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AF Association
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How long before going to A & E?

I was diagnosed with paroxymal atrial fibrillation in April and am taking 2.5mg bisoprolol. I have an appointment at an Arrythmia Clinic in September. The jury is still out as to whether I can take anticoagulants as I have a clotting disorder but should have a definitive answer on that next week. In the meantime, when an episode occurs I was told to take another dose of bisoprolol but how long should I wait before going to A & E. The last episode I had lasted 12 hours.

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I think it all depends on how fast your heart is beating and how you are feeling. If you can give us some idea of what your rate was last time you had your PAF we can probably advise you, though I bet you will get a lot of different answers.

Jean

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I’m not able to comment from personal experience because I was first diagnosed with lone Persistent AF and any episodes after treatment were stopped with a PiP. Of course, everyone is different, but many have questioned the benefit of going to A&E unless you have chest pains and/or a heart rate of around 150. Hopefully you will soon hear from folk with some personal experience..

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Hi B172 :-) I discussed this very thing with a doctor on a recent visit to the arrhythmia clinic and it was agreed if I had chest pain , or felt faint or had a heart rate over 150bpm for 24 hours I would go to A&E . At their worst my episodes only lasted a maximum of 15 hours.

That is my choice and not a recommendation for anyone else.

At my local A&E, part of a health trust 'in special measures' it isn't unusual for patients to wait for hours in a queuing ambulance outside the hospital or to spend up to 15 hours on a trolly waiting to be seen not just in the winter but any time.

My P-AF is made worse by anxiety and being stuck on a trolly in a busy A&E corridor would certainly make me anxious.

I have learnt to cope with my P-AF on my own now :-)

At the moment my episodes which were happening weekly have diminished with treatment and I am hoping this lasts.

We are all different with differing ages and comorbidities. you need to speak to your doctor and decide what is best for you :-)

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I wouldn't like to offer any advice because of the clotting problem. The usual advice, provided you are taking an anticoagulant, is that you only need to go if you have chest pain or feel generally very unwell, and some of us would rather stay home in comfort even then! If not taking an anticoagulant then I was told to go no later than 12 hours so you can be cardioverted if necessary. I think it is best to ask your GP (if they know....) or phone the Arrhythmia clinic if you know the number as I think it is an important question.

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Hi Buffafly

Thank you for your reply. The anticoagulation is my main dilemma at the moment. I am in limbo until the Haematologist makes a final decision but her initial view was 'no'. I should know next week about that at least. I have already received some very useful information about an operation that can be performed if anticoagulation is not possible. I have no idea whether I will be considered a candidate or what else may be suggested to mitigate the stroke risk. I ended up in A & E in April but was sent home with no medication. I was about to go on holiday and was apprehensive about going away with no medication so opted to see a cardiologist privately who prescribed the bisoprolol in the first instance. He tore up his prescription for rivaroxaban when I told him about my blood clotting issue! I have only had one other episode which lasted 12 hours and hence my question about how long to ride the thing out. I hope when I eventually get to the Clinic I shall be put on the correct regime.

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Best wishes.

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Sadly there is no answer to your question because we are all different and live in different locations.

For me my PIP has always been Flecainide not Bisoprolol.

I am very lucky as I live 15 minutes from one of the best centres for heart conditions in the UK and The A&E is not under special measures.

I have been in NSR for nearly a year now but thoughout the previous 25 years in PAF I had very bad symptoms when in AF and was always told that if PIP didn’t work I was to go to A&E and not to have a conscience about going.

Other just ride it out.

We are all different.

Pete

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Hi pottypete1 Yes, I have read about this Flecainide and it maybe that when I am eventually seen in the Arrhythmia Clinic that may be considered more appropriate. My most pressing concern is what are they going to do about my stroke risk.

I am pleased to know that you have been in NSR for some time now. Long may it continue.

Sue

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AF is not an accident or emergency it is a chronic condition. Most of us ride out such events knowing that A and E usually means lots of discomfort for little or no benefit and that at best we may be observed for some hours till we go back to NSR and then sent home. Treatment is seldom offered. The caveat is of course that any chest pain or fainting MUST be investigated.

