Guess it’s back!

[Trotters70]

Wanted to share my experience of my AF returning after 3 years. Was sitting at home after walking 24.000 steps the previous day when I started to feel hot, sweating and then suddenly throwing up and not feeling at all well. That’s when I realised my AF had returned with a heartbeat of over 160. I immediately went over to A&E where I was sent straight to Resus and this was were I stayed for 6 hours without any medication, given only a drip of saline and a drip of magnesium. Their protocol was to administrate amiodarone then if that failed I was to be converted by cardioversion. I explained that I had a bad reaction to amiodarone and didn’t want cardioversion so they didn’t do anything but monitor me for the 6 hours in Resus. I told the Dr that my usual way before was to be given flecadine by drip and it usually converted me into NSR within an hour or so. He said it was protocol to administrate the amiodarone then cardioversion and he couldn’t make any decisions on the flecindine without speaking to a cardiologist. After the 6 hours in Resus I was moved into A&E and this was were I seen the cardiologist who again wouldn’t prescribe the flecadine but gave me 5 mg of Bisoprolol???? This reduced the HR to 120 but still in AF. Couldn’t understand this, no Antiarrhythmic drug. I lay in AF for a total of 16 hours before I got speaking another cardiologist who gave me 100 mg of flecadine and sent me home. Went home exhausted still in AF where I took another 50mg of flecadine and I eventually reverted to NSR within 2 hours. Why wasn’t I give this at the beginning beggars my belief. We know ourselves what works best for us. Their bloody protocol kept me in AF for nearly 18 hours. Feeling like my voice doesn’t matter.

[CDreamer]

Sorry the beast returned, and can empathise same happened to me, more than once. Actually I think you did really well to get admitted! I have never, ever been treated even with a saline drip when gone to A&E.

Don’t forget that A&E regularly do not treat without cardiology input and Flecainide may work for you and I know it’s really frustrating not to be given a drug you know works but fighting ‘Protocol’ is like hitting a brick wall with your fist, you only hurt yourself.

I’ve never managed to get cardiologist input when in A&E and never been treated even on the one occasion I was admitted to Acute Cardiac unit simply because I was registered with a cardiologist and doing nothing was better than doing the wrong thing. I also refused Bisoprolol - which was the only drug the on call cardiologist was prepared to give me but I was not prepared to take.

Maybe moderate your exercise and so avoid a repeat?

Best wishes.

[Trotters70 in reply to CDreamer]

Thanks CDreamer and it sounds like I have been fortunate for the treatment I received compared to yours. I have always been offered treatment and care until I return to NSR except on this one occasion. I would not feel comfortable going to your A&E because of the lack of intervention , even though I have experienced fast AF many times it is still a scary situation, one that reverting quickly is our main objective. Hope you are keeping well and do have have many visits to A&E.

[CDreamer in reply to Trotters70]

I agree that the objective is convert to NSR asap and the target of my EP. Just A&E who haven’t helped, whereas GP was fantastic. I wish it was just one A&E but had similar experiences at several. Thankfully my pacemaker has sorted most of my arrhythmias and I don’t get worried by episodes.

[Thomas29]

What a dreadful experience! I assume you took at least 200mgs of Flecainide at home and that didn’t work. I have never gone to hospital with AFib , just upping my dose of Flecainide, it’s takes a few hours but works in the end.

[Trotters70 in reply to Thomas29]

Hi Thomas I actually took the flecainide then fell asleep as I was exhausted being awake almost 20 hours. Woke up and in NSR

[jeanjeannie50]

I know just how you feel.

I had a horrendous nosebleed and my BP shot sky high. After a few hours of this my neighbour called an ambulance, they couldn't stop the bleed, so took me to A&E. They couldn't stop it either so put a huge bung up my nostril and blew it up to press against the bleed. Was admitted to hospital, it then occurred to me that if I took my beta blocker my BP would go down and the bleeding may stop - but the nurse said no! How I wish I'd just taken it without asking. There are times when we know our bodies reaction to drugs better than anyone else. First thing I'll do if I should ever get such a fierce nose bleed again is take my beta blocker.

Jean

[Trotters70 in reply to jeanjeannie50]

Hi Jeanjeannie50 lol I was thinking the same thing. Next if I am in fast AF I am going to take my flecainide before going to A&E then they can’t refuse me.

[Auriculaire in reply to Trotters70]

If you have Flecanaide prescribed why do you not take it and then wait for it to work at home? Why bother going to a crowded A&E where you are not getting treated properly?

[Trotters70 in reply to Auriculaire]

Hi Auriculaire, the reason I went to A&E in the first place is because this is my first episode since my ablation almost 3 years ago. The symptoms were different this time. I first felt clammy then I started throwing up and feeling very unwell before my fast AF of over 160. Guess I was taken precaution in case it was something different from AF. Also I live less than 5 minutes from the hospital.

