Meds vs Ablation

[Jhcoop55]

I posted to this site in early December 2015 when I was diagnosed with AFIB. At that time, I was cardioverted twice within a week and put on Flecainide, Cardiazem and Pradaxa (blood thinner), before my AFIB issues gradually subsided. I had some additional minor events that resolved themselves during December and started to do better in January with no noticable events . As a result, my cardiologist took me off Pradaxa since my AFIB had appeared to stabilize. Unfortuntately, shortly thereafter on February 15, I had a significant event with elevated heart rate of 160 and and irregular rhythm which required another ER visit and cardioversion. Additionally, cardiologist increased my dose of Flecaninide by 50% to 75 mg, twice per day (150 mg in total) and recommended I go back on Pradaxa even though my Chad score is zero (I am a fit 60 year-old who exercises daily with no heart disease).

Since I had a repeat significant AFIB episode, we agreed that I should at least talk to an EP about an ablation. That appointment is being set up now to help me decide if this is the correct approach versus staying on meds indefinately. My cardiologist felt that I could continue on my existing medication and continue to increase the Flecainide further if I continue to have events (and perhaps hold off on an ablation). I must admit, I'm not keen further increasing my meds and I'm not happy about staying on Pradaxa especially since my Chad score is zero (my Cardiologist says that until I am relatively event free, say no more than one or two per year, I should stay on the blood thinner, which, of course, has its own risks). Therefore my alternative option is to go with the ablation which is not a panacea and often requires a touch up procedure. My questions are as follows (particularly those individuals who have had an ablation):

Has your quality of life improved post ablation? Any major complications?

Do you need to continue with any meds long term after the ablation including blood thinners (I undertand that you may need to stay on meds at least short term). Or, do you merely need the meds such as a "pill in the pocket" only when needed.

If I choose to defer having an ablation for now, how do you view the risks of staying off the blood thinner versus going on it indefinately? I am very active (Cycle regularly, ski, etc) and I'm wondering if the risks of a major bleed in the event of an accident is really less than the increased risk of a stroke by not taking the blood thinner?

I will be consulting with an EP soon who will help me come to a decision on an ablation, but it will help me to have your feedback in advance based upon your experiances in order to be better prepared for that meeting.

Thanks Much,

Jeff

[BobD Volunteer]

Hi Jeff and what a lot of difficult questions.

Lets look at anticoagulation first. Many doctors do feel that AF means that you should be on them even if your AF is only occasional. People who have implanted monitors often find that they are in AF far more than they are aware of.

That said even a successful ablation does not always mean that you can stop anticoags. There is some evidence that just having had AF increases stroke risk regardless of how often or when. With a score of 1 I was told after my last successful ablation that I could stop but chose not to. There is an old saying that you can always stop anticoagulation but you can't undo a stroke. It is and always should be a personal choice after due discussion with your doctor. What is important is that you make a choice based on full data and information. Yes there can be risks attached to anticoagulants as with all things in life and one does , as I often point out, need to look at those risks. In addition to CHADSVASC score there is something called HASBLED which judges the risk of major bleed and provided that your Chads exceeds your Hasbled then normally anticoagulants are safe. Thanks to creeping arthritis I no longer go fell walking, ride my mountain bike or do much physical stuff but I do still like to keep busy building race car engines and helping my boys build their competition cars. This occasionally means that I do leak a bit when in contact with sharp metal objects but despite being on warfarin have never needed any hospital treatment . My wife who is NOT on A/Cs bruises far more than I ever have so my personal opinion is that the risks, once understood, are often over stated or at least assumed to be worse than they are. Caveat -- we are all different.

Quality of life??? Undoubtedly my three ablations were the best thing for me and have left me AF free although I do still have some minor arrhythmias as do many patients. My quality of life was returned to me after many years and I stopped all arrhythmia meds about 8 months post ablation. A few years after my last ablation I was diagnosed with prostate cancer and elected to have the major operation. Had I still had AF this would not have been an option as I had to fight a bit for it anyway. Had I not had the operation they would not have found how far it had progressed and any treatment would have missed some of the cancer. I do not think it melodramatic to say that my ablations saved my life. I therefore am perhaps biased but there again I have met a lot of people who say they wished they had not waited so long before going that route but very few who regret it.

Regarding cardiologists and EPs somebody here once said that if you go see a carpet salesman he will sell you a carpet. Cardiologist seldom offer other than medical solutions whereas EPs do offer ablations where they think it appropriate . Again my view is if you are offered it then you have the choice and moreover the chance to be drug free if not for life, at least for a while. There are no guarantees in life other than death.

These are a few thoughts for you Jeff but I do urge you to read up as much as you can especially from the fact sheets on the main AF association website before visiting your EP

Good luck whatever you decide.

Bob

[Jhcoop55 in reply to BobD]

Bob, thanks for your detailed reply, very helpful. I'll continue to do research in advance of my EP visit

Jeff

[Hidden]

I had a PVI ablation 11 years ago and it worked straight away. No AF and no drugs (except anti-coagulants) for 8 years. Now got something else but different and back on drugs. I had my ablation specifically to get off drugs which were working very well but affecting my memory quite badly.

My CHADS score has always been zero until I hit 65 last year, so now my score is 1. Nevertheless, my EP has had me anti-coagulated since being diagnosed in 2003.

I would jump at the chance of another ablation if they thought it would work. It was no problem at all.

Koll

[Jhcoop55 in reply to Hidden]

Thanks Koll. Just one clarification. Were you continuously on the anti coagulants following your procedure or did you start on them after a few years?

Jeff

[Hidden in reply to Jhcoop55]

Hi Jeff, I have been on anti-coagulants from when I was first diagnosed at age 53, that's 13 years ago, 100% of the time whether on drugs or not, and both before, after and during the ablation.