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You are right Bob AF is not an accident or emergency so in my opinion it is the name of the department that is wrong and perhaps it should be called the ER as in USA, in fact the nurse at my local GP practice called it ED (Emergency Department) in a conversation I had with her recently.

I have no wish to fall out with you as 99.99% of the time I totally agree with you and the advice that you give.

However, you regularly state that an AF sufferer should only attend hospital if they also have chest pains or fainting but we are all so different and this cannot, in my humble opinion, necessarily apply to everyone.

In my case over time I learned that when I had bad AF and PIP didn’t work, the only remedy after 24 hours for me would be a cardioversion.

More than one EP and on many occasions the A&E Consultants, told me that this was necessary and that the only entry point for me to the hospital for a cardioversion would be via A&E and that that was exactly what I should do. It is now a big note on my hospital file.

The alternative happened once when I did not do as I was told, I then spent a most miserable, nauseous and stressful 5 weeks only to then be cardioverted after all.

Sadly the vast majority in the UK are the victims of the post code lottery and the only local hospitals do not specialise in hearts.

Furthermore sometimes are also in or near special measures and in this case your advice is then sound as the most likely scenario would indeed unfortunately be to have to lay on a trolley for many hours and then be sent home with a box of tablets with no resolution.

These poor individuals then spend months waiting for a referral and that is no doubt why so many seek out and find our forum for support, comfort, reassurance and guidance which is not forthcoming elsewhere.

Pete

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Absolutely in agreement with you Pete. My case similar. All of my 18 cardioversions were emergency ie non elective. The one time the cardiac registrar decided to put me on a waiting list for a DCCV ,and discharged me from CCU, I returned as an emergency 3 weeks later having returned to NSR but with Pulmonary Oedema.....barely able to walk and told by A&E that i was in heart failure

A very frightening time when I found myself getting more and more disabled during those 3 weeks

Sandrs

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My doctor told me heart rate of 150 or above, go to the ER. Chest pain, go to the ER. Below the 150 rate and chest pain, go to the ER if it's more than 2 hours. I've taken myself to the ER 4x since my ablation last winter. You have to be your own advocate.

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I have given up going to A&E unless I think I’m in acute danger - as Bob says AF doesn’t qualify. Different strokes for different folks. My GP has sent me to ICU because I had been in fast AF for 12 hours with HR 180 - much against my will. I was sat in a waiting room for 7 hours, not a happy bunny! Mind you, they did put an ECG monitor on me when I said I was fed up and going home (I knew I had converted back to NSR) and guess what - I was back in NSR.

I would always go though if I felt very ill, had chest pain and syncope (I have POTS as well so I have this wierd thing were I need to remain prone - try standing and I’m on the floor. Nothing anyone can do for me as I can’t take any meds and I have always self converted - eventually. But then I have lived with this for at least 13 years.

If you are a newbie and very anxious about it then you may want the reassurance of being monitored. If in doubt, check it out.

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Yeah indeed, to be or not to be that is here the big question. But at the end of the day its how one feels and as grown ups we should make our own choices.

After my ablation last year I had a few minor AF events. Much less intensive than before. Most of them I did sit out and some I went to A & E, knowing they wont do much but hook me up to an ECG monitor and in 2-3 hours it would convert back to normal. Reckon its sometimes just the "be feel protected" feeling.

Last Sunday I had a light AF and went to the hospital and did noy go to the A & E but to see one of the cardio doctors.

She made an ECG, showed me the results and said its borderline. She had me sit down there and rest, after 2h I was back to normal and she sent me home and did not even charge me a $ this time.

Cheers

T

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I didnt go fo A and E instead I went to my GP. There ensued many years of incompetent medical advice while I waited for them to catch the irregular rhythm and they never did until I had 3 TIAs and happened to be in AF when the stroke consultant was with me.

Many years later when my husband started with AF, we went straight to Aand E the result was that he was diagnosed and given anticoagulation and a low dose of flecanide within a month. His AF has never got any worse up to now.

So, I would say that it is always a good idea to go to A and E at the start of AF. As you become more used to the condition and if you are anticoagulated it may be possible to sit it out at home.

Neither my husband or myslf have needed to to go to A and E since. X

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Spot on

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Excellent advice.

