Controversy over when to go to A&E when in ... - AF Association

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Controversy over when to go to A&E when in AF, could this be a good question for Patients' Day?

Buffafly
Buffafly
50 Replies

A recurring question is under what circumstances one should go to A&E when in AF.

I have made a list of typical answers, not quotes:

Only if you have chest pain or faintness as this is a chronic condition.

It is not worth going because they only monitor you for hours then send you home with no treatment.

My GP said I should go so they can zap me.

My cardiologist was cross that I did not go sooner as he said a long episode of fast AF can weaken the heart.

1, 2, 6, 12 hours etc.

You must go before it is too late to cardiovert you if you are not anticoagulated.

AF won't kill you so don't bother the hospital.

The wonderful ambulance crew said I should always call.

The A&E department were fed up with me and called me a frequent flyer.

One thing is clear, we are confused! Of course people have different circumstances which may lead to specific instructions for them but it would be good to know if consultants agree on a general rule (I know Bob has quoted Prof Schilling on this but some people's experience has been different). I was struck by the comment that was quoted recently that continuing in PAF can strain the heart, also by PottyPete's sad report of heart scarring caused by years of AF.

If there is really no one size fits all answer, which I suspect is the case, then it seems one of the most important questions to ask our cardiologist/EP is when to go to hospital!

50 Replies
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Mejulie69

My 3 experiences in A&E in the last month have all left me with the impression that they are there to deal with averting imminent death. Death on a longer timescale is dealt with elsewhere, so unless you are having a stroke, they are not interested in AF.

But I think the correct answer is to go whenever you feel you need to.

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Buffafly
Buffafly
in reply to Mejulie69

I assume the monitoring is to find out whether there is a possibility of imminent death or whether the patient needs to be monitored further in hospital. Some posters including myself have been kept in for days for further monitoring/tests. Don't forget, you being young and fit can stand up to an AF episode much better than a poorly 70 year old 😬

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Hidden
Hidden
in reply to Mejulie69

Mejulie69 I've always found that AE is interested in AF. I guess it depends on the rate .....possibly not concerned if it was under 100 bpm

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UScore
UScore
in reply to Mejulie69

when I went to A&E with AF they hooked me up to machines and put me in the bay next to the nurses' station so they could a very close eye on me. They certainly seemed concerned. I was fast tracked through triage both times.

Maybe if I was older (I'm 40) they would consider AF a more typical thing, and in a younger person it's handled differently?

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Mike-tyson

Surely your GP should decide when you need to go into Hospital ?

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Hidden
Hidden

Should be interesting to hear views.

I usually feel very guilty when I go to AE ....the last time ( April ) the paramedics were quite insistent even though my rate had dropped and I felt better from my original 240+ bpm. Ended up with DCCV. The previous time I wanted to leave it a bit longer but the locum GP frightened me with talk of heart attack! Same outcome...dccv .

It's a very individual thing. I think we can only get general advice.

Sandra

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doodle68

I have never been to A&E when in AF and would only do so if I had chest pain, severe difficulty in breathing, or if I was in AF with a very high heart rate for long period of time.

The enemy of AF is fear and panic, it raises your BP and heart rate and adds to the trauma your body is experiencing. I prefer to manage my episodes at home in a calm atmosphere than to risk spending hours on a trolley which would be certain to cause me anxiety...

[quote'' A hospital is under investigation for the deaths of two patients on trolleys ......It is understood one patient who died after suffering a cardiac arrest had been waiting 35 hours for a ward bed elsewhere in the hospital. While a female patient suffered an aneurysm and later died in a resuscitation bay.]

itv.com/news/2017-01-10/wor...

I guess it is down to each person to decide what is the best for them...

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Buffafly
Buffafly
in reply to doodle68

Good point but I was reading one of the BHF articles today and it said that doctors have discovered that when the body pumps out adrenaline *in response* to heart failure (the natural result of prolonged AF) it makes it worse and that is why betablockers are prescribed, to block the adrenaline and allow the heart to rest. Possibly that is why following the advice to chill is so hard?

