Usual dilemma: Rate or Rhythm

Am 77 years old and diagnosed with paroxysmal AFIB last Feb, by chance. No symptoms. Now taking Bisoprolol 2,5 and Tritace 5 (for BP). Have no other health problems. The cardiologist has prescribed Flecanaide 200 but I am not taking it yet. Should I try Lifestyle changes first? Can I use Flecanaide later if they do not work? Can I ever stop with F. ? I live in Belgium and the doctors here are not much talkative either so the opinions are very welcome. Have already learned much from this panel.

[BobD Volunteer]

At your age you should also be on an anticoagulant for stroke prevention. Please discuss this with your doctor if you are not.

Life style is important. (less meat. more plant based food , no alcohol or caffeine. less stress a good weight (BMI 25 or better). Any treatment is for quality of life (QOL) as AF is not life ending so flecainide may not change your QOL if you do not notice symptoms. (You said you were diagnosed by chance so maybe you are asymptomatic?)

[Hidden in reply to BobD]

Yes, asymptomatic. I know I am in AFIB if I check the pulse (usual 60 in AFIB 80) or if the homemeasurement of my BP is abnormally high. Agree with you but if (bad) symptoms eventually appear, do you think I can still use Flecanaide?

[BobD Volunteer in reply to Hidden]

Lots of people use flecainide as a pill in pocket for such purpose. You didn't answer re anticoagulant which worries me.

[Hidden in reply to BobD]

I use apixaban although am not quite persuaded . Except for my age I have no other risk. There are also some new studies which show atrial myopathy and not Afib is the real reason for strokes. Anyway, my cardiologist said that apixaban is not 100% protection and that is why he prescribed Flecanaide.

[BobD Volunteer in reply to Hidden]

No anticoagaulant is 100% protection but it does reduce the risk by around 70%. Your choice but most of us here fear stroke far more that any other complication of AF.

[Hidden in reply to BobD]

70% reduction of the risk. OK but what IS the risk? What is the percentage of strokes without a anticoagulant? Anyway, I think your suggestion is good. Shall try the natural way and PiP + continue with apixaban. Until I get fed up with pills. :-).

[BobD Volunteer in reply to Hidden]

AF makes us five times more likely to have a stroke (that is per year by the way) and AF related strokes account for 20% of all strokes BUT 80% of the least recoverable ones. Ten years ago it was estimated that by improving our level of anticoagulating at risk patients here in UK we could save 8000 serious strokes a year.

[Ppiman in reply to Hidden]

Preserving the atrial integrity is the latest thinking, but the idea is still theoretical so far as I can see. I didn't think that the authors of that study suggested stopping anti-coagulation, though? My elderly friend has had permanent fibrillation for as long as I remember, and his atria seem healthy still at close to 90. He takes warfarin.

Steve

[Paulbounce]

Flec can be taken daily or used as a pill in the pocket depending on your doctor's advice. If used daily they normally start you on 50 mg twice a day and then up it to 100 mg twice a day. That's my experience (UK based).

Bisoprolol will be used to lower your HR - flec is an anti-arrhythmic drug and helps to keep you in normal rhythm. For many it works - for some it doesn't. Personally I found it very effective for two years and it kept the afib at bay. I'm now on a small dose of Sotalol and it's not ticking the boxes just yet. Flec did but (IMO) I should have been on a small dose of beta blockers too - keep flutter at bay. I still want to follow this route and will certainly discuss it with my cardio when I next see him.

However at your age an anticoagulant is the most important thing to follow up (as above). If you are not on one I strongly suggest you follow this up asap.

Please don't panic but it's worth doing - best to play safe.

Good luck.

Paul

Edit - since posting you said you are on Apixaban after my post. That's good I think.

[Finvola]

I'm the same age as you and take Apixaban, 200mg Flecainide and Nebivolol. For me, the most important one is Apixaban as it may save my life from an AF stroke. The other two improve my quality of life as I've had no AF in the 7 years I've been taking them.

Your question about lifestyle changes is very relevant and I would be inclined to agree with you - particularly as you are asymptomatic. If your doctor agrees, why not try lifestyle first, than perhaps Flecainide as a pill in the pocket when needed. It's a shame that your doctors don't talk much to you - some here are the same! Perhaps writing down some questions in advance might help to get a clearer plan of treatment? It sounds as if your cardiologist wants to give you the best protection he can by controlling your AF with Flecainide. There are many different causes for AF strokes put forward nowadays as understanding and research methods improve. The point many of us believe is that without anticoagulation, the risk of stroke is too high - 5 times normal.

