After unsuccessful Cardioversion yesterday, what's next?

[GeorgeStevens]

I had my first procedure yesterday since being diagnosed with AF in June. I have persistent, asymptomatic AF. I'm 68, have normal BP and heart rate, am not overweight. The one medication I take is Xarelto, 20mg.

They made three attempts yesterday to put my heart back into normal rhythm through cardioversion and all of them failed. Quite disappointing to me. My appointment to discuss with EP is in mid-November. Since I'm asymptomatic, I'm reluctant to try ablation. I imagine the doc may suggest anti-arrhythmatic drugs but from what I've read, it doesn't sound all that promising as a treatment to put me permanently back into sinus rhythm.

Lots of questions on my mind: I'm wondering if I should just start adjusting myself to the idea that my AF is permanent, that compared to what other people have, mine is something I can live with. Since my diagnosis and in the run-up to my cardioversion, I'd been avoiding almost all alcohol, cannabis, and anything else that might be a factor. But if I'm always in AF and I'm never going to get out of it, maybe I can indulge occasionally in my former "vices"? Also: Should I just start resigning myself to being on blood thinners for the rest of my life?

Is there anybody out there in a somewhat similar situation where you're asymptomatic and cardioversion didn't work, and now you're considering whether it's worth it to try ablation or anything else?

Thank you!

[BobD Volunteer]

It is important to understand that "Permanent" just means that you and your doctor agree that future attempts to obtain NSR are futile. At that point rate control is the way forward along with anticoagulation for stroke prevention obviously.

If you are asymptomatic then you really are one of the lucky ones!

[Hidden]

I'm surprised that your doctors haven't tried anti-arrhythmatic drugs *before* cardioversion which is usual, even though the likelihood of success may not be great. I would have thought that your next step would be an ablation- the earlier the more likely it is to be successful. Drinking alcohol doesn't sound like a good idea at the moment and any form of smoking is always bad, with or without AF.

[Ducky2003 in reply to Hidden]

I thought that too. After my first DCCV failed after 4 days, they put me on Amiodarone prior to the next one which then lasted 3 years.

[GeorgeStevens in reply to Ducky2003]

Thanks for your reply. I'm getting the idea from your response and Samazeuilh's that the next step will indeed be an anti-arrhythmatic and then another CV attempt.

[Ducky2003 in reply to GeorgeStevens]

They usually pop you on it for 3 months prior to the DCCV. They kept me on it and I was ok for nearly 3 years, then they took me off and I lasted about 8 months in NSR without meds. It's worth a try before going for anything more invasive.😊.

[Balearic]

It was discovered I had asymptomatic afib last December after I went to hospital for something unrelated. I had an unsuccessful cardio version in May, started amiodarone in June and had a successful 2nd cv after 6 weeks. I’ve been in nsr since. I’m due to stop amiodarone in December. My cardiologist doesn’t feel I would benefit from an ablation. I will still be taking edoxaban and starting back on bisoprolol in January, so keeping fingers crossed.

I feel lucky it was picked up as goodness know how long I’ve actually had it!

[GeorgeStevens in reply to Balearic]

Thanks for sharing your experience. It helps give me an idea of what might be recommended in my case when I see the EP in a few weeks. Like yours, my AF was discovered when I went to hospital for something unrelated. I also wonder how long I had it before it was diagnosed. Good to hear that if I pursue a similar course of treatment as you did leading to another cv attempt, that doesn't mean that I would have to stay on amiodarone permanently.

[Desanthony in reply to GeorgeStevens]

I am now in permanent AF and had 3 successful cardioversions but before an ablation could be done went into first lockdown and now they have found that my heart is too large for either a CV or ablation to have any good lasting effect. I am on apixaban only as rate control medication made me so ill I couldn't live a normal life. I don't mind as I am lucky in that my heart rate is low in the mid 50's resting and never goes over 120 during exercise and I do everything I did before AF. Only thing I find is that at night when I go to bed I get breathless at the top of the stairs - but i have so many other what they cheerfully call co-morbidities that can't be sure that just Af is causing that.

[GeorgeStevens in reply to Desanthony]

Thanks, Desanthony. You are addressing one of my concerns here which I didn't mention in my original post: Will my heart necessarily keep on dilating if it is not put back into sinus rhythm? (Also: Is this the same thing as "remodeling" of the heart?) I'm not at all keen on having an ablation since I don't experience debilitating symptoms that I'm aware of.

