Most vagal afibbers receive wrong medication

Bagrat commented on one of my posts I made a year ago and this reminded me of the following study which was done some time ago but may still be relevant. Many new people on the forum may not be aware of the concept presented.

Most vagal afibbers receive wrong medication

MAASTRICHT, THE NETHERLANDS. There is still widespread denial among North American cardiologists as to the existence of vagally-mediated AF (atrial fibrillation) and a pronounced tendency to treat all AF patients the same. Hopefully, this will now change with the publication of the results of the Euro Heart Study. This study involved over 5000 AF patients treated in 182 hospitals in 25 different countries.

A total of 1517 of the patients experienced paroxysmal (intermittent) afib and was studied in detail. Among this group, 42% (640 patients) had a distinct, physician-verified, autonomic pattern as far as triggering an episode was concerned. Another 35% reported no clear trigger patterns, while in the remaining 23%; the physician did not verify the presence of triggers. The authors of the study classified the trigger pattern as vagal if episodes occurred after a meal or during the night, and as adrenergic if initiated by exercise or emotional stress. Afibbers with no clear trigger pattern were classified as mixed.

Sixteen percent of the group had lone AF defined as afib without the presence of hypertension, coronary artery disease, or heart failure. Somewhat surprisingly, the researchers found no difference in the incidence of heart disease among vagal and adrenergic afibbers. Among the group with clearly defined trigger patterns, 18% were classified as vagal, 46% as adrenergic, and the remaining 36% as mixed. (NOTE: The distribution in our most recent LAF survey was 30% vagal, 6% adrenergic, and 64% mixed).

The major conclusions reached from the study are as follows:

•Exercise and emotional stress were the most common triggers followed by electrolyte imbalances, and alcohol and caffeine consumption.

•The majority (72%) of vagal afibbers received non-recommended drugs (beta-blockers, sotalol, digoxin or propafenone) – 57% were prescribed beta-blockers or sotalol.

•Vagal afibbers who were prescribed non-recommended drugs were more likely to progress to persistent or permanent AF than were vagal afibbers prescribed recommended drugs (primarily flecainide). After 1 year of follow-up, 19% of vagal afibbers prescribed non-recommended drugs had developed persistent or permanent afib as compared to 0% in the group prescribed correct drugs.

•Among adrenergic afibbers, 20% did not receive the medication recommended in the 2006 ACC/AHS/ESC Guidelines for the Management of Atrial Fibrillation. However, there was no indication that the type of medication affected progression to persistent or permanent in this group.

•Quality of care would appear to vary considerably between the regions in Europe. In the Mediterranean region 41% of patients received the recommended treatment as compared to 20% in Central Europe, and only 19% in Western Europe. Similarly, in the Mediterranean region physicians verified the presence of triggers in 75% of cases as compared to 79% in Central Europe and only 46% in Western Europe. Editor’s comment: It would seem that afib care in Western Europe is substandard, but probably no worse than in North America.

•The authors point out that beta-blockers are often given in conjunction with class 1C antiarrhythmics (flecainide and propafenone) in order to prevent 1:1 conduction in the case of atrial flutter induced by the class 1C drug. They suggest that verapamil and diltiazem could be used as safer alternatives.

The authors conclude, “Physicians do not seem to choose rhythm or rate control medication based upon autonomic trigger pattern of AF. However, the role of autonomic influences should be taken into consideration in order to achieve an optimal management of the disease as non-recommended treatment may result in aggravation of the arrhythmia.”

de Vos, CB, et al. Autonomic trigger patterns and anti-arrhythmic treatment of paroxysmal atrial fibrillation: data from the Euro Heart Survey. European Heart Journal, Vol. 29, 2008, pp. 632-39

Editor’s comment: Although not specifically directed at lone AF, this new European study is clearly a landmark and emphasizes the importance of determining trigger pattern (vagal, adrenergic or mixed) before prescribing medication for paroxysmal afibbers. It is interesting that our first LAF Survey (February 2001) revealed that 50% of vagal afibbers had been prescribed non-recommended drugs. This resulted in an average afib burden (# of episodes times their duration) more than twice as high than the burden among vagal afibbers taking flecainide or disopyramide. As far as propafenone (Rythmol) is concerned, the situation may not be as clear-cut as suggested in the Euro Heart Study. Some vagal afibbers have found this drug quite useful. Some fairly recent research have found that the degree of beta-blocking effect exhibited by propafenone depends markedly on how fast it is metabolized, so this may explain why it works for some vagal afibbers, while it is contraindicated in most others.

