Advice needed. New to AFIB.

[Reg8]

Hello,

I’m a 47 years old male in fairly good shape. Until this summer, I could run 5 km or bike 40 km no problems.

I’ve had episodes of what I used to call “heart palpitations” for years. It was always after an excersise sprint and would last for 30 second to one minute. This would happen once a year or so. I always got out of it on my own so it was never checked by a Dr.

Last July, it lasted 20 minutes and I decided to go to the hospital. It was AFIB. I had to be cardioverted.

It the fall, I started taking Metoprolol in very small dose. I had two episodes in early November four days appart. One episode 2 weeks later and another 2 weeks after that. Through all that, my Metoprolol was increased twice. I’m taking 50 mg twice a day. I had a CT scan of the heart. It is all good. The stress test was fine. I lasted almost 10 minutes. I take Eliquis also.

Lately, I have extra beats. I hear them with a stethoscope. I don’t feel them much. Some nights are worst.

I also skip beats. That I feel like a punch in the chest that moves up to my face. Can’t miss this one. Stress induces this one but I also have it late at night without eminent stress.

All my episodes are at night. I think it is vagal AFIB. I have all the symptoms except my HR is fast during the AFIB. Up to 180. My resting HR is 45 now with the med. it was 55 before the meds.

My cardiologist suggest I get an ablation. I agree. I see him again next Tuesday because of the ongoing episodes. I want to change my med while I wait for the ablation.

What should I ask the cardiologist? I think I want Facainide as PIP and as daily doses. Do you think I should be moved up the priority list for the EP? I’m off work and every time I return, I get another AFIB because of the stress.

Any comments or advice would be appreciated.

I stop all alcohol, drink only one coffe per day, reduce salt significantly, I eat lots of green leafy stuff and drink low sodium V8. I started taking Magnesuim supplements. It’s at 150 mg of Magnesium Citrate. I want to be careful increasing this one. I’ll ask the Cardiologist Tuesday.

Thank you very much.

[Jong1945]

Reg8, sorry to hear this - sounds quite similar to my experience except that due to my asthma I was never prescribed beta blockers. The literature and the European and American guidelines on AF management are all quite clear - beta blockers (and to a lesser extent digoxin and calcium channel blockers) are all contra-indicated for vagally-mediated AF. I agree, your age, sex, pattern of symptoms all agree with a classic case of VMAF.

Do your research, dig out the references and see if you can agree with yoru Cardio to a trial off beat-blockers and on something else - as you say, Flecainide is often the choice, and is mildly vagoloytic (anti-vagal). You could also discuss disopyramide which is strongly vagolytic. It can be hard to tolerate (dry mouth and all sorts) but in my view is worth a short trial even of only to see that it works, which confirms VMAF.

One question: do you have gastric problems? These can quite commonly lead to a high vagal tone and consequent increase in AF or ectopics. If you do, it is definitely worth trying to find the root cause of your gastric problems, but also try as a short-term measure something like gaviscon liquid regularly. The heart-gut connection is a common issue and Dr Sanjay Gupta has a number of very informative videos on Youtube.

Regarding an ablation - yes, it can be a worthwhile solution. I have had one (and a top-up procedure) and it has given me my life back. BUT, it is a serious operation with some significant risks. These risks will all be well-managed especially at the best centres, but the experience of the particular EP is absolutely crucial. My own view and one I have seen in several places, from the NICE guidelines to reliable websites such as Dr John Mandrola's is that you should only consider ablation if your AF is very troublesome ("symptomatic" as the Docs call it) and your condition has resisted adequate control by drugs.

HTH

[Jong1945 in reply to Jong1945]

p.s. - if your AF is indeed vagal, you may find that (more) coffee helps (!) since it will raise your heart rate.

and btw, magnesium is often taken at around the 400 mg/day level - 400 mg of the magnesium element in the compound - be careful that the mg's are of the Mg only. I have also seen it said that the way to judge how much you need is to increase the dose till you get the runs, then back off.