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Hi,

My experience was weird. I felt as if I were going down with a dose of flu. Nothing in or around the chest to indicate anything was wrong. As the day went on I felt worse and decided to keep a check on my blood pressure on my Omron device. My BP went ballistic, all over the place including many many error messages. During the day my BP decidedly trended downwards by the time it got to 76/50 I figured this was my Apollo 13 moment ( you know the bit in the movie where Tom Hanks says - 'Houston we have a problem').

Rang my GP who saw me immediately, sent me to A & E and AF identified and treatment started. Incidently my HR peaked at 160.

So, from first onset of 'flu symptoms' till treatment started ........... 9 hours.

My view is that the speed of diagnosis was a big factor in my AF not being very troublesome and prevented it getting a stranglehold on my life.

John

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As you're not being anticoagulated, I would argue that you should go to A&E pretty quickly, as there is an elevated stroke risk when you are in arrthymia. I would suggest calling the arrhythmia clinic and asking what the timeframe should be.

I tend to persistent AF that needs cardioversion. Whenever I've gone through A&E it has been pretty quick to cardioversion. I might be lucky in that I live in an area with a very good cardiac unit (last time was <24 hours).

There's absolutely no shame in going through A&E and if you feel that you need it then I would say always go.

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Well you have been given loads of advice and should be completely undecided by now.

This is my experience. I have ,had Irregular PAF for over 20years To start with had Pip which put me back into NSR( flecainide) For the last 3years have had Flecainide daily. Since 2015 have had 4 episodes of PAF for which I have had cardiofversion each time as extra Flecainide did not work. . My instructions from A&E were for Irregular PAF was to ring For ambulance after 30mins.

As I usually feel dreadful I don’t need any encouragement .

I wish you luck. When in doubt ask a professional. Jo.

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As others have said there is no need to go to A&E per se unless your heart rate is very high or you are feeling unwell. However if you are not on anticoagulant it is important to go after 24 hours. Any longer and you will not be offered cardioversion until you are properly anticoagulated, usually three or four weeks, to allow time for any clots to dissolve. That means that you would risk your AF becoming persistent.

Peter

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My A&E department have told me anything over 130bpm for a prolonged period that you cannot address with your normal drugs go to A&E. (even though I was asymptomatic in high AF).

What I did was take the extra dose of medicine that I was advised to take and I would wait 6 hours ish until I was half way to the next normal dose. if I was still high I would go to the A&E and ask for further advice.

A concern to me was that I was also advised that the hospital would not electrically cardiovert me if I had been in AF for 48 hours and was not anticoagulated.

So by the time I am at A&E it is already probably 8 hours or more after my AF has started. If A&E agree you have an issue will keep you 4 hours and may give you some further drugs or by injection. Then at my hospital they will either send you home if they judge you to be alright or admit you to the medical assessment unit for more assessment. You will stay there probably a minimum of 8 hours and if it is now late probably overnight. You have now consumed 24 hours of the 48 hour window for cardioversion. In order to cardiovert you you have to be nil by mouth for 12 hours, and the hospital have to assemble a team including an anaesthetist in order to do this. In my hospital anaesthetists seemed to be in short supply , probably as they are needed for more life threatening cases than just AF, and for major planned operations.

I was always worried I would get stuck with high rate AF after the 48 hour window and then I think you have to be anticoagulated for 3 weeks for an electrical cardioversion. I never wanted to contemplate this! I note in your case you may not able to be anticoagulated.

As my AF got worse I did have an 8 day period where I was in AF at 130-190 (mostly towards the high level) and I was absolutely shattered afterwards.

My final concern is that as "AF begets AF" i do not want to stay at high rate for weeks.

When I got stuck in High rate AF for 8 days it was because I went to A&E and my HR went down to 110 within the 4 hours so I went home. They thought it was on its way back to NSR. it never did, it kept low for half a day then went back to 160, so I went back to A&E the following day and did as above by which time I was over the 48 hours.

I had two overnight stays in hospital as they tried to chemically cardiovert me. Eventually I was put in the coronary care unit and was converted by an IV flecainide infusion. after that I was put on twice daily flecainide plus a rate control drug. (intrusive regime)

I caused more trouble to the hospital by going home the first day than if I had stayed.

