It appears that current literature dispels current guidelines to start rate-control first. The trial discusses that rhythm control therapy produces better results which may change clinical practice to initiate rhythm control therapy early.
Rhythm Control (EAST- AF NET trial) - Atrial Fibrillati...
Rhythm Control (EAST- AF NET trial)
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cuore
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Can you tell us what it says? I couldn't log on to it.
This was the subject of Mollybear's post nine days ago "Interesting article about the need for early rhythm control"
medpagetoday.com/meetingcov...
This degenerated into a fight about the NHS and US systems and members objected to her comments. As a result she has left the forum.
What I said then was "what it seems to be saying is that rhythm control is better than rate control.
If you look at this page ncbi.nlm.nih.gov/pmc/articl... and go down to the algorithms diagrams it shows the drug choices for each.
Rate control : Beta blockers, Diltiazem, Verapamil
Rhythm control : Dronedarone, Flecainide, Propafenone, Sotalol, Amiodarone
Might change medical practice!
Did I miss that? - I’m so sorry that the thread degenerated into a fight between Healthcare systems so much so that Mollybear was upset enough to leave!
It seems to me that treatment is constantly being reassessed, rightly so, & may be that we need to keep open minded and interested about each other, our experiences & our Healthcare systems as we may all learn from each other.
I agree with you CD.
I've just read Mollybears post, like you I knew nothing about it. I'm shocked at how her post was viewed as aggressive by members here. To me she was just putting her point over and quite well at that. We are all so sensitive to the slightest criticism of our NHS and I have to admit I'm certainly that way too, but I saw nothing that was annoying in her post.
Jean
I think she was a he. Mollybear did sound female but he talked about his wife". But then again!
The trouble was that she seemed to have read the headline and cottoned on to the word 'early' and was saying that she was glad she could just walk down to her ER and get treated. She then listed all the Mayo Clinic's possible risks of ablation without saying that they were very rare. People reacted and she walked.
I think that this is a very important subject. At the moment GPs like mine give bisoprolol and if it doesn't work, double the dose. I hope that if patients go into my local surgery in future they will be offered Flecanide or one of the other rhythm control drugs because they have been shown to have better outcomes.
‘She’ was a he and I found he had a lot to contribute and I learned a lot from him but I can quite see how he could come over and upset people. He was very much for Functional Medicine and I found him very knowledgeable. He had also trained as a herbalist.
Entirely different culture & perceptions, my husband worked in Texas & we visited often so it was a bit of a shock for me at first but I came to admire their tenacious nature - they have to be tenacious to survive as the landscape & climate there is so harsh & extreme. I believe we need to ‘walk in another person’s moccasins’ to begin to understand another’s experience.
You have to bear in mind that Socialism = Communism in the minds of many Texans - and that must be defended against at all costs.
My tutor always remarked that if you want to understand the nature & culture of a people - look at the landscape - I have found it to be a good indicator to understanding behaviours. As Cuore remarked recently- the extremes in US healthcare from a world leader in development to almost no provision for underprivileged leaves us valuing our system, imperfect as it is.
I am sorry he left as he did contribute a lot but this really does illustrate the wide divide in thinking between US & UK.
Best wishes.
I think that there is less knowledge among Americans also of different "socialised " systems of medicine. The alternative to the (to me) heartless privatised system in America does not need to be the free at the point of use NHS. There are socialised systems in other European countries that work well and actually produce better results than either. The American system has produced quite a lot of corruption which has sadly spread into medicine worldwide due to the overbearing power and money of the pharmaceutical industry. But it has also produced excellent Functional Medicine practitioners who successfully challenge the allopathic orthodoxy. We could do with more of them here in France! However these FM doctors are only for those who can afford them. Even within a free at the point of delivery system like the NHS it is the better off and the articulate who benefit more from it.
