As we have so much experience and knowledge on this site as patients and as medical professionals, I wonder if putting our heads together on this could be productive for doctors and patients.
Given that once in AF a high heart rate may persist for many hours, even days, it would be useful to have guidelines on what is a sustainable upper limit on heart rate and on duration for that raised heart rate, in order to maintain heart health in the long term.
I was thinking about this because although I had many very very helpful and informative replies to my newbie question, there was no consensus re. when to seek attention, and apparently no consistent guideline.
There were a few replies where people's heart health had suffered as a result of obeying the accepted wisdom, for example:
@P0rtnahapp1e replied "...If I hadn't gone to A &E ten days ago my prognosis from heart failure would have been very gloomy. I was fed the baloney about AF not killing you until I believed it. Not so according to my consultant. Damage has been done to my heart muscle because I waited. Meanwhile my poor heart was trying to get rid of fluids and in doing so, causing further damage.
When in doubt seek help. I'm very glad that I made the decision to jump in the car that morning.which could have led to heart failure."
Buffafly 's response to the same post calls into question whether heart rate is the measure for whether to get medical attention: "My cautionary tale is that I was 'toughing out' an episode of AF when my cross GP ordered me to go to A&E, tests showed heart damage and now my ECGs look as if I have had a heart attack. My HR was officially 130 so that is not the test!"
So maybe a guideline based on heart rate, or only on heart rate, is not feasible?
For newbies, here is BobD 's sensible and soothing reply:
"Going to hospital? Why? AF won't kill you even if it feels like it sometimes and as one old friend commented recently if he had called an ambulance for every AF event he would have one stationed outside his house 24/7 and never get any work done as he would always be in hospital. It is really up to each individual but the general advice given is that if you have any chest pain, or fainting (difficult call for you since you do anyway) then a trip to A and E may be in order and maybe if you heart rate is exceptionally high (around or over 200) but other wise not a lot of point. As above mentioned commented, AF is a chronic condition not an acute one and A and E is for emergencies.
Do read all you can from AF Association website and demand to see an EP as soon as possible. You can find one near you from the AF A website under patient information."
(Thankyou again P0rtnahapp1e , @Buffafly and @BobD.
I started thinking about a formula when one of our consultants said he goes to the gym to get a raised heart rate, so a raised heart rate is not a problem. I thought "Hmm, I bet for you that is about 145 bpm and regular, and has a clear time limit on it. It really is not the same for someone in AF".
At a gym, there is a calculation done to identify a safe higher heart rate to exercise safely. When exercising, people are advised to stay below that rate. It is nowhere near the c 200 or 300 experienced by some with AF.
I assume the formula used in the gym originated in sports science and has medical research behind it.
Would it be useful to use this calculation, which takes age into account?
Would it be useful to refine it to include other factors such as general health, condition, body mass, &c.… ?
Thankyou for reading this. I would be very interested in your ideas and hope some of our medical professionals might contribute.
I would really like to know if given the variables involved it is possible to have a formula which would give a sensible guideline to patients and doctors.
Is there any such guideline in place, or being mooted?
Is it really just simple: don't put up with a heart rate above x , if you have had it for y minutes?
Are there reasons why this is not possible, eg. as @Buffafly said, heart rate is not the thing, or not the only thing, that we should consider in this situation?
Best regards from Boombiddy.
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Boombiddy
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Very interesting post which will no doubt stimulate a lot of replies.
Personally I doubt if there could possibly be a formula to decide the critical point.
AF suffers come in all different flavours.
Me, I have had Lone PAF for 26+ years. I have had 7 ablations and every test known to Cardiac Medical science. My heart rate in AF has varied from 75-150bpm.
I have no other heart issues and never have had. Others will have AF but also with all sorts of other heart conditions. Life style, weight, age and numerous other things also affect the individuals health. Then there are other health conditions.
My view is that we are all so different the same cannot apply to all AF sufferers.
Same here, PA/F for many years with no other heart related problems my Cardio told me that if I was in AF longer than 8 hours I should go to Casualty as for heart rate mine was between 150 and 200 revs per minute
Contrary to what some others say and can do I have been told to attend the hospital if it goes on for more than 10 hours. This has happened a number of times and I have always asked the doctors in A & E if I had done the right thing and the answer has always been yes and that I had done exactly the right thing. It doesn't stop the guilt when you see others who are a death's door in the next bed.
Yes I am serious. I am not alone - but definitely the exception rather than the rule.
My 6th was for AF. 2 months after the procedure March of last year, I developed Atrial Tachycardia. 3 months after that I had an ablation for the AT. I have now been AF and AT free (apart from a 5 hour session last week) for the longest period in my history of AF.