[Auriculaire in reply to Trotters70]

That was reasonable! What was unreasonable was their insistence that they could not deviate from protocol and give you a drug that actually worked for you rather than one you had had a bad reaction to. If it happens again you might be less inclined to go.

[MrJD]

Hi Trotters70.

ED practitioner here. Also with new onset AF. Cardioverted today so I saw the patients experience of what I do to them. Hopefully it will work.

Regarding flecanide.

My resus treatment is based partly on local guidance as well as resuscitation council and ESC guidance. But guidance is just that, the clinician should use clinical judgment. It is also based on the presentation of the individual patient. Sounds like something triggered this attack, maybe a virus. Without knowing blood work etc I wouldn’t further speculate.

Rhythm verses rate control is hotly debated. I would rather shock a compromised AF patient (compromised cardiovascular status) or a new onset patient clearly within last 24-48 hours. Involves sedation in ED but that’s what our role also entails.

Flecanide is great. Has risks but also pros. However my trusts guidance is only on a structurally normal heart (now that is a debatable opinion). Some patients have imaging on file others don’t. Makes it difficult.

Amiodarone intravenous is excellent for its anti-arrhythmic properties. But requires invasive lines. Also in your case not a drug that helps.

Magnesium sulphate is often given IV because someone once thought it was effective. Not really sure of the real data with AF as it works with ventricular arrhythmias such as polymorphic VT but maybe a correlation with electrolyte imbalance.

Unfortunately then it’s often rate control. Digoxin, beta blockers or calcium channel blockers.

Ideal if infection or say a heart attack causes it as reduced myocardial function worsens these causes so slowing down helps. Treat the cause ie sepsis and then trust the AF will settle as to say.

Not all of us in ED want to just rate control and we do speak to our Electrophysiology cardiologists to get advice or support. But sometimes individual centred care can be overlooked (busy resus with other patients being one scenario. Not right but happens. Then sedation etc becomes more situationally risky).

When a patient has a handle on their diagnosis or condition it is so helpful and I’m sorry in this case it didn’t lead to prompt treatment.

I would suggest a letter from your cardiologist with a management plan to accompany you or on electronic records as it is referred to. An up to date echo is always good.

But healthcare is a two way conversation and it undoubtedly helps in management of many presentations.

I welcome conversation when clinical conditions allow. I was given that privilege by my cardiologist and it has made my journey easier. I am very grateful

I wish you well.

J.

[Trotters70]

Thanks MrMD for your reply and sharing from the lived and professional experience. I do understand that there are many factors to consider when treating each individual with AF and I believe consultation should always be considered.

I have had many experiences of being in A&E with high-rate AF and each time Flecanide has worked and this was disregarded on this occasion by repeatedly being told “this is protocol”.

Thank you for sharing your experience and outlining the many different consideration s that need to be in place for treatment.

Going on your recommendation I am going to ask for an up to date echo and preferred treatment to be put on my file so hopefully this will speed up my recovery and free vital bed space.

Regarding electrophysiology cardiologists, I don’t know if we have one, but I’ve certainly never spoke with one here.

Even though my experience wasn’t great this time, I do appreciate the tremendous work that yous all do and I that people like you exist in this world. Thank you.

[MrJD in reply to Trotters70]

My pleasure.

Although arrhythmias are part of my job, becoming a sufferer had me realise how grateful I am for communities like this forum.

As you can appreciate within ED I see the worst case scenario’s and cardiovert the sickest or the arrests. When my AF occurred and demonstrated on the echo a reduced ejection fraction, at 45 I panicked as all I thought of was doom and gloom.

Subsequent MRI showed improvement and the cardioversion was not a problem.

One day later I am still in sinus but reading the comments on this forum gave me the confidence that life goes on.

I have more of an appreciation of forums like these and when patients come in with knowledge of their conditions, to me this is not a threat. It is team work.

I wanted to reassure you and not make you or anyone else scared or uncertain when they come to an emergency department in need.

Sometimes clinicians are not confident themselves in all areas and I suspect that policy may have been used here. But having a management plan by a specialist will hopefully make your journey in future more patient centred.

The Electrophysiology consultant is a cardiology consultant (as you undoubtedly know). It could be worth looking at the hospital website where you are treated as often it lists the consultants and their areas of specialty.

Thank you for taking the time to reply, particularly the last paragraph. It is much appreciated.

J.

[secondtry]

Attending hospital seems to get more of a challenge these days. No doubt your experience has forewarned yo, get prepared in advance for the next one and run those planned options past your cardiologist in a private appointment. I find this is a great way to reduce anxiety and reduce the future burden on the NHS.

[ETHEL103]

That's incredibly scary.Glad your OK now.

[seasicksurf]

24,000 steps is about 20 kilometers! Wow. I'd need to be walking with a rolling IV of electrolyte solution to keep my heart stable. Maybe you just had an electrolyte imbalance for all the exercise?

[rosyG]

they have to be sure you don't have heart structural problems before giving flecanide and if 3 years has passed....