Flecainide before Cardioversion

[Siebertgirl]

My EP's plan was to have me start on Flecainide and then have Cardioversion in hopes that my heart would keep rhythm. EP changed his mind because my INR was below threshold and told me to not take it until AFTER the CV in case the med converted my heart. I was instructed to have an ECG done 2 days after the CV and he would review it and let me know when to start meds.

Unfortunately, no one called me back even with me calling and leaving messages 3 times so I didn't start it until almost a week after the CV. When I went in for follow up ECG, I was back in Afib. EP wanted to schedule me for another CV which would have been 2 in a month. I told them I was hesitant to do so until I could discuss this whole mess with them. I spoke with his NP this past Tuesday and he says I need to decide whether to have another CV in the next 2 weeks. I told him I was thinking of just not trying this process after all since the CV failed in just 5 days.

My question is, I am still on Flecainide but is there a minimum or maximum number of days you can/should be on Flecainide prior to a Cardioversion?

Sorry this is so long, but wanted to give as much background as I could.

[Murphy10]

I have not had a Cardiversion but I had an abalation. I have been on Flec. and now coming off it following my abalation. Flec. Helped me to go back into Sinus Rhythm and is often call pill in a pocket. My cardio would increase my dose of Flec. when my heart went into Afib and I never required a Cardioversion.

[CDreamer]

Firstly to answer your question - yes there is a maximum daily dose for Flecainide - for AF it’s 300mg daily but often starting dose would be 50mg x 2bd to maintain NSR. The cardioversion dose is 300mg in one shot, usually taken for the first time under medical supervision.

You can take Flecainide for years if you stay within guidelines and regularly monitored if you remain in NSR - question is why would you want to - if it’s obviously not working for you and as it’s a toxic drug?

Is there a good reason for you continuing on Wafarin? Have you a problem with DOAC’s? It would be more normal to change to DOAC then you wouldn’t have to worry about INR.

This is purely a personal view but in your place I’d be interested in asking the following questions:- as CV proved I can revert to NSR, even though it only lasted 5 days, why not referred for ablation?

Secondly - the dose for Flecainide to convert AF is 300mg in one dose. As you didn’t start your Flecainide at the most efficacious time through no fault of your own - why continue Flecainide at all if it’s not working for you? What is the plan moving forward?

TBH I think if I were you I would be looking for another EP team.

[Siebertgirl in reply to CDreamer]

They did not do a first dose of 300mg to convert. They intended for me to start on it 50mg/2x daily PRIOR to having a electrical conversion. EP changed his mind to start me on it AFTER the CV as my INR was low at the time I was to start. His nurse's exact words were "He doesn't want you to convert to NSR and not be sure you don't have a blood clot" Nothing was said to me about doing the 300mg dose first at any time. I asked my regular cardiologist about having to be in hospital to start on it and they said "No, we don't require that". Apparently just starting on a low dose prior to CV and then maintaining dose to keep in NSR is the way they do it in my area of Kentucky. So I don't really know if it is working for me since I was not started on it before I reverted to Afib. I won't go on DOAC for 2 reasons, cost and G/I bleeding risk is greater on those than warfarin. I have had 3 surgeries for intestinal cancer and do not want to risk a G/I bleed. Thanks for your input though.

[CDreamer in reply to Siebertgirl]

We in the UK tend to forget about the cost element, apologies but I get the higher risk for intestinal bleeds, given your history. Was ablation ever considered or is that not possible?

I didn’t go into hospital when I had my first PIP 300mg dose but my GP insisted I stayed under observation at the clinic for 4 hours following - linked up to a 12 lead ECG. Having said that he was also a practising Cardiologist.

Different parts of the world, even within the same country, have different protocols.

Hope you get some support and resolution very soon.

[Siebertgirl in reply to CDreamer]

Yes one of the great disparities in the U.S. and Europe, drug cost! I'm hoping to avoid ablation if at all possible, but may be that is my best option anyway. Just so tired of being in hospital the thought of even that worries me. I have a friend who did not go into hospital to start her meds either. So, yes different thoughts everywhere! I think I just need to take a step back and address this with my regular cardio who I've been seeing for 20 years and has always done his best for me. Not confident in this EP at all at this point. I went to him to discuss whether meds or ablation was best and decided on meds first. Thanks for your good wishes!