It shows that if you have a willing team (I have had 5 EPs over the years) and they persevere they can make your quality of life better. For me my heart issues are at the best they have been for 26 years with only a few Ectopics each day.
No guarantees in this game but hopefully the Grim Reaper will not get me yet. AF in iteself is not life threatening but it is life changing.
I really do not think heart rate alone is a good indicator of anything. Years ago Before AF I was given a guide of 200 less your age as a good training rate. So in my 40s for example 160 on the treadmill was fine. Later post my second ablation I went into atrial tachycardia (a fast regular beat) at about 140 on my way to the airport to see my sister in France. Having no problem with this rate (other than feeling knackered ) I continued my trip whilst e mailing my arrhythmia nurse and a couple of weeks later once back in UK she arranged a DCCV to correct this. Since raised HR post ablation is very common the resulting 90 although not significantly different did make me feel a lot better.
If the rate is highly irregular and fibrillation rather than just tachycardia it can be harder to live with I know but it is important to understand that AF is NOT an accident or emergency it is a chronic condition and needs to be treated as such. If your daily symptoms change dramatically then one should see your GP and get their advice unless one has chest pain or is passing out in which case emergency treatment may be advisable.
Many people live quite normal lives in permanent AF so it is not just the AF one needs to worry about. For many people AF is one of a number of parallel cardiac issues so this is complex and it is important to know YOU and what YOU can deal with on a day to day basis.
Yes, the more I look at my post the more woolly it looks and I wonder if it is unhelpful to leave it up.
I have been thinking about a formula for when someone is already in AF, whether permanent or paroxysmal, so that they can have a sensible guideline, as the picture I got from people is that doctors do not have a guideline and present such varying advice.
However, I wonder if my post could be too much for newbies as it majors on those who have put up with an episode which was too much for them as individuals, whereas most people do not have any problem caused by the AF except the horrible symptoms.
and others your max safe heart rate during exercise is calculated by subtracting your age from 220, and your target heart rate is 50 - 70% of that number.
This number applies to people with no medical conditions which would limit their fitness (In my case, MHR is 147 but I have a leaky mitral valve, enlarged ventricle and breathing difficulties, which I assume would reduce my score). The score would also be affected by any passing illness. Clearly it would be impossible to calculate an exact score even for one individual.
So the test is whether you are haemodynamically stable, that is your heart is pumping strongly enough to circulate your blood adequately. Signs of instability are chest pain, breathlessness, faintness, low urine output, cold extremities. When you are monitored in hospital for hours and then sent home, what the medics have been doing is checking for instability, which would be an emergency, so the time has not been wasted!
I have hesitated to post my last comment, for fear of scaring members, but as this subject has come up, I'm going to, then I'll duck! I was watching a documentary programme 'Inside the Ambulance' when the crew were called to a man in a state of semi-collapse. It turned out he had recently had an episode of AF and was still feeling ill though now in NSR. One of the crew explained to camera later that this was because a long episode of AF was like running several marathons back to back without training so therefore the heart would still be tired for some time afterwards. She added that AF was dangerous because a too high HR for too long would cause cardiac arrest, so they took AF very seriously.
We always say to newbies that AF doesn't kill you, but maybe that should be modified to 'as long as you know when to seek medical help'? During the episode mentioned above I had spasms of chest pain and nearly blacked out whenever I got out of bed, only phoned the GP to convince my husband I didn't need to go to A&E. Result was three days in hospital.......
Well said Buffafly. When I have had AF at 160/ 245+bpm I have been whisked into A&E and read the riot act by paramedics if I showed reluctance. Have also gone into heart failure after nearly 3 weeks of fast AF. I guess you get to know your own limitations with experience.
I think that is the answer - you need to know your own limits - but also the limits of your local A&E and recent experiences would make me VERY reluctant to go to A&E unless I was feeling extremely unwell.
Says she sitting with HR of 160 for the last 12 hours - in and out of AF! But I DON’T feel in the least concerned or unwell, my BP, SATS and Mg are all within good limits for me.
Forgot to say - symptoms which shouldn’t be ignored if AF is going on for a while is fluid retention - swollen ankles, extreme breathlessness, low BP. - less than 90 systolic - feeling clammy and with chest pain - then blue light may be required!
I am so symptomatic there is no way I could be as calm as you seem to have been at 160bpm for 12 hours. I take my hat off to you. Maybe I am just a wimp!!
This reinforced what I said earlier, we are all so very different.