I live in Canada, not the U.S. The Canadian system is similar to the U.K. system, but one step down. Private clinics are banned (at least in B.C. ); so we don't have the opportunity of a private consultation to speed up the process. Our waiting times are horrendous. The quote was not mine because I have limited knowledge of the U.S. system.
Yes I agree,I was on 10mg bisoprolol and it made me very sluggish and breathless on stairs,after a recent afib onset and cardioversion,I know take flec100mg am/pm and 1.25bisoporal am also rivoxaban this as made such a difference to my fitness I cycle, use a treadmill and walk regularly with a lot more ease.
I can see that your link is reporting on the same subject, thanks for posting.
Both Mollybear's site from "medpagetoday" and mine from "practice update" deal with the same trial: EAST-AF NET. My collapsed conclusion is that, for producing better results, rhythm control ( drugs and /or ablation) is superior to rate control which was the standard procedure with early on-set AF. Plus rhythm control should be initiated right after diagnosis, not rate control, in the hopes of preventing atrial damage in the early weeks of AF.
Let me quote a passage from practice update:
"According to Dr. Kirchhof, patients with atrial fibrillation have the highest risk of severe cardiovascular complications during the first year following diagnosis, which suggests that early initiation of therapy may have the most benefits.
He also noted that early rhythm control could reduce or prevent atrial damage that is often caused within a few weeks of onset of atrial fibrillation, which may lead to additional benefits."
In Feb. 2, 2016, my diagnosis date, I was placed on rate control by my GP. I was not even asked if I wanted to return to sinus rhythm and stay there. His concentration was only to keep the rate below 100 b.p.m. , and he was not licensed to prescribe rhythm control because he was a G.P.
On Jan. 13, 2017, I became persistent. By then, I knew what was happening to my heart because I had read Dr. Harrigassurre's paper on rotors:
afsymposium.com/library/201...
I knew that the longer I was persistent, the more damaged my heart would become. (According to the EAST-AF NET trial, if I am interpreting it correctly, damage was already being done at the paroxysmal stage. )
Because I live in Canada, it was a horror story for me to be kept waiting just to "apply" for an ablation let alone the waiting time for an ablation. (The time-line would have been beyond one year persistent, if at all.) So, I packed it in, applied to Bordeaux, France, where within one month of application, I had an ablation. In my case, had I not had the ablation at the six month persistent stage, I would never have returned to sinus rhythm because my heart has been so severely remodelled. I have had to have three, and chose to have all three in Bordeaux, not Canada.
I am elated with the outcomes of the EAST-AF NET trial. Even though it is too late for me, it is not for the newly diagnosed AF patients. I do hope GPs, cardiologists, and electrophysiologists take heed of this groundbreaking trial. No AF patient should be condemned to live in AF if the patient can be kept in sinus rhythm.
Yes I totally agree sinus rhythm should be paramount.
There was a definite resistance against rhythm control, coming from my cardiologist when I was diagnosed to the point where he refused to consider anything but Bisoprolol for me. Whether this was a ‘wait and see’ strategy or not, I’m not sure but six years later he is very pleased with how Flecainide has worked for me.
My cardiologist, (I use the term 'my' loosely as I've seen him about 3 times, once 7 years ago and twice in the past 12-15 months) just talks about toxic medications used for rhythm control and seems dead set against them. He advises against ablation so far anyway. I was on Bisoprolol, it gives me horrible pain, stiffness and at the same time weakness, in my legs and feet. When I complained he said I could have calcium channel blockers. But I wanted a different BB first to try. My GP has finally authorised Nebivolol.
But I don't know why they wouldn't think of rhythm control for me because at 55 and with menopause and hypothyroidism going on at the time the AF went persistent, I had quite enough energy blocking going on. I can barely move now. I hate it all. I have my Nebivolol script but am feeling too anxious to start this week.
I'm sorry that you are having so much difficulty getting a treatment plan which suits you - after 7 years too. I complained (mildly I must say) about Bisoprolol which made me useless because of fatigue and breathlessness.
