Third ablation, beta blocker change or something else?

[kitenski]

Afternoon all,

Looking for a bit of advice, I had my first ablation which was a 5 hour operation Feb 7th 2019! Had to shock me 6 times as well as do the ablation! Eventually put me onto flecainide which kept it in rhythm.

I came off flecainide in May 2019, and was ok until July when AFib returned. I had a 2nd ablation Sept 2019. This was a much quicker operation and the consultant said there was only some minor patching to be done. This time I came off flecainide in October 2019.

This seemed to keep me into SR until Sept 2020 when I started getting more episodes, 2 I went back onto flecainide.

I've been on 50mg flec twice daily and 1 or 2 x 2.5mg bisoprolol since then. I've then been having Afib episodes on and off since then, the service here in Leeds has some arrythmia nurses who are contactable via phone and they've been very helpful. We've tried 100mg flec twice daily along with 2.5mg biso twice daily. I noted in the diary I've been kepeping that in May resting HR whilst sleeping had suddenly risen 15 BPM from an average of 50 to 65 overnight. Higher when walking dog and double ectopics, I reduced biso to one and flecainide to one, resting HR dropped that night to normal, & ectopics went instantly.

This winter I really struggled with cold hands and feet, got chilblains and I already suffered with Reynolds before the Afib. After speaking to the nurses, we switched on the 27th Jan to a calcium beta blocker, Adizem 90mg slow release twice daily.

Prior to that I was getting an episode of AFib weekly, which has continued and actually got worse. At the moment I am seemingly getting a daily episode. If I take a 50mg flecainide as soon as I spot the episode it does seem to go back into SR within an hour or so.

After discussing all this with the nurses, we wondered about wether it was the Adizem not working, but they tell me that the beta blocker is more for rate control, as on regular flecainide with organised atrial arrhythmias a beta blocker is indicated. The flecainide can organise atrial fibrillation into an atrial tachy but it has no effect on the AV node, therefore is no rate control.

So I went to 100mg flecainide twice daily, starting last night and then this morning. I've just done a 90min indoor bike ride and gone into Afib afterwards which is incredibly frustrating.

A bit more background, I am 55, very healthy (I think) 75kg, exercise regularly and play competitive hockey during the winter. I don't appear to have any triggers, it does seem to come on after exercise, but then Fri I had a short episode just at my desk. I do drink, but have been tracking that in 2023 and am between 9-14 units a week. Alcholol is definetely not a trigger, I drank nothing early in Jan and still had episiodes.

I do have two strange things which the GP is investigating, one is a very red rash which started on 11th Feb and is still hanging around and some kind of acid reflux/GERD which is still under investigation.

I was wondering a few things.

1. I believe flecainide is fairly quick acting, so is it a good assumption that moving to 100mg twice daily hasn't worked? Or should I continue a bit longer for it to build up in my body?

2. From googling I see that Bisoprolol prevents the neurotransmitters (chemicals that nerves use to communicate with other nerves), norepinephrine and epinephrine (adrenaline), from binding to beta receptors on nerves. So I am wondering if Adizem doesn't do this and the adrenaline from exercise is a trigger which the bisoprolol might help with if I went back onto it?

3. The Nurse asked if I would consider a third ablation. From a quick search on here it seems a number of people have had 3. Has that worked for people who have had 3? I understand AFib does tend to come back so would a third likely mean it comes back within a few years?

Thanks for any thoughts, sharing of your experiences.

regards,

Greg

[mjames1]

Give the increased dose of Flecainide at least 10 days before making any assumptions as to if it's working or not. Meanwhile, they should be following up the increased dose with an ekg in about a week e to make sure your heart is tolerating it. The Adizem is a nodal blocker used as a safety measure if you're on Flecainide to help prevent 1:1 flutter and other dangerous arrythmia's. I would also re-evaluate having alcohol with Flecainide and exercise more in moderation until at least the new dose of Flecainide has a chance to work. With afib, exercise is good, but too much may be counter productive.

Jim

[kitenski in reply to mjames1]

thanks mjames1 , wondering where the 10 days come from? And also any thoughts on adrenaline and bisoprolol vs adizem (which doesn't appear to have any affect) on adrenaline.

On exercise I did a very slow, very steady jog on Thurs and still had A Fib after that!

[mjames1 in reply to kitenski]

The 10 days came both from my ep and my own experience with Flecainide. I had a rough couple of days when I started flec on a daily basis and asked my ep to increase the dose. He said give it another week to kick in. At about the 10 day mark, my afib episodes stopped. Later, when I experimented with different doses, I found that it took around 3 days for a new dose to take full effect. So maybe in your case, you might know in three days, but I would not draw any conclusions from overnight.

Most people are prescribed either diltiazem (adizem) or a beta blocker like bisoprolol to take along side flecainide for safety reasons. Not sure which one mediates adreneline better, but with being on flecainide, not sure how important that is. Before flecainide, I never took either of those drugs because I felt the side effects outweighed any of the benefits. Still cool it a bit on exercise until you get stable on the flec dose.

Jim

[mav7]

How are you monitoring your heart rate and afib episodes ?

Though Kardia and other devices are accepted by the medical community, nothing beats a 24 hr or longer continuous monitoring medical device like a holter monitor. May want to ask your GP. The results will provide information on your heart and help determine the proper dosage and type of medication versus experimenting.

You don't mention consulting with an EP or cardiologist. Assume the nurse's actions are in consult ?

As  BobD often states, management of afib is about quality of life (QOL) and what we seek. It does not sound like afib is greatly affecting your QOL though it may progress.

Lastly, at your age and overall excellent health, if you choose it seems you would be an ideal candidate for the minimaze procedure vs another ablation. Lots of discussion on the forum that can be found using the search function.

[jeanjeannie50]

My third abstion was the one that really helped me the most. Years later I now have permanent AF but at a rate between 60-90. I can now live a fairly normal life. Jean

[kitenski]

mav7 I have an Apple Watch which has caught a few overnight episodes automatically and then I use the ecg function. I’ve been living with this on and off for 4 years so I can also feel an episode myself & the Apple Watch (and Kardia initially) has confirmed it. The nurses are nhs specialised arrhythmia nurses and I’ve had telephone consultations with consultants. I’ve had 3 day ecg holsters previously. Interesting that the consultant have said experimenting with drug dosage is fine to work out what works well for an individual.

Minimaze sounds intriguing I will do some more digging.

jeanjeannie50 thanks for sharing, do you know what they did differently the third time? The consultant who did my 2nd ablation was saying less is more for scarring which was a concern for a 3rd one!