Glad to see you are now in NSR. Take it easy your heart has been running a marathon there are no two ways about it.
Thanks I am taking it very easy and will for another 12 hours. I can operate normally 120-130 but upward of 140 I just sit with feet up. I guess I’ve had it so many times...... other than feeling very fatigued I am not symptomatic. Have a good week-end.
Just to remind everyone- when we are in AF the heart rate recorded is the ventricular rate and the atria are beating at a much higher rate. I think it is unwise to ignore high rates of what are essentially weak contractions- it can't really be compared with the strong healthy beats from exercise. As many have said above, it also depends on underlying conditions but in healthy hearts it still isn't wise to allow rapid rates for too long,
My view as well rosyG . I'm not really qualified to respond in this debate, as I've only had three goes with AF so far. However, the first time I ended up in A&E where nothing was done for hours and hours (other than the staff keeping an eye on the monitors). Max recorded heart rate went way over 200 - I remember seeing 235 at one point. I reverted to NSR spontaneously as the nurse was inserting a cannula to make blood tests and drug administration more easily available. They still kept me on the monitor for another 8 hours, and then gave me an aspirin and sent me home. They mucked up the referral to the heart unit, and I had to sort that out myself with the GP. The heart unit got the wrong end of the stick, and eventually gave me a clean bill of health with no reference to the AF!
So, the other two occasions, I have avoided going to A&E. I understand now that it's not an emergency, and that they are not really the right people to be able to help me. I'll sit it out until it either goes right, or I get scared that it won't! I keep my own records with a Kardia.
The point I think that you are making is that the Atria are zizzing away at a frantic random rate, which if prolonged for too long will cause damage, and meanwhile the Ventricles are pumping at random intervals, sometimes with a full chamber giving a healthy blood flow, but mostly missing the best point in time and making the blood flow reduced together with pumping when only part full, which may also cause damage? This should not be allowed to continue for too long before you get some help, somewhere. Mine has always gone normal after 6 to 10 hours, so I'm happy with that. I can do other muscular things for that length of time without too much ill effect, and I hope my otherwise 'healthy' heart can as well. I'd definitely seek help if it was still happening the next day though . . .
You had a bad experience - in some hospitals they would intervene with rates as high as yours were, I would definitely go to A and E with such high rates I feel OK at 130bpm but rubbish at 160!!!
Thanks rosyG . It has never been as high again since, I think I was in full 'panic' mode at the time and now I'm much more relaxed about it. During my last bout, I recorded only 164 at the highest (first after noticing) reading. It came down from that to the 130 - 150 range while I was resting.
I think the rate and time at a high rate would normally be very important- several cardiologists and EPs have said this. Also it's generally agreed on this site I think that symptom such as pain, dizziness syncope should be taken seriously.
Those people who are in permanent AF and have no symptoms are quite happy but there won't be many of them who haven't been put on some sort of rate control by their doctors,- if they've had a high rate. I E rate is thought to be important
I think the length of time you've been in AF is important too. My doctor says if I'm in AF for more than 24 hours to go to A&E. Having said that, many people are in AF permanently, so I guess it's how you feel in the end. I think chest pain beyond the normal mild discomfort or fainting would make me reach for the phone, but honestly, hospital is such a faff and so far away for me that bits need to be dropping off before you can drag me in...
I think all discussion hinges around the term 'acceptable'. Such a subjective concept!
The popular approach of 'AF won't kill you' doesn't inspire me with much cheer. Although I'm generally an upbeat person, I know that having PAF has severely impinged on my quality of life and on my overall health. Now I'm 'in the system' with a diagnosis and treatment plan including an EP, it is deemed 'acceptable' by medical staff that I endure any amount of AF episodes without being treated as an emergency. I understand... having worked as an A and E nurse, there are very limited resources.
However, I personally don't find it acceptable that my cognitive health has declined significantly (I have posted previously on AF and dementia/cognitive decline) due to poor cerebral oxygenation during episodes. As it is highly unlikely that AF patients are ever going to be offered oxygen therapy for home use during AF episodes, I now do my utmost to keep my sats levels up, by breathing deeply and keeping movement to a minimum. I have also lost weight to reduce the load on my heart and no longer have angina during AF.
I'm sceptical that research will be carried out on AF patients to determine if oxygen therapy will be beneficial, as it doesn't carry any promise for Big Pharma to increase their profits :o)
Like Hidden and CDreamer I would need to be fairly moribund before I'd go to A & E.
Rather than how fast is your heart, I think it may be more worth while taking into account other things, like do you feel quite seriously not right, have you gone pale and shaky, would your condition give other people concern, is the state you are in a significant departure from what's your AF norm?
