Exercise induced AF - a few months on

[CyclingRunner]

Afternoon all,

Thought I'd share my experiences of navigating my way through PAF so far. My history is in a previous post - 4 experiences of high HR / AF during big efforts over the last 12 months, but seemed to be getting more frequent. No issues reverting to NSR.

Cardiologist driven testing - I've got a very strong family history of heart disease, so had a CTCA (I'm top 10% for calcium score for age group). Had an angiogram yesterday and all clear - cholestrol <3, but increased statin dosage to 20mg / day. Gave me some beta blockers to try (metopronol tartrate) .

Diet / sleep / alcohol. Trying to get closer to 7 hours per night rather than 6. No major changes to diet (I'm 6ft6 and 82kg). Reduced alcohol to max 2 drinks / night and only 3 days / week

Devices. Got myself a Wellue AI ECG device. It's not much good during exercise or lots of movement (fine walking, not so good if moving upper body lots like painting / gardening etc). However, has shown me I have loads of PAC's. Here's fairly typical one minute ECG after exercise and then the summary of a day. Came back from exercise and put it on just before 7am, then work, then walking around towards the end of the day.

Exercise. Still doing 6 days a week, but certainly not going quite as hard. Aiming to peak at 150bpm, and max avg 130bpm when out. Way more conscious now of rhythm, and it's clear to be that above 150bpm I start to get irregularities, and if I keep on pushing it then it could lead to AF. I suspect that previously I pushed into this AF zone more frequently than I thought, but not for long enough to tip it over the edge. It's also clear that this threshold appears to have been decreasing.

Betablockers. In the last week I've trialled 1/2 tab of 50mg metopronel tartrate before exercise, with very good results. See two runs - one at 5:03/km and 5:05/km on the same route. You can tell the BB - avg -20bpm. Also tried with cycling. The advantages are it does a very good job of lowering and putting a cap on my HR. Not much affect on PAC's. The disadvantages are that it has impacted performance - for example I could run a bit quicker than below, but on a BB my HR won't increase and my legs starve of oxygen. Same thing with cycling - in a group pack when you need to contest the sprint then you can't push as hard. When I stop exercising if sitting down then I can get into the high 30's, so it's probably -5-8 bpm down when resting. No other adverse effects. I can take the reduction in performance if I can still get out there.

So overall compared to what I was thinking a few months ago I'm in a pretty ok place. It seems like I am more aware of the triggers (going too hard, alcohol). I've got a device I can use to assess / baseline some indicators to know if I am getting worse. And good results with a BB to take the edge off without appearing to sacrifice performance.

I've found this forum to be very helpful and one of the better sources of people lived experiences - understanding that my situation is different from a lot in that I'm early stages with a fair degree of control over what's bringing it on.

Cheers,

Tom

[Speed]

Hi Tom.

Very interesting post and very similar to my situation where I’m trying to find a compromise whereby I can continue to exercise but at a level that does not bring on episodes of AF, nor progress my AF. I’m currently on Flecainide - 2 x 50mg daily - came  off the Beta Blockers years ago in agreement with EP as they absolutely destroyed my pace by capping my max HR.  I am however 57, so suspect a fair bit older and not exercising at your level of intensity.

After 3 mths of symptom free, yesterday I went out for a run and after 5 mins, my HR progressively climbed through my normal HR of 130 up to 203 (Garmin with chest strap). I noticed from my Garmin (rather than symptoms though it would have become apparent within a few minutes due to fatigue) so slowed up and it dropped back < 120 b/min and back into NSR. When I increased again above 130, AF returned but stopped again as I slowed. Clearly it was directly related to intensity / pace / HR with a HR threshold.

 I’m now contemplating my next move: at what level do I compromise, the level of exercise v risk of worsening AF? I’m resigned to the fact that AF will progress as I age irrespective of exercise, and an ablation may at some point be required, but how do I manage my overall QOL, both short and long term?

Interested in any other similar experiences & resulting strategies from other contributors.

[johnMiosh]

Hi CyclingRunner. You remind me of me, with the exercise and alcohol; I also had a coffee addiction, so perfect storm for AF.

I come from as a cycling family and have a long history of running and swimming. In 2015, I started to have AF episodes while cycling, but the HR of 240 I was seeing seemed so impossible that I assumed the monitor was faulty. I put any performance deficit down to age. In 2016, I was getting worse and AF was diagnosed, my main worry was how to continue exercising. Initially, I was restricted to a max HR of 150, which I couldn't even get to due to the bisoprolol. Living in the peak district, I was finding it difficult to go anywhere on a bike, so I fitted some fatter tyres and brakes onto an old track frame and explored the local canals and trails.

A year later post-ablation I didn't want to risk going back into AF. I dropped down to a slower group with the club and stopped going to the velodrome. I am now 5 year free of AF and medication. I am still slower than I was, but not trying to get back to full fitness. I am enjoying the more relaxed approach to cycling.