My cardiologist believed it was the 'drug of choice' (his words) but after four years of it, I'd had enough. I saw my GP and explained the limits which it was putting on my life and was changed by him to Nebivolol 2 years ago. It has made such a difference with much more energy and no breathlessness.
I hope Nebivolol works out well for you as it doesn't act on lung tissue, only cardiac - unlike Bisoprolol which acts on both, hence breathlessness in some people. Best wishes.
Thank you. I do get a bit breathless but not much. It's the horrible stiff, painful and weak legs I'm hoping it will help. If not I will have to try a switch to calcium channel blockers. I can't say I've been badly treated for 7 years. I had my first recognised and diagnosed AF attack then, but I only had about 1 attack every 10 months or so and wasn't on any medication. It wasn't until a year ago February that it became continuous and with a high pulse so I needed help. Hence I've seen him twice in that time. Oh, and a phone call in place of an appointment the other week. I'm not impressed though. He doesn't seem very interested to me. But it's a small hospital so it's the best we have.
I'm just nervous about switching over in case of disruption. Will try and start tomorrow. I'm so weary all the time. I never do anything. I've not got to work yet today and it's 4.45pm. I have to go and do some things which means I won't be back until late. I'm fed up of this.
BobDVolunteer
Many Americans have quite the wrong idea about our NHS for the most part and whilst I did not get involved with that particular thread it did follow a traditional pattern. That said I do not see why she felt obliged to leave but heh it happens.
Regarding the subject at hand there has always been differing views not just between countries but between EPs as to the best way forward. Only recently we have seen comment that the "All treatment is only forQ O L " mantra may not be currently correct so as CD comments AF treatment is constantly changing.
I think the importanat thing to understand here in UK is that GPs are not permitted to prescribe rhythm control drugs which can only be authorised by hospital consultants. Also that whilst our healthcare is free at point of treatment , unless there is an emergency and we go to A and E (ER in US terms) we are unlikely to get rhythm control offered in the first instance and only then if a consultant is on duty.
16 years ago when I started my AF journey my GP refered me straight to a rapid access clinic at my local hospital where within two weeks I had been assessed, tests like ambulatory stress tests and ECG completed. blood tests for thyroid functione etc done and I was given a beta blocker (atenolol) and flecainide as PIP. Within three months I was referred to a larger hospital where I was offered ablation which I declined but given the option to change my mind "when it got worse" which of course it did. I was then refered to a top London heart hospital where I joined the ablation circus. All within about a year or so of first presenting ! I think that is good by any bodies standards.
Edted to say and I wasted six months prevaricating over the ablation!
Yes, we should be able to debate ideas without someone flouncing out. I decided not to post on the thread either as I found the original post to be unnecessarily aggressive and ill-informed. Replies given to the OP did not appear to be unpleasant but merely pointed out the facts regarding the NHS. Absolutely no need for him/her to take umbrage.
16 years ago was 2004. And you were prescribed a rhythm control drug (Flecainide) as PIP, plus offered an ablation within three months - another rhythm control therapy. Your treatment was ahead of the times due to the speed plus choice-- BOTH rhythm controls.
Ironically, you were following the results of the 2020 EAST-AF NET trial.
Wish I had been so lucky.
Offered yes. Declined yes. Waited another 12 yes. Repeated twice more but finally no AF since 2008. Maybe I was lucky, My GP knew a consultant who knew another consultant who knew a top London EP . My GP's mother had AF which is why SHE knew what was wrong with me. I spent ten years before that in a different town being told I had anxiety and stomach problems. Being pro-active often makes you lucky but knowing the right people helps. as back then there was diddly squat on the internet about AF and most doctors thought it was a benign nuisance.
In early 2007 Royal Brompton Hospital asked me to help set up a patient support group for people with AF but when Atrial Fibrillation Association was formed in October that year we abandoned our sole group and joined forces. The rest is history.
OK I'll park my hobby horse now.