24 Replies

  • Thanks. Interesting post. My AF is paroxysmal / vagal and from what you have posted it looks like I am receiving the correct treatment. Very Reassuring.

    Thanks again.

  • I am pretty sure my af is vagal. I take flecainide and bisoprolol but I'm now wondering if I should talk to my gp about the bisoprolol. Thank you for that post, it has provided some useful information. JanR

  • I've tried to find what I said but can't and the little grey cells are not what they were. Suspect it was about bets blockers not being a suitable treatment for vagally mediated AF. I've probably ended up on the right treatment by chance as beta blockers slowed my heart rate too much. I do remember my cardiologist being at a loss as to why my abdominal symptoms, bloating, nausea etc have been better since starting flecainide. By the by, years ago before pain clinics were readily available, I remember flecainide being used to control difficult nerve pain in people with advanced cancer.

  • Interesting to read this. I'm on Disopyramide which helps my AF but Bisoprolol has very little effect , if anything, on my heart rate. Flecainide doesn't work for me either .

    May be having an anatomic ablation this year which hopefully may ' cure ' .

  • Very interesting, thank you... no-one's ever said what sort of AF mine is, but it almost always comes on at night (once during the day after a lengthy bout of a stomach bug). However, I can almost guarantee that around a week after a major stressful event such as a conference, with unusual eating and drinking patterns, I'll get it. Go figure, as they say. I'm on biso and warfarin, which is pretty much standard in our surgery/area and gets trundled out for everyone I think.

  • I have been prescribed Bisoprolol 3 times by GP's and even by a cardio once. EP said it was totally the wrong drug for me and has always taken me off it and put me on rhythm control drugs instead, which have always worked, when we've found the right one.

  • Very interesting reading thank you.

    I am def on the wrong drug and need to change.

    I confess to be a little wary of taking flecancide but perhaps I should just give it a go while waiting for ablation as it has been recommended before but had then heard such negative press about side effects. (They also said bisoporol in morning too)

    I am still working and am concerned about feeling unwell in the classroom. (Am a primary school teacher so lots of stress now daily with ofsted looming too!)

    Can anyone please give guidance as to how they felt initially when starting it?

    I will obviously consult GP / EP (if possible) before starting

    Thank you

  • I had no problems or symptoms when starting Flecainide. A few adverse effects materialised after many years. You do however need to be careful when initiating as it can cause ventricular problems in some people, very few and usually shows up immediately.


  • Pleased to read this as was struggling with multiple episodes but now on flecainide after seeing consultant, who also halved Bisoprolol dosage. Have always felt that AF was vagal and had definite triggers including stress and alcohol.

  • I can't help but wonder if there is a link between folks who have vasovagal responses and having a vagal trigger for afib. Vasovagal commonly found more in men. For me, if they draw blood, I get a big time vasovagal response and practically pass out if sitting. I get real queezy, get horribly pale and start having diminishing vision. I have those who are drawing blood lay me completely down and I'm perfectly fine. Isn't that something?? I've tried all kinds of things before I began laying down for the draw......even looking at naked women. I brought a magazine....... No kidding. Just to get my mind somewhere else just to see if that might have an effect. The nurse didn't mind after I told her of my experiment. But absolutely nothing has worked. Maybe a study should be done to see if there's a connection between vasovagal response and having afib.

  • Thank you for this, EngMac. I am also a vagal afibber and while I tried flec for a week, it didn't eliminate afib episodes, so I'm about to talk to my EP this week about using flec as a pill in pocket, instead of atenolol to reduce heart rate when I'm afibbing. I'm glad to be able to show him this article when I see him on Tuesday. Thank you1

  • It is good to know some people have benefited from my post. I am curious to know if most people whose GP's or EP's believe vagal AF is real are in Europe and if any people are in North America. In the study, at that time, North American doctors did not recognize vagal AF separately. I was wondering if anything has changed. My EP did not seem to address it separately. He prescribed the wrong medication and made my AF worse. I am in Canada.