I probably ended up on the intrusive drugs regime earlier than I would have done by being in high rate AF for 8 days.

Please also note I managed my AF attacks mostly without going to A&E. I probably had 14 or 15 high rate AF attacks over the 30 month period before I was ablated and only went to A&E 4 times.

To some extent this did not help overall as by not recording my AF attacks no-one medical knew how frequent my AF was. - maybe I would have been sent for ablation earlier if this had been apparent to my consultant?

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My A and E told me never to wait always call 999. So I do. I do have other heart issues so maybe that's why because it puts my heart under too much strain. Sue

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I've been advised to go to A&E if my PiP didn't work within 3 hours,

by the following people :

GP

Private Electrophysiologist

NHS Electrophysiologist

Arrhythmia Nurse

Dr at A&E

Cardiologist at A&E

All the nurses at A&E I spoke to about it.

I have been advised not to go to A&E by:

people on this forum.

I fully understand the reasons why people here give this advice, and I am not criticising them in any way. But you can imagine whose advice I will follow.

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I'm inclined to agree with you!

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Everyone's circumstance is different. There is no single right or wrong answer to the question "should I got to A&E with AF".

If you can cope, you are anti-coagulated, and going to A&E isn't going to benefit you in any way, then obviously it probably isn't a good idea for you.

For me, I was quite symptomatic, not anti-coagulated, and I believe in that scenario if an electro cardioversion is to happen then it needs to happen within that first window of a day or two - otherwise you might have to wait weeks for it.

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I've had paroxysmal AF for more than 4 years with weekly episodes lasting 24-36 hours (74 year old female) and I've never been to A&E (emergency room as it is known in USA). While my GP warned that if my heart rate went above 150 I would have chest pains, I have never experienced that. (My usual heart rate in AF is around 100-120, but with exertion it has reached more than 150.) I think many people over react to this very common condition unless they've done their research and realize that there is usually no need to panic

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I think that a heart rate of 100/120 Is quite manageable at home. In fact mine is going at 125+ at the moment. I'm just ignoring it. Now when it gets towards 180/240+ then I get things together and no-one can dissuade me !

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My EP even said it was safe to exercise (treadmill) while in AF and I've seen my heart rate at 185-195 without being symptomatic. I really believe my magnesium/COQ10 supplements have made this possible. Even at that high rate, never had a chest pain or even extreme shortness of breath. I generally stop if it stays that high for more than 5-10 minutes.

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Personally I think it's a bit daft to continue exercising with a heart rate approaching 200 particularly at age 74 but if that's what keeps you going.....I am almost 74 and don't get chest pain, just an uncomfortable feeling at very high rates.

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It is amazing how different we all are and the way each of us is treated.

I was reading your reply and it occurred to me that you are tolerating a much higher heart rate than I ever have had.

A year ago after my 6th ablation I developed Atrial Tachycardia resting at around 120bpm.

I found a way to cope but my EP was not happy to leave me at this rate. He said it was likely to cause other issues and despite previously being reluctant to give me yet another ablation arranged to carry out my 7th last August and since, apart from a short burst of 5 hours in March I have been AF free.

I cannot tolerate AF for very long as I have severe symptoms so that is why, unless PIP works, being anticoagulated I go to the hospital for a DCCV.

Pete

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I've been having a lot of A/tach/flutter....whatever...for a long time, lasting half hour to hours in the main. Finally agreed to let EP have another look and so am on the list for 4th ablation. Also have AF of course which almost always lands me in A&E for dccv without further ado.

I can't help feeling a bit of a nuisance and slightly embarrassed when I have to present at A&E but paramedics, GP etc have all been most insistent and I have been read The Riot Act on many occasions !

Sandra

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Yes Sandra

Your “guilt” mirrors my feelings yet like you I have told them numerous time that I feel I am a time waster only to be told that I had done exactly the right thing to turn up at A&E and was also told that I manage my AF very well.

I hope your next ablation comes soon and that it is as successful as my last one. I have to be honest I never expected to ultimately be as free of it as I am now (touch wood).

Pete

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Good to hear that Pete. Must admit that once I decided thst I had to give ablation another go I feel more relaxed. Can't imagine what it must be like to feel free of all the funny goings on in the heart after so many years .

