Cardioversion : I am very disappointed. I had... - AF Association

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I am very disappointed. I had cardioversion last week and went back into sinus rhythm and was so happy and felt great but this morning I flipped back into AF. I am on 50mg x 2 flecanide, 125 mg of digoxin and 200mg dilitiazem and 20mg of the new rivaroxiban. I had a successful cardioversion in 2012 for five months. I always seem to go into AF after waking up and usually on a Sunday! I had kept very quiet no vigorous exercise. Does dehydration affect AF? Since taking these drugs I have noticed I have to drink a lot more water.

How many cardioversions can you have safely and if I had another do you have to wait a couple of weeks. How does it affect your heart long term? I was converted into NSR so it shows I can get back in but wish it would hold. Perhaps if I had a third quickly, it would whack it back into sinus.

My gp and anticoagulation clinic refused to contine my riveroxiban and say in a month I have to have warfarin. However, I would prefer to stay on the new one. Does anyone have advice on this one in order to get it. My EP has suggested it. It seems they feel that the only criteria to have the new drugs is if you are confused, prone to falls or have an allergy to warfarin. I thought NICE ageed the new drugs. I was also told the policy in south london was different to that in the north by a hospital doctor!?

14 Replies

Hi Moonriver

Sorry to hear you are back in AF, to be honest I don't know anyone (except some very young sufferers usually performance athletes) who has had a CV keep them in AF indefinitely.

You can have as many CVs as you like I think, but not sure why you would do that, as they nearly always revert at some point. I think you need to talk to your EP about possibly an ablation.

Re the NOAC, you actually have a right to it now, this is a quote from the NICE guidelines published June 2014

"The drugs must therefore be made available for prescribing within their licensed

indications, and should be automatically included in local formularies"

The whole guidelines are here

But note that you should be informed of the pros and cons of all the options, and then you are free to make up your own mind. I am aware that many areas and GPs are not yet working to the guidelines, but of course you are free to challenge them and ask them why not.

Not my personal preference to be on a NOAC (yet) but everyone does have that choice.

Be well


islarose in reply to Beancounter

All the reference to certain parts of your treatment which are in CAPITAL LETTERS I have no idea what they mean I do know GP which is General practitioners. I have recently had two heart valves repaired and another pacemaker with two wires. I started with AF in Feb 2009 off and on until 2013 then I was in AF all the time.

Janet Norris

BeancounterVolunteer in reply to islarose

Hi Janet

CV is cardioversion, or more properly Direct Current Transthorasic Cardioversion, we tend to abbreviate and use the initials and you can probably see why.

NOAC is Novel Oral Anti Coagulant, and it simly means the new drugs which have come out in the last few years prior to which we only really had warfarin.

EP is electrophysiologist, they are specialist cardiologists who look after heart rhythm disorders, the "electricians" of the heart.

NICE is the National Institute of Clinical Excellence.

Hope this helps


Two tips:

I find it helpful to print things off e.g. The NICE guidelines that Ian mentions and give them to the GP, with a friendly comment along the lines "I know you're busy, but I'll leave these with you". This tactic worked a treat when I wanted a referral to a specialist cardiac clinic. The guidelines said that I was entitled, GP had never heard of the clinic. Highlight the relevant passages if necessary.

Get your EP to write to the GP, even if s/he has already done so. My cardiologist wrote something like "Mrs X is adamant that she does not wish to take warfarin." To be honest, I think the GP was OK with the principle of prescribing a NOAC but it gave her back-up with the local clinical commissioning group who control policies.

If you are still not getting what you want, you have a right to challenge the CCG and there will be procedures described on the website for the area where you live.

BobDVolunteer in reply to Mrspat

Sound advice.

Following my ablation the EP wrote " she was commenced on dabigatran 150mg bd as her INR was sub therapeutic. Dabigatran should continue without interruption for 2 months at which point I would be happy either for dabigatran to continue long term or for her to once again recommence warfarin ( chads vasc score 2)"

My GP didn't bat an eyelid and gave me a repeat prescription for the Predaxa

My INR was 1.8 for the ablation. They used heparin which they reversed with protamine.