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doodle68
doodle68
in reply to Buffafly

Hi Buffafly :-) I am taking a Beta blocker for PAF and they have indeed slowed both my heart rate and blood pressure and blocked adrenaline receptors and I feel 'calmer' overall thought I am also avoiding stressful situations when I can. Since I have been 'medicated' (starting in June) I haven't actually experienced any episodes although I am vaguely aware they are happening, they are being picked up my BP monitor and my pulse.

I am a success story for Beta blockers.... for now ....though I guess the episodes which are at the moment being contained may break through in time. When they do if I still have PAF and haven't progressed to persistent or permanent AF I will up the dose of BB's to control the heart rate and request a PIP to control the rhythm.

No hospitals for me if I can avoid it :-) it is my body and as with most things in my life I will take control of it's management.

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Mike-tyson
Mike-tyson
in reply to doodle68

If you have electrical problems with your heart which i understand causes AF. You cannot cure that yourself ??

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Arveno
Arveno
in reply to doodle68

Doodle 68, my spontaneous reaction is that it is really better to avoid hospital which you are speaking about. In case of need use ANOTHER better hospital.

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pattiannj

I have always had good reception by paramedics & A&E. My AF always starts at night I've been to A&E when heart rate 200 plus & feel very unwell Ie can't get to loo without fainting Generally I can cope if it's gentle & I don't feel unwell. Guess we all have to decide for ourselves when we feel we need help but would be a good question for patient day

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Thomas45

Between my initial visit to hospital A&E when I was kept in overnight and prescribed Amiodarone to seeing a cardiologist for the first time 10 months later I had 2 visits to A&E, once after I'd presented myself at the local medical centre. They rang the hospital for advice and an ambulance was called. The second time I was on the motorway when sudden onset of AF caused me to feel very unwell. I managed to drive off the motorway and got within 2 miles of a hospital when I could go no further. I waved down a "passenger transport ambulance" and they let me rest on their stretcher and they called an emergency ambulance. I was at A&E for about two hours when the AF stopped, without any treatment. That was about 11 years ago. Now I have long term persistent asymptomatic AF. My resting heart rate is within the "normal" range, so there's no need for A&E to be involved.

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checkmypulse

My only visit to A&E with AF was after 3 days of h/r around 160 and managing to get to GP for my regular INR testing at which the nurse fetched the GP to me. He was unable to read my pulse as he said it was so high, and sent me to hospital who seemed concerned that I had left it so long to get there. This was around midday, I was kept overnight during which time I stabilised and they got an EP to see me next morning.

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pottypete1

I think you hit the nail on the head, we are all different and sadly it is impossible to make a general rule.

For me with PAF and being so badly symptomatic, I was firstly told to take extra Flecainide. If this did not precipitate chemical cardioversion within about 10-24 hours I knew my heart would not respond.

On arriving at A&E and expressing my concern for 'wasting their time" I was told on numerous occasions that I had been right to come to the hospital and to stop worrying.!!

I was, on nearly every occasion, eventually electrically cardioverted.

I hope my comments help.

Pete

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BobD
BobDVolunteer

Lots of opinions and I know you all know my feelings but that wasn't the question. The 64k$ question has been asked at conference before and the answer from the particular eminent consultant was that AF is a chronic condition etc etc not for A and E but that any chest pain etc etc. which is what I usually suggest.

With the Agenda already set you would need to ask this question during general Q and A sessions but do remember that this and any other question should not be personal in any way shape or form as the doctors concerned can not answer individual medical questions.

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Hidden
Hidden

Bob, with due respect to the eminent EP and others, they ought to experience a wildly erratic heart rate....often approaching 200 and over...and the sense of impending doom before advising to stay out of A&E

Also, if AF is considered as not proper for A&E then why are patients not sent home instead of prepared for cardioversion?