Regarding stopping Flecainide - many members have done so, or reduced their dose. Unfortunately, I'm not one of them and could not cope with a lowered dose.

[Hidden in reply to Finvola]

Very interesting, I was reading your reply again. Exactly my situation except that I am a newbie :-). If you had no AF for 7 years why are you still taking Apixaban? Is it not possible to take it only when you have an episode? And, if you do not mind me asking, how you could not cope with a lowered dose? AF reappeared? Did you have any side effects from Fl.?

[Finvola in reply to Hidden]

I take Apixaban because my CHADsVASC score is 3 which means I am strongly advised by all the science that anticoagulation is necessary. An episode of AF is not the only cause of AF-related strokes - our risk is heightened by such things as age, hypertension and other co-morbidities listed in the CHADsVASC table.

When I tried to cut my dose of Flecainide from 200mg to 100mg daily, I had almost constant, debilitating PVC's which left me breathless and were almost as bad as AF. I assumed I had lowered my dose too quickly so some months later, I tried again, lowering the dose morning and evening by only 25mg - with the same result. I discussed it with my cardiologist who felt that it might be better to return to the higher dose, which I did.

Perhaps, if I had persisted the PVC's would have stopped but it was too much for too long and I didn't want to risk AF returning. Flec has been a real friend to me and the only side effect I have had a few years back were short runs of AFlutter but those stopped after I started taking Nebivolol instead of Bisoprolol.

[Hidden in reply to Finvola]

Excellent reply! Thanks a lot.

[The_Lord_is_with_Us]

You need book THE AFIB CURE by EP John Day (comes in audio, too). He answers all your questions about Lifestyle changes, meds, ablations, and what's coming in treatment.

I'm 67. Had 4 ablations. One gave me 10 years of peace. Recent one in OCT might be my last one ... I'm hoping. Also, might get a WATCHMAN Device installed with a short procedure soon. With that ... I'll be able to quit blood thinner for Life, if everything works out.

Went many rounds with flutter, AFIB, cardioversions, Flecainide, tests, etc. Just got tired of it all and went all-in with ablation. Good choice for me. It's a quick and painless procedure. My top EP does people well into their 90's.

Good Luck! with your path forward . . .

[Bayonnejoe]

Please look into the anti-coagulant. The 5x increase in severe stroke risk isn't theoretical. I know. I had one prior to using an anti-coagulant. Lost a good deal of my peripheral vision. That said, the doctors at Johns Hopkins said I was one of the 'lucky ones'. AFib clots tend to be big and destructive. They generally tear into the brain rather than go elsewhere in the body. I too am asymptomatic with permanent AFib. Just use a beta blocker for rate control.

[Decaf_Andy]

I have PAF too with no major impact on my life when in AF.Aside from stroke risk which has been well covered here already (I will start anticoagulant when I hit 65) the issue relating to drugs and ablation is 'quality of life' rather than health concerns. Many here are unable to function and uncomfortable when in AF, so they need to do something. Your AF, like mine does not bother you much. I take no drugs and do not plan to unless things change. The AF passes naturally in due course and whilst in it I can do anything except very vigorous exercise (I'm a cyclist and in AF my power performance is 25% down). I think we are fortunate that our heart rate does not rise excessively in AF.

[secondtry]

I think the important thing to tackle first is to stop the AF completely as otherwise there will be further trouble down the road; suggest trying a comprehensive range of Lifestyle changes first. If that doesn't work after a year, I would take the Flecainide.

Caveats: I agree with your reasoning over Anticoags but only if you stop the AF and have Lone PAF with no comorbidities. I have no experience of Bisoprolol or Tritace for BP as this could change the above suggestion, which is based on my experience. I have taken just Flecainide 200mgs for 7+yrs with no significant AF (just x2 30 min episodes)and have excellent QOL but the problem then becomes dare I wean myself of the drug, which very likely will have long term consequences!

[Hidden in reply to secondtry]

Thanks, that is exactly what I am going to do. Tritace is used to keep BP under control but with serious lifestyle changes it may not be necessary. Bisoprolol is needed with Flecanaide, I understand. Weaning of the drug could be a problem but people have done it.