It has been suggested before that we should be saying "'Managed' AF won't kill you". I think this thread confirms the point. Thank you all for your very interesting insights. I will be taking very careful note for the future!
I think rate is misleading, I have been and still am in AF for the last 4 days but I cannot say what my rate is as it's all over the place, I have an app that seems to be far better than my old one as sometimes it was unable to trace my heart rate because of its irregularities, according to my new app in a one minute reading my rate goes from 130bpm to 45bpm with average of 86bpm, so what is my rate?
Is this normal for AF as my rate is rarely constant unless I'm not in AF when it is a metronomic 58bpm.
Brizzy50000 If you are using something that is looking at your 'pulse' by measuring the swelling of the capillaries during the pumping of your heart, or is something measuring the beat of the 'pressure' during the pumping of your heart, then you are measuring the wrong thing for checking on AF. The problem is that your heart is trying to pump some times when it is already empty, and not producing any pressure pulse through your blood vessels. The only true way to measure whilst in AF is by measuring the electrical activity of the heart.
This is why I carry a Kardia device, it's the cheapest option I know of to check on the actual heart, not the results of errant heart beats.
A most interesting question, Boombiddy with some really informative answers.
I cannot really comment from experience as my last AF episodes were four years ago and were usually shorter than the time it would have taken me to get to A&E and get seen. Rate was around 160bpm lasting usually 2 hours.
However, this thread gives all of us an invaluable insight into the aspects of AF that make seeking help essential.
I do think that the use of the sports science formula for maximum heart rate should not even be considered in this discussion, as not very many of the AF heart beats are resulting in correct pumping of the blood flow, which is what the heart is there to do.
Yes I agree that that formula would not be adequate or safe on its own.
Having a formula like that, though, is what gave me the idea of having some kind of formula, with more variables, mooted, researched, tested...
Personally I am one of those people who tells themselves off for being a wuss even if my head's hanging off, and I know I am not the only one... so I thought putting our heads together (patients and professionals) to consider what would be a set of parameters, might get a lot of useful information in one place.
I am finding it very helpful to have so many people’s experience and knowledge brought to this subject and will be taking notes.
So thankyou momist and thankyou to all to contribute here.
There are so many variables to this question I would doubt if you would get the medical profession to agree to a figure without lot of research and looking at what available statistics there are also, keep in mind AF has only been taken seriously for the last 20/30 years so research and statistics are still developing.
I have worked a lot with heart rate sets with athletes, believe me individuals chemistry can be so different "One size doesn't fit all".
I was asked this week to deliver a talk at the Heath hospital, Cardiff to third year nurses from a patients prospective of living with a AF as I was there for most of the day I got the chance to sit in on number of their other cardiac lectures heart failure was talked about in some depth and is something that doesn't happen over night.
Its been mentioned in a lot of replies use the common sense approach and listen to your body if you are experiencing something unusual then get it investigated.
Very interesting post I would say we are all so different and some such as me have multi conditions that can and do make a great difference to how it can affect you. I had a Heart attack while driving but had no knowledge of raised heart rate or AF? When I was admitted EMU I was rolling on at 236 bpm and making the monitor beep madly . I have been told all of the time not to go past 150 which is a little hard when I have an at rest rate of 90 to 120 but it does settle back most of the time fairly quickly. To help it all along I have allergies to some of the treatments and drugs and do not play fair with anaesthetics, I wake up far to early other than that it very much depends on how I am feeling?
I have done it twice in in the operating room it seems to shock them more than me. I did wake when they put a another chest drain in and it went a little awry I Woke and said "That's not good as I bought up blood" I was supposed to be in an induced coma?
Initially, I was told to go to emergency if I had AF of any kind. Mine would convert to sinus in less than 4 hours so by the time I got there and got attended to by someone, I would very soon after or before go into sinus. After a few trips like this, I decided this was wasting everyone's time. Other trips for chest pain and no AF too were a waste of time. What I really noticed was the different approaches taken by each different doctor; and once I had more knowledge myself, then I realized how little specific AF knowledge the ER doctors, that I happened to see, really had. General knowledge; and if you are having a heart attack, likely a good place to be; but if you want expert AF knowledge, you will not likely find that.
