BPM does not sound like too significant of a rate. At least not for sudden cardiac death. It can however cause a problem with reversible  cardiomyopathy if you were to stay at 125BPM permanently leading up to the appointment. So I would say that the amount of time you spend in a 125BPM heart rhythm per 24 hour period (frequency and duration) is something to look out for.

2. Whether or not the flecainide and Metoprolol you took was what actually terminated the episode is debatable at 4 hours. It is fully possible that the episode just happened to terminate on its own. Alternatively it may have simply slowed down. A lot of this hinges on whether or not you were, in fact, in Sinus Tachycardia as opposed to AF/AFL.

3. *Most* (Roughly 50%) of all cases of AF are chronic/degenerative in nature. This means that it would not be particularly surprising at all if a medication was no longer effectively surprising AF.

Explanation:

50% means half of EVERYONE; to include young patients who get AF just one time for one reason or another.

The chance of AF being a chronic/Degenerative type of process INCREASES with Age, Male Gender, Caucasian Ethnicity, Hypertension (High Blood Pressure), Sleep Apnea, Congestive Heart Failure/ Valve Disease/ Prior Heart Attacks, Liver Disease, Chronic Kidney Disease, Diabetes, Endocrine Disorders etc.

Most with AF have at least 1 or 2 of these other things and thus the probability is much higher in most cases

Chronic/Degenerative Disease means that AF stays with you for a very long time and that the disease tends to get worse not better.

In other words, for 50% of patients there is no “Cure”. All that can be done is “delay” the PERMANENT takeover of the heart by AF basically.

Medications play a role in this in patients who either refuse ablation or who can’t afford it. However its quite common to find out these medications are beginning to fail and that AF is slowly creeping back in. Again, this does not get “better” in general. You most likely technically have AF for the rest of your life and will be prone to fall back in to AF at basically any time.

Once medications fail, love it or hate it the next step is PVI/CTI ablation. This works for about 50-70% of patients.

30%-50 of patients will require a second ablation 3rd and even 4th ablations are often offered. Some may even be offered any one of a number of Cardiothoracic (open heart) surgical options before the Rhythm is declared to be “permanently” AF (Untreatable).

For these patients who have failed all the options; the only remaining option is to “cut” the wiring system of the heart and implant a cardiac pacemaker. Essentially meaning that we’ve accepted that the atria can not be saved and have decided to abandon it in favor of artificial heart rhythm.

And to clarify again, the goal of the above is not to “cure” the AF. As I mentioned previously, there is really no “cure”. Rather, each treatment is only realistically expected to “delay” the AF; hopefully for at least a few years. The idea is more along the lines of “delaying” AF for longer than a human can typically stay alive. If everyone was immortal however, eventually every single one of the above steps would likely have failed.

Now don’t get me wrong; I’m not saying this to scare you or anything! You can absolutely take a medication or get an ablation and wind up in sinus rhythm for 15 years!

Rather what I hope I accomplished here was rather a little bit of education about the *nature* of the disease. Just because a medication stops working as effectively, or the AF comes back after an ablation, does NOT necessarily mean anything is different or something went wrong!

Unfortunately this is just sort of what AF does. It’s sort of expected.
20748650 tn?1521032211
COMMUNITY LEADER
Forgive the typos above. Was pretty tired when I wrote that.

Who knows? Maybe it WAS actually Sinus Tach. Maybe it went down because you calmed down and will never come back again! Every case Is different.

I still wouldn’t regret typing all that though! I think just.. mentally preparing yourself for possibility that this pattern of seeing EP, then experiencing a return of palpitations, then seeing EP again etc could very well  just wind up being your new “normal” at some point in life.

At the end of the day, having to get a medication change or even an ablation every few years is still better than 24/7 palpitations and early death from stroke or heart failure.

With science where it is right now I’m afraid the “5 year ablation plan” is really the best we can possibly offer some patients.
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