Sandra

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I still get Ectopics daily and as I suffered AF for so many years every time I get a little ripple in my heartbeat of which I am very aware, I cannot resist checking my pulse.

So far so good but I don’t think, even if it stays this way, I will ever mentally be rid of the fear. that’s was 20 DCCVs and 7 ablations had done to my brain.

Pete

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Much the same for me Pete! I'm looking forward to having an Echo shortly as I'm a bit concerned about breathlessness etc after walking slight incline or any distance at a pace. Haven't had one for a few years.

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My cardiologist told me I have an 8 hour window before going to A&E, if the symptons haven't eased. The last time I had an episode it lasted 6 hours then although exhausted I felt I was in better control. Hope you don't have to put it to the test!

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B172. You have had lots of good advice so far, so I'll just add my limited experience. After reading all about AF on here after my first attack of AF, I became so disappointed in the experience I had at A&E I decided to buy a Kardia and simply record my events for future evidence. My second attack came while caravanning in a farmer's field miles from home, where an ambulance might have had difficulty finding me and then take me to a strange hospital A&E. I just 'sat it out' (actually went to bed) and awoke in the early hours to find I had reverted naturally to NSR. My third one happened in the evening while dancing at my son's wedding, again I just took it to bed and awoke, again in the early hours, in normal rhythm.

My attacks seem to last about 6 - 10 hours, and since the first one, which had a heart rate of 280+ (I was terrified!), they have only reached the 170/180's, resting rate. I put that down to the Bisoprolol and my more relaxed attitude about it.

YMMV, as they say, as everyone is different.

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I have just had my second rather unpleasant episode of Paroxysmal AFib since my ablation on 27 June. The first one (already mentioned on this site) was after 2 weeks of the ablation, when I had a gin and tonic on a hot day. The second, last week, was after I had just had a manicure and had been drinking lots of water. I have cut out alcohol and caffeine. I began to feel, 'iffy' in my heart area as I was going down the stairs, and said I needed to sit down. Then it all kicked in - racing heart and then the dizziness, and I felt as though I was going to pass out. I took Bisoprolol 1.25 as advised my the electrophysiologist at Royal Brompton Hospital. Eventually, an ambulance was called and they did catch on ECG that my heart was doing 150 bpm. But, I know it was more than that before they caught it. I was waiting and suffering with this for about an hour. It was not getting better and I couldn't wait for the ambulance to turn up, yes for reassurance and yes, to catch what's going on! I feel the pill does not work, as I was getting worse!

They decided to take me to A&E, but as some have said above, it is not an Accident or an Emergency - except it feels like it. Over the phone, the 999 staff were asking so many questions and I knew the answers (from previous call outs) and it was stressing me out, as I could barely speak. I had to hand the phone over to the staff in the salon and I nodded or shook my head for the answers! How anyone can suffer 150 bpm or more, and not FEEL the symptoms is beyond me. I was feeling as though I was going to die. It was terrifying! I was so dizzy and nearly falling off the chair, the staff had to hold me up and hold my hand - they were so kind to me!

Of course, once in A&E and being seen ultra quickly, to my surprise, I went back into sinus rhythm. The doctor suggested I ring Brompton and find out if 2 big episodes like this are normal in the first 3 months after an ablation - or is something else going on. He said the fact i did NOT actually pass out was good, but I was close!! Also, he said my pounding heart showed good heart muscle!!

I had another 'episode' the following night but took the PIP (only I took one of my normal twice daily pills of 2.5 mg of Bisoprolol - Flecanide does not agree with me at all). Eventually, it settled down. I don't want to go to A&E but when it gets terrifying, and I feel so dizzy, I am afraid of passing out, as I live on my own. I also take Rivaroxaban anti-coagulant.

The good news is, I had my son and little family visiting from the USA for the past few days, and I had no AFib at all, and we did many visits, to HMS Victory, Arundel Castle (I did not go up inside, but stayed in the gardens!) and other places, and NO AFib at all. I think my heart felt happy being with family!!! New baby grandson of 4 months and granddaughter of 4 years. Wish they lived nearer!!!! Maybe my AFib would vanish!

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