Re Flecainide and PIP - from what I understand it's either PIP or regular doses. As a QT-interval lengthener, it's not wise to add a slug of Flec on top of a daily dose

[Reg8 in reply to Jong1945]

I fear increasing the magnesium until I talk with the Cardiologist. I understand I need to measure the elemental mg. Thanks.

[Annaelizabeth in reply to Jong1945]

Ablation is not an operation, it is a procedure.

[dmac4646 in reply to Annaelizabeth]

It is indeed but can take every bit as long to recover from as an operation.

[Reg8 in reply to Jong1945]

Hi,

Thank you so much for the reply JohnGrover.

I don’t have any gastric problems.

My symptoms are very strong. Fast HR, tight chest, very dizzy. AFIB is very disabling and I’m convinced I need an ablation. The EP I’m scheduled to see has about 6 years of experience. I don’t know how to find out how many ablations he has done and his success rate.

[Hidden in reply to Reg8]

Some consultants put performance data on NHS Choices. You could ask the GP, the cardiologist or the EP.

You are entitled to information that helps you make difficult decisions

Success and complication rates can be difficult to intetpret.

They depend on patient selection. Age, duration of AF, co morbid conditions etc.

[cuore in reply to Reg8]

Just directly ask him.

[Hidden]

Flecainide seems likely to be a good choice. My experience was that it induced atrial flutter/tachycardia after the first dose. My anecdotal experience should not put you off if your EP recommends it.

If it is effective, you have time to research and consider the question of ablation. My history is similar to yours and my instinct is that you will need an ablation in time.

By the way you are seeing an electrophysiologist (EP) and not a general cardiologist presumably. The former will give you the information you need. The latter may tell you what you need to know. An experienced cardiologist will have seen the problems that arose with ablation in the early days, and be more circumspect.

Increasingly with time, there are more and more experienced EPs about, who have learned from their early difficulties and are less gung ho.

I think the advice I got to go with an EP who has done at least 1000 ablations remains sensible.

[Reg8 in reply to Hidden]

Thank you Bager25.

I haven’t seen an EP yet. The wait time is very long. I have the impression that as long as the regular Cardiologist has options with adjusting my meds, I will not be urgent with the EP.

[Janith]

You should be taking magnesium TAURANT... in powder form. Mix it in a daily drink or hot tea. It seems to normalize things over and above our meds. I wouldn’t be without it.

[Reg8 in reply to Janith]

Janith,

Ok. I heard about TAURANT. I’ll search for some.

Thanks.

[Janith in reply to Reg8]

I spelled it incorrectly ... Pure Magnesium Taurate (powder) ... 125 mg. By Vital Biologics ... vitalbiologics.com ... l HIGHLY recommend ... l am new to afib as well ... l have had two episodes ... so terrifying! None since l started this ... plus other meds of course. Good luck to us all ... and Merry Christmas!

[UScore]

Definitely ask about Flecainide. It works for me, and I get late night AF, often the night after exercise. Knowing that I can pop a pill and be symptom free within few hours meant the 6-9 month waiting list for an ablation was not particularly daunting.

I had similar thoughts about priorities. During the times before I was diagnosed, and then before seeing an EP, I went to A&E a few times, once by ambulance. It would have been cheaper for the NHS to have got me to a cardiologist sooner, but unfortunately the beancounters don't work that way.

I ended up getting a private appointment with an EP. I picked someone who also worked in the NHS, and it worked out well because they then took me on as an NHS patient. So I skipped a lot of the initial wait. They prescribed the Flecainide as PiP and I was immediately less stressed about the situation. Which is possibly why I didn't have a reason to take the medicine for another 5 months.

I also get ectopics occasionally, they are bothersome but not overtly so. From reading these forums it seems to be likely that an ablation will not make them go away.

Good luck on Tuesday.