[Desanthony in reply to GeorgeStevens]

The 2 EP's and cardiologist agreed that even though my last cardioversion lasted 15 months to keep on doing them with the size of my heart as it was would not necessarily mean that they would work - ie the risk of both CV and ablation working now for any good length of time was low and getting lower all the time. Now of course, the waiting time is about 18 months for ablation and he felt with that wait time it just wouldn't work so it was not worth carrying on the ablation. I didn't necessarily feel good about that which is why I consulted with another EP - as it happens the first EP's boss a professor at the teaching hospital. He agreed and the only thing that concerned me the most about this was that they original cardiologist and EP wanted to put me on rate control drugs which were the main reason I wanted the ablation as presumably if done earlier it would last longer than a CV and I wouldn't have to take the rate control medication. The Professor checked everything and as my BP is better than most people I know of my age and younger - my wife's is higher than mine but still within normal rates and she is 17 years younger, my resting rate is very good in mid 50's and doesn't go up to much over 120 at exercise - cycling weight training and walking - haven't run for years as back too bad for that and said that as long as I kept watch over my heart rate etc - kardia once a week, fit bit every day and BP and pulse once a week - or if I felt any differences then to carry on without them. To be honest if someone had told me that 4 years ago when all this started and they were trying me on all forms of rate medication which was driving me barmy I would probably have settled to this earlier - or if the NHS in my old home had been better and I coudl have got to see a cardiologist and EP within the first year of having been diagnosed with AF and I could have got a CV and ablation earlier things would have been different - but then we don't know that for sure.

[GeorgeStevens in reply to Desanthony]

Thank you for this long report. The one thing I'm unclear about is why they were pressuring you to go on rate control medication when your heart rate was already under control. You write that your resting heart rate is very good and that your BP was normal. So, you're saying it was not until you saw the professor at the teaching hospital that it was recognized you didn't need to be on rate control drugs? Fortunately, so far no mention has been made by my EP of my needing any rate control drugs. But I'm preparing myself for what his colleague will say when I meet with him soon to talk about the unsuccessful result of my CV and to discuss whether I'd be a candidate for ablation.

[Desanthony in reply to GeorgeStevens]

I was just put on rate control drugs with apixaban - though only seen by a nurse as no cardiologist at our hospital at the time and wondered why I felt so awful. That's when they started changing type of rate control medication and for a few months I came off all the new medication ie rate control, beta blockers calcium blockers - whatever I was on at the time and apixaban because I felt so bad. Then when I finally saw a cardiologist was told to go back on all the medication before I could have a CV - about a year after first diagnosis, but when I said I now believed it was the rate control that was causing my problems she put me on digoxin 125 - this caused exactly the same problems within 4 weeks and my GP then put me on the lower dose 62.5 but wasn't on them long enough to note if these also gave me the same side effects as had my first successful cardioversion so came off everything other than apixaban. thankfully between CV's they only put me on apixaban - but only waited at most a couple of months in AF between CV's - then when the EP and Cardiologist agreed that further CV's and an ablation - cancelled twice 3 times due to lockdown and coronavirus in the cardiology unit, would not be worth doing I was sent prescription for rate control - again. due to the problems I had had previously I refused to go back on them but the GP was loathe to take me off them as I was prescribed them by both an EP and Cardiologist which was when I demanded a second opinion. Since then neither EP nor Cardiologist have contacted me for check ups - leaving it to their nurses to call me.

[Hidden]

I would say it must be unusual for even “asymptomatic” AF not to affect exercise tolerance. Is there nothing you can’t do now that you could do previously? Like run up 2 flights of stairs without feeling short winded.

[GeorgeStevens in reply to Hidden]

Good question. I have to say, it wasn't my usual practice previously to "run up two flights of stairs." So, I don't know if I've lost that ability. I might walk up two flights of stairs, but I've never found it necessary or interesting to race up stairs. And now, at the age of 68, regaining an ability I never used or knew I had is way way down on my bucket list. It's not something I miss. Currently I live at the top of a long tall staircase, and when I climb it I notice it somewhat; I guess you could say I feel a bit "short-winded," though it's not as if I'm gasping for breath. My EP said something about their doing a stress test on me. I would imagine if they do, they/I will find out more about what I can and cannot do.

[RickyM]

Hi George, I was diagnosed with AF in 2013. They tried 3 cv's with and without Amiodarone. Came to the conclusion that my AF was permanent. I'm on Xarelto and Digoxin. With no symptoms except with moderate to high exercise I decided against ablations.Do you get resistance to exercise?

My heart rate seems jump all of a sudden. All the best.

[GeorgeStevens in reply to RickyM]

Thanks, Ricky. I have to say, I've been avoiding vigorous exercise since my diagnosis. I do take a brisk walk every day of 2.5-3 miles where the first half the walk involves a gradual uphill incline. I'm able to do it without slowing my pace. Since the pandemic started, I stopped going to the gym, where I would sometimes use the cross-trainer to really get my heart rate up.