I am not surprised you had connections via your GP. That explains the speed and treatment.
Ten years before 2004 places you in 1994, the year ablations got going. It is no wonder you were not properly diagnosed in that earlier town.
I congratulate you in being one of the founders of this forum. It is invaluable to me in my AF journey, a definite ongoing one. The fact that you are still contributing your wealth of information thirteen years later is more than a credit to you. Your "hobby" has enriched so many affibers! Carry on!
I recently posted on the European cardiology guidelines which also put more emphasis on early treatment and on rhythm.
My recent thorough NHS cardiology appointment which I also posted was clear that in his view early treatment so important for AF that he fast forwards referrals for AF (contrast with GP. who said non urgent and you won’t be seen for a year, many people ok on beta blockers & Flecainide as prescribed by previous private consultant). Consultant not keen on beta blockers for me as my episodes associated with depressants and may be because rhythm affected first.
Mollybear was not simply being unfair about NHS he/she was stridently recommending lifestyle cures, and at an extreme end of opinion about the dangers of conventional treatments. Other posters said he had done this before. I don’t need someone who is a herbalist promoting a particular view so strongly and frightening the socks off me and others. I am sure he is active on other forums and doesn’t need us, and I don’t benefit from such partisan rather non science opinions in my inbox.
There are many health proponents out there, they think everything can be solved by diet, all cardiologists everywhere are in the pockets of Big Pharma, and the NHS is the slippery slope to communism. A smidge of truth in some arguments masks a worldview that it is impossible to rationally engage with.
I was tried with rate control (Bisoprolol then Diltiazem) for 6 months and then, after a cardioversion lasting 4 days I was put onto Amiodarone and re-cardioverted and stayed in NSR until they took me off it, after nearly 3 years. Gave it a go without any meds and lasted 8 months in NSR. Back on Amiodarone, cardioversion number 3 done two weeks ago and, touch wood, still in NSR. On the ablation list again now. The rhythm control has certainly fared better with me than rate control, which still didnt control the rate properly anyway and that was taking the Bisoprolol and then Diltiazem every day, not as a PIP.
My GP first prescribed the beta blocker Metoprolol which made the AF worse. Next was a short period of the rate control Verapamil. Within one year of diagnosis, I was persistent. I was neither asked if I wanted to return to sinus, nor told a GP cannot prescribe rhythm control. I wasn't referred to a cardiologist until I became persistent. The cardiology episode was also a disaster.
Fingers crossed for your next ablation.
I was prescribed the Bisoprolol by the hospital when first admitted and diagnosed with the AF. After subsequent, regular admissions, they upped the dose and I felt dreadful on it. My pharmacist explained the effect it can have on the lungs so when I actually saw a cardiologist, fortunately after 3 months, I begged him to take me off it and put me on Diltiazem (I'd done some research) which he did. Neither did anything much with the rate control which is why he then went down the Amiodarone path. Wasnt keen and it did affect my eyes but hopefully, a short term means to an end as I was incredibly symptomatic with the AF. On the list for first ablation now as I'd been accidentally removed from the list 18 months ago 🙄. All good fun.
Good for you for researching your drugs. I would be careful of Amiodarone because it is toxic and it does stay in your system for a considerable time even when you stop. 18 months is a long time to be kept waiting for an ablation only to be told you were accidentally removed. May I suggest you be more assertive if you are kept "waiting" again. Good luck on your ablation. You sound young. All should be well.
I had had AF undiagnosed and then untreated for 10 years before moving area and receiving better treatment. It was therefore a long time before I got the rhythm control drugs I should have had and my AF was already well advanced. A few more years down the line my husband developed AF and as he also had chest pain he went to A and E. His AF had gone when he got to A and E but my Kardia had picked it up and they accepted that. He was referred to my E. P. Who put him straight on a low dose of flecanide and a low dose of bisoprolol. His AF has never progressed and is totally under control. I only wish I had had the same swift treatment with anti arrhythmics. X
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