I wrote a Post here last March as we were worried about the choices being offered to my Husband for the management of his PAF (anticoagulant, pacemaker, ablation). Many of you kindly answered our questions and gave us the benefit of your experience and my Husband felt pretty confident when he saw his Consultant in June. However, as is so often the case, having dealt with our earlier concerns, we now have some new ones and we’re hoping that some of you will be kind enough to help us again.
My husband, age 75, has been taking 200mg Flecainide every single day for 35 years ( prescribed by consultant cardiologist)---originally to try and make sure that infrequent and short-lasting salvos of SVT did not cause panic or anxiety to affect his career which involved public speaking/chairing meetings/etc. On flecainide, the SVTs have not caused any major problems and have remained infrequent and “weak”, and mostly asymptomatic. He has been monitored over the years and echocardiograms have shown that his heart is structurally fine.
In early 2023, a routine heart rate monitor for 7 days (a “Zio Patch”) showed one episode of AFib ( lasting over 2 hours in the night), which was asympotmatic, + many SVTs/ectopics (14%). The A-Fib episode caused his current consultant cardiologist, after many years of “laissez-faire” to immediately become very anxious about the continuing use of flecainide----he wanted it to be gradually stopped. He also prescribed lowest dose of beta-blocker ( bisoprolol) but it caused bradychardia as low as -40 bpm and was stopped. A calcium channel blocker was deemed to be likely to cause similar problems and was advised against. An anticoagulant was recommended but my husband has a history of stomach bleeding ( not serious but occasionally noticeable ) caused by longstanding hyper-acidity/reflux/hiatus hernia, as well as nasal bleeding ( not serious); and these factors made anticoagulants a risk and have not been used, nor does my husband want them to be.
Jumping to 2024, a 14 day heart rate monitor (“Zio Patch”) showed no AFib episodes but indicated 30% permanent numerous SVT/ectopics (SVT/ectopic beats in isolation, in couplets and triplets with <1% isolated ventricular ectopic beats) which in total left my husband with only 70% of beats in sinus rhythm . Ablation or pacemaker have been discussed but neither my husband nor the consultant is very keen on effectiveness of either in this particular case and have been decided against. Consultant shows little or no interest in SVT/ectopics but is solely concerned about the one AFib episode 18 months ago and the continued use of flecainide, on the grounds that he fears the pro-arrhythmic properties of flecainide may lead to a stroke and would like my Husband to stop taking it.
We understand that “traditionally”, a beta-blocker/calcium channel blocker is used for AV node protection against the pro-arrhythmic properties of flecainide but being unable to tolerate them is not, in our view, a reason to stop what has been an effective drug for SVTs over 35 years. Flecainide is one of the main drugs of choice for someone diagnosed with AFib and it has made my husband’s SVTs/ectopics mostly asymptomatic for 35 years. To our mind, without flecainide, how much worse would the SVT/ectopics be ? How many more Afib episodes would he have? And no-one seems worried about the loss of 30% of sinus rhythm---shouldn’t we be concerned about that , especially as only one episode of A-Fib has been noted but the SVT/ectopics are there continually ?
The current position is that the Consultant “understands” my Husband’s views and it’s been agreed that he will not be taking an anticoagulant and he will continue with the flecainide 100mg twice a day; with it being made clear to the GP that both decisions have ultimately been made by my Husband.
We would welcome your views/opinions on any of the above please. In particular,
- is my Husband being foolhardy in refusing to stop the flecainide as the tablets may be keeping Afib episodes in check and possibly keeping the SVTs/ectopics asymptomatic?
- is the loss of 30% of sinus rhythm/the increasing burden of SVT/ectopics a cause for concern?
Sorry for the long post but I’ve tried to give you as much info as possible.
Thanks for reading, BTW, I've posted this on BHF and AFib forums because of Afib management and SVTs/ectopics.
Peg
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Peg99
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To our mind, without flecainide, how much worse would the SVT/ectopics be ? How many more Afib episodes would he have?
Compromise might be a temporary trial off of Flecainde, as that is the only way you can answer the above question. If the trial is unsuccessful, you might try a lower dose and see if that works. If that doesn't work and the SVT episodes are bothersome, maybe you should be discussing an SVT ablation if you haven't already.
And no-one seems worried about the loss of 30% of sinus rhythm---
How symptomatic is your husband with the ectopics or are you simply concerned about the EKG report? If his ectopics are not highly symptomatic., they may not need to be treated. And 30% ectopics does not mean he's a normal rhythm only 70% of the time. It means he's a normal rhythm 100% of the time, but has a 30% burden of ectopic beats. Big difference in many respects.
I take your point about compromise and it's something my Husband will need to think about. So far, he is very reluctant to reduce his Flecainide, even on a trial basis. SVT ablation was mentioned but the Consultant didn't feel it would be likely to be a success.
His ectopics are not highly symptomatic but they are a nuisance and they prevent him getting a reliable BP reading at home.
I am confused about your last 2 sentances - "30% ectopics not meaning that he is in sinus rhythm only 70% of the time. It means he's in normal rhythm 100% of the time, but has a 30% burden of ectopic beats. Big difference in many respects." My confusion is due to my lack of knowledge and Google has not helped me. Is it possible for you to explain this to me please? There is so much to learn on this and any help you can offer would be gratefully received.
Basically I was differentiating between having a 30% burden of afib versus having a 30% burden of ectopics.
A 30% burden of atrial fibrillation can have potential consequences such as increased stroke risk and heart failure that would probably not be associated with a 30% burden of a ectopic beats.