  • Gotta love that Canadian health system. Mrs Clinton is already screaming about adopting single payer health care at her sparsely attended "rallies". Sure hope I can still use the cardio doctor of my choosing and get the meds I want if she gets in..... :(

  • I have been living in US 40 years and my vagal AF has been treated only here. You are absolutely right. American doctors would say I heard about it , why don't you google it. They are starting to catch up like in Washington and Johns Hopkins in Baltimore. But I had to leave three doctors because they just didn't want to make any changes in their routines.

  • Can you post the exact reference? The author name + original title would be a good start, then I can try to find a link

  • I think you refer to

    Atrial fibrillation management: a prospective survey in ESC Member Countries.

    I am now going to plug this reference into google scholar, and find some more recent references on this subject. There have been 674 citations since it was published, of which 91 were since 2015

  • I am convinced my Afib is vagal in nature and after a discussion with my EP, just recently switched off Sotalol to disopyramide, mainly at the prompting of what I have read in this forum. So far ( 2 weeks in) very mixed results: resting HR has come up to 60bpm, and Afib episodes have been just a frequent, but a little more uncomfortable ( faster HR) and of a longer duration along with some syncope ( had a 26 hour stint over the weekend) I will give it time though as I had been on Sotalal since 2012 after my 2nd ablation. I am an the US and when I mentioned I had read here that North American EP's were apparently a little less cognizant of the role of the vagus nerve in some AF he quite indignantly told me he has been well aware of it and has been for 20 This gentleman is a new EP for me and perhaps we did not get off to the best of

  • Had to go off of beta pace AF due to my blood pressure crashing. Only worked for about 4 years. Had a heck of a time having my insurance provider cover the full cost of betapace when I first began taking it, since the generic version, sotalol was available. My cardio doc told me that I should never take sotalol since it is SIGNIFICANTLY different in effectiveness than betapace AF. Most generics are practically the same as their original formula counterparts but not for this particular heart drug. Might want to talk about his with your doc.

  • You are right, they just don't progress with the research very well in US, but they love to do ablations as the practice.

  • A few days ago I was given an unpleasant job to do at work. Five minutes later I had heart problems, so took 50mg Flec, and one hour later 50mg more. This calmed me down. I have a home ECG machine, and the new trace matches a confirmed non-AF trace.

    I am convinced my AF started due to chronic bronchitis wearing me down, + the stress of a second move of flat in a year + then walking up eight floors of steps, at work (no elevator). Main reasons for Vagal AF: Overstraining myself in exercise + high stress. Exactly. On a checkup with a doctor, no physical reason could be found -- the heart was in good condition.

    Only recently, I had been puzzled. Why this emphasis on rate control? As I see it, thinking from first principles, in the heart there are two variables, each with their controller. I presume there are good biological reasons for a non-steady rhythm, just as there are good biological reasons for varied rate. But, sometimes, the non-steadiness gets out of hand. Then the rate controller picks up on it, and speeds up, in an attempt to restrain the unreasonable variation. It usually succeeds, then sometimes, itself, gets stuck in high gear.

    The answer then is to straight jacket the rhythm until it calms down. When you do, the speed drops of its own accord. When two children fight, you must catch the one who started it.

    This has been my experience. Now I have some biology to investigate. In particular, there must be a role for a certain amount of irregularity. Thanks for a very helpful post.

  • Hi ILowe, unfortunately I don't have the author's name or other particulars. I saw this study on this site:

    Please post any more references that you may find that are related to this and are relevant.

    If you can, please tell us what you use for a "home" ECG machine and if it can be purchased by someone who wishes to do so.

  • I will look for up to date references later. I may start a separate thread.

    I have just started a separate thread about home ECG machines

  • I should have read your posting before I posted my question. But you quote study from 2008 . Don't you think there have been some changes in the research? Well, there was a suggestion by my doctor that if the propafenone doesn't work we go to tikosyn and if that doesn't work we would go for cryoablation.

  • Hopefully you researched these drugs. On this website the information on tikosyn is scary.

    Maybe you can find other info that is somehow different.

    Propafenone has beta blocker properties and may make vagal AF worse for some people as it did for me. This is the drug Michael Jackson was taking when he died. So tasking it correctly is likely important.

    Dr. Jonathan PittsCrick made a comment on a post that he has had success with pacemakers. You may want to check that comment.

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