Now our health care is so bad in Nova Scotia, 18 to 20 hour waits with 18 to 20 ambulances lined up to dump patients at many hospitals on a fairly regular basis and a huge part of the population without a family doctor, even if you do get to see an ER doctor, there is no where to send the report and no one to follow-up on your care, which includes getting future prescriptions for drugs you may have been prescribed. And you cannot get to see a specialist, unless requested by a family doctor. Walk-in clinics do not do follow-up care. And then some options for treatment, even though recommended, are not done because they are too expensive. So here some people must decide if their symptoms are worth the ER challenge, is there health care immediately available and of what quality, and is there an option for follow-up care. Our province has the highest number of old people in the population and 40% of the provincial budget is devoted to health care, which is in shambles, so if you have AF don't move here. Supposedly, you won't die from it, so your place in the cue is decided accordingly. This dire example of course does not apply to everyone; but definitely some and getting to be more.
We do not have a private health care option. For example, I wanted to get an X-ray on my back and neck. The chiropractor is limited to who he can send for an X-ray; and, if he sends too many patients and nothing shows up, he can be blocked from sending anyone at all. The same applies to my family doctor. He is older and near retirement, so I could soon be without one, and Gp's are in short supply, so he lied and got me an X-ray and nothing showed, so one more negative for him. I cannot pay for an X-ray since only public sources are available. But you can pay, at some provincial hospitals, to have your cat have a CAT scan after regular hours. My daughter is a vet and she told me this. And what a bunch of hoops I had to jump through to get a copy of the x-ray for the chiropractor. It took me two days of effort and a lot of pressure from me. If I wasn't retired and had the time, I could not have done this. I was told the provincial health care paid for it so I could not have a copy of my X-ray for my chiropractor. Our very high taxes pay for health care or whatever we should call it.
So there can be a lot more to some people's AF challenge than just the AF.
OMG. I knew it was bad in some parts the other side of the pond, but I didn't know how bad. I do hope you never get anything even more serious than AF!
I completely agree that these questions have to be answered on an individual basis. That is why it is so important once it becomes clear that you have a tendency to AF to ask to see an EP-
or at least a specialist Cardiologist in order to get the answer to that question that is the right one for you.
Whilst it is certainly true that one may not need to go to A&E every time one has an episode (hence the practice of giving people a PIP) - this may not be true for some of us - depending on the current state of heart function and also other risk factors connected to stroke. For example (and I mean by way of example only) when I had my first couple of AF episodes I was told always to go to hospital. Once I had had full cardiac tests and other tests I was told that I needed to go only if my heart rate was more than 180 or I felt pain or faint or if the PIP hadn't worked after 24 hours. (The reason for this is that after a certain time it is not safe to use IV drugs or high dosage of drugs such as fleccanide) and obviously they wanted to avoid having to do electrocardioversion. BUt I used to be given IV fleccanide in much higher doses with monitoring in hospital than they would give me to take as pills. Now I am 30 years older than the first time I went to A&E the advice from my EP is to go to A&E if my heart rate is above 150 and/or the PIP hasn't worked after 6 hours.
Sorry to arrive late at this post, but interetsed to see that there is a pretty good consensus – that heart rate alone is not an adequate guide.
The first thing to say, as Brizzy50000 and Momist pointed out, is that pulse rate is not the same as heart rate because at higher rates many heart beats are ineffective (because the heart is empty and has no blood to pump) but still require work – so the heart becomes inefficient, wasting energy. Therefore you need an ECG, such at the AliveCor / Kardia to tell the true heart rate.
The second is that exercise heart rate recommendations (maximum 220 minus your age or 70% of that for training) does not apply if you are not exercising because the circulation and heart itself behave quite differently with exercise, in particular the blood is pumped back to your heart by the leg muscles and the heart contracts more quickly leaving more time for it to fill between beats.
The third, as Momist also mentioned, is that the atria are going much faster than the ventricles so they are affected by prolonged attacks of AF whatever the heart rate (ventricular rate) is.
But the most important thing, as BobD, Buffafly and many other people have said, is that the haemodynamic effect, i.e. the state of your circulation, is what really counts in deciding whether you need to go to hospital urgently. This can be judged as "not good" if you are pale, sweaty, faint, breathless, very weak or have central chest pain.
Another thing to mention on the "AF won't kill you" issue is that even if an AF attack causes "acute heart failure" (including with a mild troponin rise) this usually does no lasting damage.
Just one more point: if you are feeling bad enough to go to hospital, the best treatment will probably be electrical cardioversion, but this can only be done straight away if you are (1) "starved" i.e. no food or drink for 6 hours, and (2) on anticoagulation, or certain that the AF has only started within the last 12-24 hours.
So don't have a cup of tea while waiting for the ambulance!
Thankyou JonathanPittsCrick and to all who have replied. There is such a lot to take in here and I really appreciate such practical advice. I really hope to remember it all at the right time! I will re-read it all periodically.
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