I documented my treatment here, so you could check some of my past posts, but I also discussed my treatment and exercise in a blog.

afibandcycling.wordpress.com

[saulger in reply to johnMiosh]

Hello John. I had a read of your cycling blog. Very interesting.

How long did you wait after your ablation to restart the cycling, and how long before really pushing hard?

All the best and NSR always. Saul

[johnMiosh in reply to saulger]

Hi Saulger,

I had the epicardial ablation, entry through the chest wall, so a little more debilitating post-op than the catheter version. I was in the high dependency unit for a day, then had two days on the ward before they let me go home. I was OK for a little light walking six days after the op, but progressed quickly. After two weeks i was back on the bike on a short flat ride, and continued at this level for a couple more weeks. It took me three months to get back to the hills, but this was at a much reduced pace.

Prior to AF, I had a ramp-tested Max HR of 185. I now try to keep below 165. I am back out with the club, but with a slower group. I have kept away from the squash court and the velodrome due to the short sprint bursts required, this is not medical advice, but it seems wise not to push myself too far. I now ride in a much less competitive way, I keep my efforts constant, no signpost sprints any more. But crucially, I am still enjoying cycling and have no AF since April 2017.

[saulger in reply to johnMiosh]

Thank you, John, great information. I wrote to you in more detail on your cycling blog.

Did you have your procedure with Mr Steven Hunter (Alison's [MummyLuv on the AFA site] surgeon) ?

I am off to Tokyo in a month's time for a similar endoscopic surgical ablation (WMM) and will follow your suggestions for the recovery, albeit marked down as suitable for a 75 year old rower...

When you re-started your gentle exercise, around what level HR and watts effort?

All the best, John, and really appreciate your taking the time.

[johnMiosh in reply to saulger]

It was Steven Hunter; I think I was either his first or second clinical trial subject. I can highly recommend him.

I did not use power in training, but my max HR was 185. When I returned to exercise, I was on bisoprolol and I was advised to "raise my HR slightly but not continue until exhaustion". My max for a while was 120. After three months I was getting noticeably fitter, but stayed at a max of 120 as I was still waiting for the second part of the process, RF ablation by catheter.

After this, I felt better immediately. I still tried to stick to the 120 max, but it occasionally went above this for short periods without any problems.

Six weeks after this (a total of seven months after the first ablation) I was given the all clear and was told that I could exercise without restriction. However, I considered that excess exercise had caused the AF so I kept my artificial max HR at 165. This has had only a minimal impact on my average speed, and I am still enjoying cycling. I daren't think of anything approaching competitive cycling though; its a loss, but compared to the alternatives, I am very happy with where I am now.

AT the time of my first ablation I posted on here with details of advice I had found from various sources:

OK to get back to normal after a couple of days (Cardiologist)

Do nothing for first week, and very little for the second. Take it easy after that, don’t undo all the good work. (Bob D, Here)

Do not lift heavy objects, play squash or cycle for 10 days (Hospital discharge leaflet)

Give yourself weeks to months to recover. (drjohnm.org)

You’re also instructed to take it easy 4-6 weeks after the ablation as the heart is still fairly inflamed. They advise minimal exercise (if any at all) and no hardcore activities. (livingwithatrialfibrillation.com)

It usually takes a couple of days for the small holes at the top of the leg to heal. Light exercise can then be resumed. Strenuous exercise is best delayed for a week after the procedure. (totalhealth.co.uk)

In cardiac rehab we recommend beginning with an RPE of “light” to “moderate” (11-12 on the Borg scale). If this feels manageable, then you can graduate to “somewhat hard” to “hard” (13-14) (drbillsukala.com.au)

Absolutely no consensus, so I erred on the cautious side.

[saulger in reply to johnMiosh]

Thanks, John. Good to have your experience, invaluable !

Alison was correct and you had it with Mr Hunter (Sheffield) and Alison is less than 6 months after her procedure, in NSR, and forgot all about her Afib, after 5 years in persistent.

I will also err on the side of caution and will go slow. I miss the glow that a hard workout used to bring and the calm that followed, but am happy to adjust to doing as much as is recommended.

I will post my Tokyo diary in about a month's time, and wish us all great health.

Saul

[MrJD]

Hi Tom,

Interesting post.

Seems there are many on this forum like you and me who enjoy (need) exercise etc.

I had an ablation 2 weeks ago (I have mentioned many times my journey so won't go over it again).

I use my Apple watch and have been trialling a Whoop device as in my recovery I am trying to keep my strain lower (according to Whoop) whilst I recover.

I have been walking 5-6km last three days and although the data should be taken with a large pinch of salt, my apple watch showed I had a reasonable VO2- When my AF occurred in July it markedly plummeted and almost in a V shape since ablation, It is starting to pick up (I see as a good sign). Looking at the 6 month History it is clear that regardless of accuracy the Apple watch picked up my blunted cardiac fitness prior and during treatment.