Sandra

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seasider18
seasider18
in reply to Hidden

I have twice gone to A&E after going into AF after about a year in NSR. Neither time did they offer a cardioversion. First time after being allowed home I phoned the consultants secretary who got me an appointment with a registrar the next day but he just put me on the 14 week waiting list.

Other time they kept me overnight and put me on a waiting list for a 7 day ECG.

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Hidden
Hidden
in reply to seasider18

seasider18 I think this all depends on the severity of the AF .....heart rate and other symptoms. My AF is classed as persistent in that it usually requires DCCV. All of my 17 cv s have been ' emergencies ' .....carried out after presenting at A&E. I've proved refractory to chemical cardioversion. The one time I was put on a waiting list after a spell in ccu where they managed to reduce my rate a bit, I went into heart failure ( one off ) so not something I'd want to repeat I can tell you. Horrific time.

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seasider18
seasider18
in reply to Hidden

I have never heard of anyone at my local DGH having a cardioversion in A&E. I have presented immediately so I could be done without being on warfarin. Each time my return to AF was due to a procedure that stimulated my vagus nerve. Their attitude is always to put patient on Amiodarone and Warfarin for eight to twelve weeks.

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Hidden
Hidden
in reply to seasider18

seasider18 I suppose it depends which hospital you attend. I've only had one cv actually in A&E, quite recently in fact. The others have all been in the theatre ante Room, cardiac ward or Cath lab ( if I'm in on the day they're doing cv s I'm tagged on the end).I've been on warfarin for about 14 years and I self test.i always make sure I stay in range so no problems with DCCV s. Prior to that I used to have Dalteparin or similar administered.

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seasider18
seasider18
in reply to Hidden

So it is better to go to A&E in the morning. I have always needed to go later in the day.

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Hidden
Hidden
in reply to seasider18

I've gone all round the clock ! Must admit I now try to hang on as long as possible hoping for a return to AF. Once i had a cv on the cardiac ward at 11.30pm. Personally I find early in the day is best if a cv is on the cards .....gives them time to find a slot in theatre.

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seasider18
seasider18
in reply to Hidden

Can you have a 'one off' heart failure ?

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Hidden
Hidden
in reply to seasider18

I did wonder that myself. When the AE doc told me i had ' a bit of heart failure ' and then the cardiac registrar told me that having AF for such a length of time had caused heart failure I thought I was doomed ! Once the fluid was removed from my lungs i was able to function properly. !

However an echo not long afterwards showed that I now had normal LV function.

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seasider18
seasider18
in reply to Hidden

That is the problem with throwaway remarks. They stick in your mind and you to speculate.

I had fluid in a lung after my aortic valve replacement and again after my pacemaker was fitted. That one was about the most painful experience of my life when a young Ukranian doctor pushed the needle into my lung. I think I must have been her first patient for the procedure.

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Buffafly

The question is academic for me because I have been told I must never again take any medication for AF unless told to by a medic so if I am ever unfortunate enough to have a bad episode again I don't think I could do anything else.

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rosyG

I think there is one answer that might fit all- i e it depends on how you are feeling. If you have a fast heart rate and symptoms of pain/dizziness/ feeling generally unwell then go to rechecked out

Agree there are many interpretations!!

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UScore

My ep told me to go to A&E if my flecanaide pip didn't stop it in 3 hours. She wrote it in a letter to my GP. That's the last instruction I've received so that's what I'll do.

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Buffafly
Buffafly
in reply to UScore

Good to have clear directions.

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UScore
UScore
in reply to Buffafly

Yeah, that's that sorted I guess.

I wouldn't know what else to do apart from go to A&E or see my GP - and because of that letter from my EP my GP would just tell me to go to A&E!