[Karendeena in reply to Siebertgirl]

I am in the UK and under a fantastic team and am EP in one of the best heart University Hospitals - I understand the risk of internal bleeds are far less on DOACs than Warfarin.

[pusillanimous in reply to Siebertgirl]

My situation may be unusual. I went for a six monthly check- up after diagnosis (I had been on biso 2.5mg and Warfarin.) After all the checks. echo. ecg etc. the Cardio told me I was in AF, would I like a cardioversion?. I replied since I was in his rooms and the cardio ward was just upstairs, I might as well ! It was morning and that afternoon he came and zapped me ! One zap and a chicken sandwich and I was good to go! Fortunately I had got my son to take me as the parking in the hospital where he was situated is dreadful. Every annual check up since has showed NSR, but I think I've had a couple of episodes (not long ones I don't have any fancy gadgetry to check) since, as I am virtually symptomless. My cardioversion was 5 years ago, and no special preparation for it.

[Siebertgirl in reply to CDreamer]

And to my surprise I actually am feeling better being on Flecainide right now. Just I am not in NSR like hoped for. So I think it may be would work if all was done properly and I get another CV.

[Buffafly]

I don’t know about the minimum but there’s no maximum as some people take it for years. But as Flecainide is a drug that works immediately as it is used at maximum dose for a ‘chemical cardioversion’ then my guess is that the minimum is quite short so probably two weeks is OK. Did you actually have the ECG two days after the CV? I would go for another CV because the longer you are in AF the more your heart forms a ‘habit’. Then if you have the same poor result you know an ablation is the only further treatment. I agree about the DOAC but as you are in the US maybe cost is a factor?

[Siebertgirl in reply to Buffafly]

Delaying the CV isn't too much of a worry as I've been in Afib now for nearly a year apparently. Mine used to be paroxysmal but now is most likely persistent which I understand is harder to correct. Trying to avoid ablation since I dont' have severe symptoms yet. Yeah cost is a BIG factor. $200 a month with insurance and both me and husband are on anti-coag. So that's $400 a month versus $0. The INR testing isn't an issue and usually mine is stable, just happened that I had one of the hiccups in it just prior to this. Thanks for your input!

[Model52 in reply to Buffafly]

As Siebertgirl is asymptomatic and she is already used to live with AF for a year, I would not call ablation ‘the only solution’. Controlling rate and anti-coagulation is often offered in these circumstances, with no difference in life expectancy to rhythm control.

[Buffafly in reply to Model52]

With that new information I would agree with you although recent research has shown that permanent AF even if rate controlled can lead to heart failure which is why I think an EP would try to achieve NSR.

[Ducky2003 in reply to Model52]

As per Buffafly's response below, in my case, the AF has caused my left atrium to enlarge and I now need mitral valve repair surgery so, with hindsight being a wonderful thing, I would have chosen to go down the ablation route earlier than I did. Hopefully, this would have prevented the valve issue.

[Abbyroza in reply to Ducky2003]

Was your rate controlled when you had AF? Normally there should be no damage to a healthy heart from rate-controlled AF.

[Ducky2003 in reply to Abbyroza]

I am on rate control medication and have been for 8 years. When I have an AF attack, sometimes it's with RVR, sometimes not but the EP said its the irregular rhythm that has caused the issue.I didn't have the ablation until 5 years in so that obviously didn't help.

Normally, doesn't seem to apply to me with anything in life 😁.

[Abbyroza in reply to Ducky2003]

That probably has to do with the high ventricular rate. ‘Rate control’ means that your resting heart rate stays around 70-100 bpm. Then there is practically no risk for heart failure, even in patients with permanent AF.

[Buffafly in reply to Abbyroza]

That’s the theory but I question it. AF can be slightly irregular or very irregular regardless of the average rate and I find that very irregular ‘slow’ AF at 70bpm is worse for me than a slightly irregular AF at 110.

[Ducky2003 in reply to Buffafly]

Very true. As we usually say, one size does not fit all. In theory, an elephant can hang off the edge of a cliff with its tail wrapped around a daisy but in the real World, it may be a different kettle of fish ........ or elephants. 😁.

[Buffafly in reply to Ducky2003]

🤣

[Abbyroza in reply to Buffafly]

Of course, I agree. The more irregular the rhythm the more symptomatic and uncomfortable. But it makes little or no difference as far as the risk for heart failure is concerned, as long as the average rate is kept within a reasonable margin.