If the new anticoagulant suits you then you should push for it.

Thanks to you all for your helpful replies in response to my cardioversion and query about new anti coagulation meds.

I chose to have another go at cardioversion because it is less invasive and worked for me for several months last time. My cardiologist at the time thought he had taken me off the lock in drug flecanide too early at six weeks and he says that is why AF came again. Who knows?

Reading the notes here, it seems that ablations are not always successful and the procedure seems to be repeated several times.

Are there long waiting lists for ablations? When are you regarded as an emergency for NHS treatment? Do medical insurance policies cover them? If you were to pay for one yourself, how much are they?

What is vagal AF?

Also why is digoxin regarded as an old fashioned treatment and not used very often today? It seems to lower my heart rate.

My concern is my thyroid stimulating hormone being kept lower than normal to stop cancer returning. However, on this occasion it was 1.6 so could not be implicated in my return to AF. Seem to be running out of drugs now. Bisoprolol was effective but they thought it made me wheeze. Isn't it all a pain!

BobDVolunteer in reply to Moonriver

The vagus nerve is the main neural superhighway between the brain and both stomach and heart. In some people either stimulation or relaxation of the vagus nerve may trigger AF. (note the word trigger not cause). Typically vagal AF may happen in response to food triggers or at night when the person is sleeping or relaxed. Doctors talk in terms of "when the vagal tone is low". For those patients beta blockers which slowdown the heart are not usually a good idea and can exacerbate the problem.

Waiting lists for ablation vary greatly by area but should not exceed eight months and may be as little as four. Cost again vary but around £14k in England for a private one I understand. Hospital hotel costs are usually in the region of £500 per night so depends on how many nights you are in,. Most case either one or two nights.

Ablation should be considered as an ongoing treatment and many people will need a second or even third procedure. I had three. At present there seems to be a 50% chance of AF returning post successful ablation within five years., I'm over six now and it was worth every second! I had root planing at the dental hygienist last week which was worse than my ablations. Methods and results have been improving since my last ablation and many people seem to get relief the first time once the three months recovery period is over. Many EPs feel that early intervention by ablation has the best chance of success.


bayoucoon in reply to Moonriver

My husband had his third cardioversion 6 weeks ago, which was again successful, but again for only a couple of weeks. He is back in AFib and the Cardiologist is hesitant to have him go through an ablation. The EP hesitates also because of my husband's age, he is 76. They both feel it is too invasive. His resting heart rate hovers around 50 and will sometimes dip into the 40's.

Re Digoxin: the latest guidelines say that it should not be offered as mono therapy unless the patient has a sedentary life style. However, it can be offered in combination with other medications (see guidelines).

I've been on Digoxin for 5 months in combination with Bisoprolol. This has worked very well for rate control. I certainly don't have a sedentary life style. These drugs don't suit everyone and you must obviously be guided by the professionals. The alternative offered was Amiodarone, which I've had before and worked but gave me side effects. Also, it has implications for the thyroid if you are worried about that.

I don't have experience about cardioversion but NICE have said patient preference must be allowed when it is being decided which anti-coagulation you have- also I would refuse to wait another month before having an anti-coagulation , especially as you have come out of NSR.

Please go and make a fuss asap!!

re your question about vagal AF- it's the type of AF where the vagus nerve is involved - often AF starts at night or after heavy meals. Importantly, beta blockers and digoxin are contra indicated if one has vagal AF

Moonriver in reply to rosyG

Rosy, I am on rivaroxiban and have another months supply, after thatbtheyvwant me on warfarin but I shall contest it with the useful info given here.

rosyG in reply to Moonriver

That's great- download the NICE guidance and take it with you !! The speaker from NICE at the Surrey Cardiology Conference confirmed you can choose as long as your choice is clinically suitable for you.

Moonriver in reply to rosyG

Rosy, how do they diagnosed vagal AF?

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