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Shellyrich

My EP advised me that if I had an episode and it lasted 3+ hours I should go to A&E (especially as I am on quite a high dose of Flecainide). When I attended A&E I would often wonder if I was wasting their time but was always told I had done the right thing by going in. Unfortunately on the majority of my trips to A&E I would have to be cardioverted. As many have said we are all different and react in different ways to this condition. Therefore we are receiving different advice and treatment from our EP's on how to deal with it. Therefore I don't think there is an answer that would fit all of us.

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UScore

I'm not really sure what the alternative is, particularly for people with infrequent PAF. Is it to go via the GP?

Wouldn't that mean some people having to wait days or weeks for an appointment? My GP surgery is quite good and will usually get you a same day appointment if you push for it, but I believe it's not so easy for everyone.

If I didn't have my EP's advice to go to A&E if the flec fails, I'd probably phone 111. My experience of them on previous calls tells me that they'd say go to A&E.

My GP didn't seem that knowledgeable about AF. I think if I went to her, she'd also send me to A&E.

I reckon all roads, at least for me, lead to A&E!

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Shellyrich
Shellyrich
in reply to UScore

Same here UScore, I have contacted 111 or seen my GP when in PAF and both times the advice was to go to A&E.

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Hidden
Hidden

Never went to A and E just sat or lay down till I felt better no matter where I was. Never had chest pain or trouble breathing mind.

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Hidden
Hidden
in reply to Hidden

That's fine. It works for you and you are aware of the likely outcome. Wish we could all be like that!

Sandra

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Hidden
Hidden
in reply to Hidden

Wasn't meaning to offend I wasn't aware of outcomes at that time in my case open heart surgery for tumour in heart and cox maze and pacemaker. I answered the question

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Hidden
Hidden
in reply to Hidden

Hidden no offense taken! Im genuinely pleased that you can cope at home. Best place to be!

Best wishes

Sandra

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Hidden
Hidden
in reply to Hidden

Aye pills and pacemaker keep me level ish as ex nurse prob helps plus I hate hospitals

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reedman

I have persistent AF and have had the condition for about 6 years or so, I am 75. I have been to A+E twice both times this year. First occasion as a result of pain in the chest. I told them upon arrival I had AF. I was thoroughly examined and given 2 identical set of tests 4 hours apart and eventually discharged at 1am with the diagnosis that it was most likely that I had strained muscles in my chest due to some work I had been doing, ticker fine. Turns out it was the preliminary chest pain to a bout of shingles!

Second occasion was 4 weeks later. Working outside doing a little sanding on some woodwork I collapsed unconscious and came to some time later having also been incontinent. Admitted to A+ E with a resting heart rate of 137 bpm. Once again thoroughly examined and it was decided that I needed some form of rate control since although I had previously been taken off Bisoprolol since my HR tended to be below 100 bpm anyway (I felt much better and far less lethargic), it would seem that over time my resting HR had gradually increased. I was then put on a drip of Digoxin since I was negatively affected by Bisoprolol, kept in overnight and now take a daily dose of 125 Mcgms of the stuff along with Anti-coag. I feel fine again. Resting HR once more comfortably below 100 bpm.

On both occasions the A + E people told me I had done the right thing by coming in to them.

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UScore
UScore
in reply to reedman

That's one of the key things for me too. In my experience Drs and nurses at A&E can be quite forthright about whether you should be there or not. They told me I'd done the right thing. Their actions told me they were taking it seriously.

The Triage system is designed to be a filter to help prioritise patients. When I've gone in with heart symptoms I got pushed to the front of the queue to see the Triage nurse, and the nurse has deemed them severe enough to admit me immediately. I was put in bays where they could closely monitor me.

111 have told me to go to A&E when I spoke to them. I called 999 one of the first times (middle of the night panic) and the ambulance was there in minutes.

Every part of the system, both directly and indirectly, was telling me that going to A&E with my AF was the right thing to do.

They had every chance to make me wait, send me home, direct me to the GP. They didn't.