Originally, that was Aspirin because it was thought to have a similar effect at the time. They changed me from Aspirin to Warfarin about 4-5 years ago and now Apixaban.

As I said, I had a CHADS score of zero and also no family history of anything either.

For the vast majority of the last 12-13 years, I have had no AF (i.e. no symptoms) and a total normal heart beat because of the drugs or the ablation. I have repeatedly asked my EP about anti-coagulants and he always confirms I'm better on them than not.

Confusing isn't it!

Koll

[FrankC]

I guess I'm similar in terms of risk, in fact I'm a bit younger (59) but similar fitness profile. I had similar dilemma 5 years ago and opted for ablation on advice from EP. Best thing I did as I've only had the odd episode since then for which I've used Pip to clear things up. I think I was on warfarin for a month or so post-op but no other meds since then thankfully.

I've been able to carry on my cycling etc. with no adverse results, but I guess everyone's different so you need to listen to your EP and go with your gut. Best if luck either way.

[PeterWh]

Jeff

Bob has given excellent answers and information as usual. I'll chip in a few bits from my own experiences. Not trying to scare you into your decision.

I was diagnosed as being in persistent AF 17 months ago at a few weeks over 60. No obvious reasons but with hindsight had had AF for some time but largely asymptomatic. Had cardioversion 6 weeks later. Lasted 24 hours in sinus. EP stopped flecainide and said only realistic option was an ablation. Had an ablation 7 months after diagnosis but went back into persistent AF less than 72 hours later. My EP had said that in MY case it would not work first time but he had hoped I would last 6 weeks. I am waiting for my second ablation.

I think that the cardiologist is 100% right re Anticoagulation. As it was explained to me until someone has had full investigations and been AF free they are considered at a significantly higher risk than the normal population. Also you will see from AFA website and stroke association website that the majority of major strokes and mortality from strokes is due to AF. Also I have seen the absolutely devastating effects of debilitating strokes - one was only in early 40s and another in early to mid 60s had stroke which left him paralysed from the neck down and only able to do a few grunts but brain 120% active and he lived like that for 17 years. Devastating is an understatement. Personally I have already decided that I am staying on anticoagulants for life.

In my case just before Christmas when doing a scan re my varicose veins the scan showed that I had a "historical" blood clot in one of the superficial veins in my leg that had blocked off that vein. When that happened who knows.

As for bleeds well if you have a major bleed they have plenty of ways of stemming it. If they didn't many people who are NOT on coagulants would die in accidents. Also as they give people transfusions the effect of the anticoagulants is reduced because the transfused blood does not have anticoagulants in them. I think this may be less with the NOACs.

As for touch up who knows. From what you have said you have paroxysmal AF so the chances of success first time (and overall) are very much higher than for those of us with persistent AF. In any event that is a good question for you're EP because it does vary a lot from person to person. I specifically asked my EP "Please give me a honest and frank answer but in MY case what do you think the chances of success first time and overall are?".

Good luck and feel free to ask questions.

[CDreamer]

Cannot contribute much more than what has already been very comprehensive answers - just offer my experience - yes there can be complications as with any procedure and I had several things go wrong with mine and my first ablation made my AF far worse and I ended up in Acute Cardiac Care for a few day several months later. I had faith in the doctor who performed the procedure however, and very glad I did as I am now AF free and have been since Mar 2014.

The choice for me was easy as I never wanted to be on drugs, to me the idea of years of slowly poisoning myself was not acceptable at that time, although I was glad to take Flecainide when it stopped my very frequent episodes. If I knew then what the results of taking Flecainide for me were going to be I would have not taken anything and just ridden out the episodes or pushed for an ablation much earlier. (Flecainide can exacerbate other latent conditions - which is what happened to me - it can also immunesuppress and cause liver & kidney toxicity).

These are not not easy choices for any of us to make and for me it always comes down to risk/benefit analysis for you as an individual because evidence based medicine relies upon statistical analysis of the herd - not whether or not it is best for you as an individual.

My decision was ablation, ablation, ablation - every time and the sooner the better as earlier intervention has much higher chance of success.

Anticoags? I chose to discontinue as soon as I was 3 months post ablation as I had at that time 0 on the risk factor score, I am about to revisit that choice in June with my EP as I will hit 65 and being female now score 2. I am well aware of the stroke risk having several family members who suffered strokes and that for me will be by far the most difficult decision.

[Hidden]

Hi Jeff, re your penultimate para, I have justified deferring an ablation on the grounds that the EP quoted only 70% success likely (2 years ago) and as I had Lone PAF I wanted to try some other lifestyle/diet things first.

I am also active, CHADS 0 and stable on Flecainide, my cardio said not necessary to go on blood thinners. I am in the minority here and if I recall directly the stat is usually you are x5 more likely to have a stroke if you have had AF in the past even though not currently. Whilst I have no grounds to challenge that stat, it remains an individual decision as whether the chances are still very remote. I don't know what the figure is but say if 1:1000 over 5 yrs from 60 to 65yo old, I am happy to stay off the thinners.

I believe most EP's will recommend an ablation when it is marginal either way, as that is what they do when not in the consulting room.

Good Luck.

[mikeymike7]

Hi Jeff, I'm 62, was on a range of drugs for 5 years, with AF getting progressively worse.Had a PVI cryoablation a year ago. Result? No drugs at all apart from PIP sotalol, virtually no AF. QoL vastly improved, so for me it is a total no brainer!

[Jhcoop55]

Thanks Mikeymike and everyone else that responded. What I've learned is that AFIB is an incideous condition that affects everyone differently. Nonetheless, you have all armed me with great information that will allow for a meaningful discussion when I meet up with the EP

Thanks Much

Jeff