My own experience of taking Flecainide without Beta Blockers as I could not tolerate them for different reasons, did not end well. I believe the pro-Arrythmia effects of Flecainide with AF are very different to those taking for ectopics beats. I developed some Flutter, which felt far more disabling than AF, then signs of developing long QRS at the same time as exacerbating an auto-immune condition. I suspect this is why your cardiologist is so cautious about continuing Flecainide.
The pacemaker option - is it being recommended for management of PAF ie: CRT - cardiac resynchronisation therapy or simply to counter the bradycardia so that Beta Blockers alongside Flecainide would be tenable? The latter is a common treatment strategy. Ask more detailed questions on this.
My personal experience is that because I was unable to tolerate most meds, I was fitted with CRT pacemaker back in 2018 - which has resulted in a reduction of AF burden from about 75% to 2%. I now take no heart meds, other than anticoagulants.
If the risk of taking oral anticoagulants is higher than benefits received there could be other options for reducing stroke risk so I would suggest you ask about alternatives if the personal stroke risk is very high. At this stage of life it’s all about balancing risks to benefits and how it affects quality of life. All I can say is that my QOL has been vastly improved by pacemaker and with hindsight, very much harmed by drugs but as it is so individual it’s very difficult to choose what will work for each person, now only if we were born with foresight!
Hubby started taking Flecainide for SVTs, Afib was only found last year. Yes it might have been 'caused' by years of SVTs and taking flecainide or, it could just be age related. We'll never know. There has been no sign of atrial flutter (touch wood) and the only other abnormality is first degree heart block with a slightly higher PR interval than normal. Cardiologist is not concerned about this.
The pacemaker option was suggested by an EP for management of PAF and as an alternative to taking flecainide without a BB or CCB. Seems too drastic a solution to us which is why Hubby said no. Hubby is asympotmatic PAF so it is not possible to say what his burden is. However, thinking back over the years, we can recall 3 occasions in the last 20 years when he had rapid heart rate and felt really ill for about 3-4 hours. With hindsight, we think that might have been Afib but of course, we don't acutally know that for definite. It does seem though that he does not have Afib often enough (in his view) to warrant pacemaker.
It is precisely due to QOL that Hubby has declined anticoagulants. He is aware of the risks re stroke and I have already told him about your experience. He is quite definite about it though; QOL for him would be ruined with anticoags. AS to his risk of stroke it is just his age and PAF which puts him in the risk category. As you say, if only we were born with foresight.
Thanks again for your detailed response, it is very much appreciated.
The small number of self terminating VT episodes is likely what has caused the concern as flecainide can be pro-arrhythmic and can cause this. The risk of stroke is related to the AF, and perhaps the atrial ectopics and I would, myself (also with gastric issues, controlled by esomeprazole) want some kind of anticoagulation, but that is up to you and your husband's doctor. A trial, as Jim says, of no flecainide sounds a good idea. 30% ectopics / AF sounds high and is similar to me (although not yet persistently). I, too, can't take much bisoprolol owing to bradycardia and a PM has been suggested as a way to allow a higher dose while I await an ablation.
Thanks for the reply. A trial of reduced/no Flecainide does sound reasonable and Hubby will mull it over. The PM suggestion seems too drastic an intervention for Hubby's Afib and like my Husband, the cardiologist doesn't think it would help him that much (the suggestion came from an EP).
Thanks again and I hope you don't have to wait long for your ablation.
I am an 80 year old female and I have found that taking 100mg of Flecainide twice daily works very well at keeping me AF free without any other medication - just put on statins recently too as it seems my cholesterol requires that despite having a healthy diet and never having been overweight and my heart is structurally fine. We know we are all different and I hope your husband is able to maintain what works for him.
Hello Vonnegut and thanks for your reply. Hubby was very pleased to hear about your situation and hopes he can be the same at your age. He's certainly going to try and stick to his guns and hope that all is OK.
Peg, it seems to me that the Flecainide may be losing effectiveness if he has up to a 30% burden, so it is hard to say if that is success or not. A burden that high CAN cause Cardiomyopathy, but it also may not. It is very variable and the research isn't clear. If his rate is also fast with the SVt, then that is more concerning., which may be the reason the EP is pushing for a Beta Blocker. Ultimately, you guys have to decide a course if action, which certainly could include do nothing, and keep on with the Flecainide, or stop it and see the burden, or consider an ablation for the SVT/PACs. None of those is necessarily better or worse than the other because it depends in where you are in life. At 45, I didn't want to be on meds and went for the ablation. But I've had two now, and am in meds anyway unless I want a third. I know others who had one and done, others who have a pacemaker, and others who just take meds. Everyone is different! I think you are good to question and think realistically about the options!
We are concerned about the 30% SVT/ectopic burden but feel that the flecainide is must be helping and at least they are mostly asymptomatic. The 14 day heart monitor gave sinus rhythm as 39-65 bpm and the longest run of SVT was 3 minutes at a rate of 101bpm. How may of these there were we don't know as the report simply says 'frequent'. We monitor Hubby's heart rate at home and we don't get any high readings - mostly 55-80 so we don't think he has a fast heart rate, even through SVTs.
Thank you for sharing your own experience and those of others you know. As you say there doesn't seem to be any definitive right or wrong way to go. Age does has a big influence on all this and Hubby and me will continue to consider and review his decisions as we go along.
Yhanks again for your response and good luck for the future.
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