On the other side of the coin, I've gone into A&E with a broken nose. I had to wait ages to get triaged, then hours waiting back in reception, then a lot of sitting in a side room with very infrequent contact from the staff. When they don't consider you a priority they don't hide it!

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jondeanp

When i get AF it tends to be persistent for long periods until cardioversion or once where i self reverted (but that was still after about 6 months)

I went once to A&E after the start of an AF episode.

I had to be persistent to persuade the triage doctor to consider me for a cardioversion, as i was not on anticoagulants at the time. I was trying to get treated within the magic window.

They did see me and successfully performed a chemical cardioversion in one of the bays.

If they hadn't done that i would have been on a long waiting list whilst in a persistent AF state

I'm currently on an NHS waiting list for an ablation......it's been approx 12 months now

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Buffafly
Buffafly
in reply to jondeanp

😢

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Valdoot

My recent on call doctor told me not to wait any longer than 15mins! You can imagine my fear now. I felt crappy this morning for a while and kept remembering a couple of members advised to me settle down and relax, so I came to work (I live on site) and am sat number crunching. To be fair, I did feel thumpy for longer than 15 mins and I'm ok now. But I have no idea what to do now. I see my cardiologist very soon for the results of a Nuclear test, so I,ll ask him. I think in truth, if I feel tired out, and teary (which isn't often) I'm going to take it as a warning and go to hospital. Ive contradicted myself here. Nope, don't know what to do!! Just hoping my meds will cover me so I wont have a stroke.

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RichMert

OK, I know I have said this before but........

The Ambulance crew will tell you to always ring. If you are hoping for an ablation then, points make prizes. You are likely to get an ablation earlier if your AF is witnessed on a regular basis. I am sorry but, out of sight out of mind. Make yourself visible.

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Mike-tyson

I was admitted by my GP as he wanted my heart rate monitored as had Rate of 160 Bpm at times. I was kept in until my rate reduced to below 100 Bpm. But also given additional medicating to slow heart rate down. I was then referred to special clinic of doctor who specialised in heart rhythm priblems. I can Catheter Ablation three weeks later. All this treatment was carried out at the Royal in Stoke on Trent. Their cardiology dept is first class. My Ablation was successful and my heart rate now down to between 60-70 Bpm.

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Gwersey
Gwersey
in reply to Mike-tyson

Can I ask how old you are?

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eleanor--1941

I USE PIP (Flecainide).Advised by Cardiologist if this does not work within 8hrs to go to A&E.Works for me 40mins to 2hrs I am back to normal.,so never have to go to A&E now for about 3/4yrs now.Hope this helps.

Eleanor.

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Mike-tyson

I was told by NHS emergency no 101 I think it was when my heart rate went to 130 one saturday evening, to get myself to Cardiology in Wolverhampton or Stoke in the next hour. My son took me to Stoke as been there before, they put me on Degoxin and other medication overnight. They would not let me out of Hospital until my heart rate was below 100BPM. This happened the following afternoon. I was then refered to a specialist clinic for Catheter Ablation. After further tests it was agreed I should have one which was carried out last December. I felt really tired for couple of months after the ablation but ok again now with heart rate down to between 60 & 70 BPM. if it does kick off a bit i just take 25mg of attenolol which seems to calm things down So it has been so far so good as I am now nearly 76 years old.

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Zombiebenny

Well I had a ablation over 2 weeks ago after having been cardioverted 5 times over the years for going into af and after 13 days from having ablation I had some palpitations and went out twice but it went back to normal then went out again but when it didn't go back to normal rhythm I went to local a&e and all they done was monitor me over night put me back onto bisoprolol and sent me home saying they was referring me back to the QE who don't the ablation. It's the 1st time I've ever been sent back home still in af . And my rate is around 90 to 140 when moving . Don't know how long till hear anything from anyone but after 4 days back home feels uncomfortable but I haven't had any palpitations or chest pain .

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