What has been more successful for you? Chemical Cardioversion, DC Cardioversion or Spontaneous Cardioversion?

[jedimasterlincoln]

I have experience of spontaneously reverting to NSR, as well as one successful chemical cardioversion and many failed..... and a dozen DC cardioversions which put my back into NSR but little else. I wondered if anyone else had more luck with the chemical aspect?

[Kaz747]

I had a chemical cardioversion for atrial flutter which was unsuccessful. It dropped my HR from 150 to 80 momentarily then it went straight back to 150. The following day I had an electric cardioversion which worked on the first attempt.

[pottypete1]

I have successfully used PIP for over 20 years every few weeks but have also had about 20 DCCVs when this did not work.

In all the years I had AF I can only remember spontaneously cardioverting once and that was probably 20 years ago after laying on an A&E trolley for a number of hours waiting for a DCCV.

I think my heart got fedup with waiting!

Pete

[CDreamer]

I’ve always cardioverted spontaneously - often with vasovagal maneuvres. Never had a cardioversion, never been offered - despite EP writing treatment plan with chemical cardioversion ASAP but every time I presented to A&E in fast AF - once being sent by my GP - I waited 9+ hours in A&E without even having a heart monitor on - I think it was the boredom that cardioverted me!

[KMRobbo]

Only had one chemical cardioversion intravenous drip of flecainide.

I also have cardioverted once with a high extra dose of flecainide (150mg) after I was put on 50mg x 2 daily (this was 2.5 months after the IV flecainide)

Never had an electric cardioversion .

[JonathanPittsCrick]

The attacks of AF happen for a reason (a viral illness, stress, high blood pressure, alcohol, a slow natural pulse rate, thyroid disease, fluid overload and others we don't know about). Spontaneous cardioversions mean that the cause has gone away – but even when it has, the heart may not be able to sort itself out without help. Electrical and chemical cardioversions work fine in this situation but are much less likely to be successful if the underlying cause for the attack is still there.

Chemical cardioversion (e.g. with flecainide) can temprorarily counteract the cause but often is not immediately successful. Electrical cardioversion is usually immediately successful (and very safe) but there is a high rate of early reversion to AF.

So the best approach is:

1) try to identify the cause of the attack and correct it if possible.

2) try chemical cardioversion with "pill in pocket" medication (usually a combination of flecainide and quick-acting beta blocker).

3) go for electrical cardioversion (IMPORTANT: don't eat or drink so you can be given a brief general anaesthetic ASAP) and immediately follow it up with antiarrhythmic medication to prevent relapse – it has been shown to double the success rate.

4) as even a short attack of AF can make the heart irritable and because the cause of the attack may be still active, continue the antiarrhythmic medication for at least a month afterwards.

There is no limit to the number of cardioversions you can have.

In general, "the sooner the better" applies, but unless you are certain the AF only started within the last 24 hours or you are already on anticoagulation you either need to have a month's treatment treatment with a NOAC (non-warfarin oral anticoagulant) or a TOE (trans-oesophageal echocardiogram) to ensure there are no blood clots in your heart, before undergoing electrical cardioversion.

[BG2017 in reply to JonathanPittsCrick]

Hi - just a quick question JonathanPittsCrick- I struggle to identify the cause of the Af sometimes (I am lucky enough to be otherwise healthy, with a vegan diet, I am 44 and exercise moderately with a healthy BMI) When I was diagnosed with Af I was also diagnosed with SSS and Bradycardia- the pauses of 6 seconds definitely went hand in hand with AF (supporting your slow heart association) I now have a pacemaker but still have Af - the pacemaker is set to 50 (and 40 at night) to take into account my naturally low resting heart rate - could it be that this is too slow and still contributes to some of the Af with no known cause? Your thoughts would be appreciated.

[JonathanPittsCrick in reply to BG2017]

Absolutely, yes.

Many attacks of AF start at night BECAUSE the natural heart rate drops then. I would suggest you ask for your pacemake to be set at a normal rate, i.e. 70 during the day (with increased rate on exercise up to 120 or more, and slow fall-back) and at least 60 at night*, with hysteresis OFF to prevent pauses.

Some people are concerned that keeping the rate up at night will interfere with their sleeping but usually, once you are used to it, it actually helps (by suppressing pauses and ectopic beats).

* 65 would be good but unfortunately Medtronic pacemakers don't allow that, so you have to choose either a drop to 60 or keep the rate at 70.

[BG2017 in reply to JonathanPittsCrick]

Thank you so much for taking the time to reply- I am definitely going to get my settings changed. Kind regards, Becky

[pottypete1 in reply to JonathanPittsCrick]

Hello Jonathan

So good to hear it from the oracle!

Pete

[JaneFinn in reply to JonathanPittsCrick]

Thank you so much for taking the time to explain things - I really appreciate it. You always bring illumination to things that have been confusing and unclear

May I ask a cheeky question following on from your comments? Feel free to ignore it if you don’t have time.

I have been told I can’t ever take Flecainide due to a run of VT caught on a loop recorder. At that time I was not on any medication other than ramipril for hypertension. I have since been diagnosed with PAF (with events showing average rate of 180 bpm, so far always self converting) and given Bisoprolol and Apixaban.

My question is - does this mean that I have no option now for any preventive/PIP antiarrhythmic medication? And that if I were to go into persistent AF, my only option is electrical cardioversion, without the additional help of rhythm control?

Many thanks J x

[JonathanPittsCrick in reply to JaneFinn]

Hi Jane,

Flecainide is a very safe medication for AF and actually helps to suppress "normal heart" ventricular tachycardia as well. Unfortunately there are a lot of misconceptions about it, based on the CAST study in 1991 which showed a significantly higher mortality in people who had just had a heart attack (and had also had a previous one with residual scarring) if they took flecainide. It suggested that the changes in the heart caused by ischaemic injury (having the blood supply cut off) combined with flecainide to convert a harmless arrhythmia into a fatal one. So the people who should avoid flecainide are those with previous heart attacks and those at risk from having one (e.g. those with angina). In addition "circumstantial evidence" has suggested that people with very weak hearts are at increased risk from just about any antiarrhythmic drug. For someone with neither and an echocardiogram showing a normal left ventricle the risk from flecainide is low.

As there is understandable doubt about using flecainide when you had a recorded run of VT (though that is probably not predictive of pro-arrhythmia) I think the best solution would be to take flecainide (tablets) under hospital supervision and ECG monitoring the next time you get AF and see if (1) it works and (2) it doesn't cause any problem with VT.

Regarding the prevention of recurrence of AF following cardioversion there is another drug that is effective: dronedarone – which is similar to amiodarone but a bit less effective and importantly has much fewer side-effects.

[JaneFinn in reply to JonathanPittsCrick]

Wow thank you! That’s massively helpful - once again you’ve helped me understand this stuff so much better. Due to the VT episode, I was simply told the rhythm-control route was shut off, but now I can talk to my cardiologist about options...

THANK YOU x

[jedimasterlincoln]

Appreciate the input Jonathan, some of which I was aware of but often unable to articulate myself.

I did have a chuckle at identifying the cause, if I knew that I wouldn't have had nearly 4 years of misery!

[JonathanPittsCrick in reply to jedimasterlincoln]

Yes I'm afraid the cause of the AF tendency is often mysterious (occasionally genetic) and not possible to reverse, but sometimes the cause of a particular attack is more obvious, especially a chest infection or a more-than-usual alcohol evening, or forgetting to take BP or other medication. So if you see one of these scenarios cropping up you could take an extra pre-emptive pill-in-pocket flecainide (but not more than 200mg at a time).