I normally lift heavy weights but I am holding that at the mo, at least for a month or two post ablation (my EP said after 2 weeks) I am pacing myself as I do combat sports and I am desperate to return when allowed and off apixiban.

I went to the gym today and noted that as I went beyond 120bpm I felt a little irritability (skipped beats) which I felt if I pushed myself further I would not benefit. ? Overthinking/anxiety or just post ablation-settled when slowed.

I have turned my Apple Watch irregular heart rhythm function on since ablation as I have been in SR since then and even post CV unto the ablation. It picked up my first episode so I am just relying on that.

I certainly agree with you re pushing beyond that point, I am off BB at present but when off the amiodarone I may discuss that to reduce the threshold for ectopics/PACS. The technology helps definitely when exercising, and continuing doing things which gives us a quality of life.

A question: are you anti coagulated being a cyclist?

All best

J

[CyclingRunner in reply to MrJD]

Thanks all - appreciate the replies. It's taken some adjustment not to go hard all the time. I'm more long distance, so in a group pack I'll still be doing turns when others have blown up, which I realise now I can't do. It also slightly frustrating when I get passed on climbs due to moderating my HR, knowing that I've got loads more in the tank (although that's debatable now).

I did run a marathon quite a few years ago after having the flu all week (I googled "can I run a marathon with a fever"...) and ran 5 hours instead of 3.30. It was very hard, but it showed me that the 5 hour marathoners are trying just as hard if not harder than the quicker runners, but also reset my focus from achieving a certain time / pace to just finishing. So I've kind of gone through a little bit of a grieving process, and changed focus from times / ranks to slowing down and enjoying the journey a bit more.

I was interested in the whoop device or the oura ring (probably the latter as I don't want to wear a device on each wrist) as was interested in recovery. The new apple watch also looks interesting but $$$.

One thing I've found interesting about the BB is that so far my Garmin is telling me my VO2 max has increased from 52 to 53, and that my "performance condition" when I start running is better. I am thinking that the BB is restricting my HR so affecting the big efforts, but most of the time I'm running in lower zones so the effect is a lower HR with limited performance drop off.

The cardiologist has not suggested any anti-coagulants yet. I'm going back to see him in a month.

[johnMiosh in reply to MrJD]

Hi MrJD. I was anticoagulated during my wait for an ablation and for six months after. I was very happy to take them s my mother had undiagnosed AF for most of her life and had a number of TIAs. My AF has not returned and I have had my LAA removed, so the risk of stroke no longer warrants ACs. When I was on the Rivaroxaban, I still rode and I wore a SOS band, just in case. The one I bought was from one life id.

onelifeid.com/category/id_m...

I was advised by the cardiologist not to fall off and certainly not to hit my head. I did manage to fall off at one stage, leaving a slight cut on my leg and arm. Although these did continue to bleed for half an hour, it was very, very slight.

[AFCyclist]

An electric bike is a great help. I am still doing 120mpw at age 74 and completed some big climbs in the Pyrenees this summer.

[CliveP]

A couple of observations on things mentioned in both the OP and replies.

An evenings drinking is much the same as a multi hour cardio effort from a heart stress perspective.

Exercising too soon after an ablation is a bad idea. Walking 5k after only 2 weeks is too much imo. I did almost nothing for 3 months then started back really slowly. Allowing your heart to heal properly before stressing it will give much better long term performance ime. I know people who assumed it was ok because the EP said so and went back too soon. Their results have not been so good.

[Jajarunner]

your countryman, Dr Andre Le Guerche (sp?) does an excellent podcast called Racing Hearyou may be interested in. Good training

[Alphakiwi]

You dont actually nee that alcohol Tom. All the best.

[CyclingRunner in reply to Alphakiwi]

Yes - the alcohol thing is interesting. I’ve always felt after a super big night that my heart is all over the place - skipping beats everywhere. I’m definitely not a big drinker, but the latest research on cancer and alcohol linkages are interesting. When you drop down a bit you really notice how much everyone else drinks, and then how much better you feel after one drink a few times a week compared to 3.

Just invested in a new wine fridge 6 months ago and I also home brew - reckon I’ve got enough to last me for many years to come. My Dad (who admitted he has afib) would go through a couple of beers and 1/2 bottle of wine when he comes around - I feel strained keeping up with him. I suggested to him the other day that the alcohol is not good for irregular heartbeats and it was the first he’d heard of that linkage!

[beach_bum]

I have learned , that at 67, that my competition days are long behind me, so I just enjoy my daily 40k gravel/ road rides, and keep my HR under 150 and average 130…not going to win any races, but my doc considers me “extremely fit” so stats and performance levels no longer concern me. No more Strava obsessing for me 🙂

[BobbyGee]

Very useful input. Thank you! I'm not in a position to be guilty of pushing things too hard but have recently got myself out on my bike again, and, although I don't wear a heart monitor I can sense when I'm overdoing it. Isn't it good, though, to be back in the saddle?!