[Ducky2003 in reply to Abbyroza]

After 8 years with AF I know what rate control means, trust me 😁.My heart rate range during my last AF stint in April, was between 32 and 190 but my average was around 70. My usual average is 48.

Sadly, one size does not fit all with AF and I can only offer info/opinions based on my own experience and hope that it goes to show that other factors may influence treatment. 😊

[mjames1]

Assuming your INR is now within acceptable limits, I would assume they would want you on daily Flecainde for at least 1-2 weeks prior to cardioversion to give it ample time to work. I don't know what dose they prescribed, but starting the starting daily dose is usually 50-100mg, twice a day.

You might also ask if you could try a PIP conversion dose followed by a daily maintenance dose -- which might make the cardioversion unnecessary. A conversion dose might be anything from an additional 50mg to more, depending on how your ep accesses the risk of the drug based on your unique history. 300mg a day is the maximum dose for afib patients, however that does not mean that you will be allowed that much. I was never allowed more than 200mg in a 24 hour period.

If Flecainide doesn't hold you in normal rhythm -- with or without CV -- then getting evaluated for ablation might be a next step, depending on multiple factors.

Good luck and hope you feel better soon,

Jim

[Siebertgirl in reply to mjames1]

Thanks that is very helpful info from your experience. I was only given 50mg/2x daily to start and it was suggested that they increase it since the error of not starting it in time to keep NSR. But EP said repeat CV and then continue on this dose. So I'm just not sure what the heck to ask for or agree to at this point. And the EP only comes to our city once a week and i would have to travel 2 hours one way to his locale to have it done there unless he had an opening here. Just a royal PIA!

[mav7 in reply to Siebertgirl]

Were you referred to the EP by your primary care doctor (GP) or a cardiologist ?

As mentioned above by CDreamer , it would be wise to get a second opinion on something this important. May want to check with the referring doctor for recommendations and/or do your own research. If not in your area, your records could be electronically transmitted and a video conference initiated.

You many want to begin by googling for the best doctors/hospitals in Kentucky for afib perhaps at the University (UK) or in Tenn (Vanderbilt) has a renown hospital.

Best to You !

[Siebertgirl in reply to mav7]

Yes this is the specialist my cardiologist works with for needs he is not certified for. EP is with a highly respected/skilled facility in Nashville (not Vanderbilt) and I checked his qualifications carefully. Thought he was good, but now am questioning it completely due to his waffling on plan and failure of his nurses to follow up properly.

Thanks for the encouragement!

[mav7 in reply to Siebertgirl]

Good to hear of his qualifications. May want to question him on his plan and express your concerns. We all sometimes question our medical professionals.

This is a great community with helpful advice. But only the EP truly knows your exact condition and proper treatment.

[OzJames]

I went into AF about 5 days before going overseas so the Professor got me to start Flecainide in the hope I would convert to NSR before I left, didn’t work but he said don’t worry that he will book me in for CV when I return in 3 weeks as he’s found CV’s tend to be more successful when patient has been in Flecainide for a few weeks before. He said before I went that my HR was in the 70’s and well controlled. He was right I converted first go. He kept me on low dose for 30 days post CV then we stoppped. I lasted 10 months. I’ve had 2 CV’s since then the closest 4 months apart. So now we’re trying 20mg Flecainide twice daily plus 10mg Metoprolol twice daily and so far going well after last AF in January. I also check my blood levels and was low in magnesium vitd3 and coq10 so now supplement as well

[Budken]

I really do not understand here. When I was first diagnosed for Afib, I was scheduled for Cardioversion. They decided first to see if Flec would stop my Afib. It did, so I never needed to have a Cardioversion. So what you said, makes no sense to me. If the Flecainide works, there should be no need to have one.

[Siebertgirl in reply to Budken]

I am now understanding the difference with use of Flecainide as a first line attempt at restoring NSR and what they gave it to me for. I understand if you are newly diagnosed with Afib they can have success with using Flecainide or another AAD to restore it. But if you have been in Afib a while, like me probably at least a year again, giving Flecainide prior to CV is the protocol. Then you remain on it to retain NSR. At least that's what I'm gathering from all the info I've read on reputable web sites like Mayo Clinic and Cleveland Clinic. So for me that is what they intended, but screwed up.