So I am PAF for 2 years now. Cryoablation last November. So far so good, apart from one 2.5 hour AF episode 3 months ago, which stopped on its own.
I have been advised by the cardiologist NOT to take a PIP flecanide (or anything else) if I get AF in future because my resting HR is very low normally (below 50).
I am otherwise healthy and have done all I can do to optimise my diet and lifestyle. I take Mg and have stopped over exercising..moderate now. I have no known comorbididites.
How do I manage an AF episode without taking a PIP? Should I go to A&E or wait it out?
Any advice much appreciated thanks
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intheweeds
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Hopefully you won’t get another episode and if you do it might revert again on its own as last time. I had mine just after you in December and I think we need to learn our new normal following the ablation. Your new normal might be the very occasional mild episode which self reverts, if it doesn’t then look at contacting the arrhythmia team for advice. I never used flec anyway but Bisoprolol kept the rate under control. I’m now off all the AF meds but still learning my new normal. See my bio by clicking my badge which I keep updated.
Many thanks. I hope i learn to live with this ‘sleeping dragon’. It has made me more cautious, but maybe that’s ok. You are right, it’s is getting ourselves used to the new normal.
Given the concern of your cardiologist about your heart rate going too low...
If your heart rate is below 110 in atrial fibrillation, and the episode lasts under three days, you can probably ride it out safely at home without any additional medications. If the episode lasts longer than three days, you should have an agreement with your cardiologist that an electrical cardioversion (ECV) would be scheduled right away.
If your heart rate is above 110, you would want to head to the A&E where they can either give you an ECV, or at least monitor you safely.
With only one episode in 2 1/2 years, this strategy may be all you need. Should your afib frequency increase, you might want to revisit the PIP strategy again with your cardiologist, or get a second opinion.
thanks for your reply. Good advice indeed. I had AFib events every 2 months before the ablation and hopefully I will get less since having it. I feel a bit anxious not having a PIP but I clearly cannot risk it with such a low HR normally.
Have you tried deep yogic breathing during a PAF episode? I have PIP Flec but find the side effects strong - so when I have an episode I always first try controlling the rhythm and rate by deep yogic breathing. And sometimes it works.
Take a deep breath in so that the belly expands and the whole diaphram expands, to the count of 5 - then a long slow breath out to the count of around 9 or 10.
It's the long breath out that calms the vagus nerve which controls the heart. I practiced every morning so that when the 'sleeping dragon' woke I would know what to do. In fact it has helped my health generally and fingers crossed seems to be helping to reduce the frequency of my episodes ...
As someone posted above, if the rate is high and it goes on too long then go to A&E ...
Hi 108cat, thanks very much for your great advice.
I have tried this breathing and you have given me the reason to keep trying that. It is hard during an episode because the heart is so out of control. I had not realised that the long breath out calms the vagus nerve. My cardiologist told me that it is the vagus nerve that can spark my AF, so that makes sense.
Yes it's hard during the episode ... hence practicing when 'the dragon' is sleeping ..!
When I start the deep breathing during an episode I notice on the inbreath the heart bangs even faster, but then gradually during the long outbreath it starts to calm down but you're right it's not easy. I have to be quite determined, focus on the breath, keep my mind calm and just keep at it.
Of course if the rate is high and it goes on too long then definitely A&E ...
Another thing I do is drink a glass of cold water immediately the PAF starts
That really is useful thanks. I didn’t know about the glass of cold water either, so I can try that. I feel that it’s useful to have a sort of ‘toolbox’ of things I can try. So now I can add the yogic breaths and water to the toolbox.
May I ask, what side effects the flec PIP gave you?
Yes after I've taken it for PAF I have episodes of tachycardia for a few days afterwards ... they are usually at night. I have a strong sense that it's really not good for me.
Having said that - if the breathing hasn't worked on the PAF and my heart is crazily banging away I do take it. It usually works pretty quickly, but I'd much rather not use it.
I have a low resting HR and my PAF is always at night
Thanks for that. Yes, I also have low resting HR and PAF always at night. Interesting the flec affects your heart I that way. I suspect it will be the same for mine!
I'm confused,as Flecanide is a rhythm control not rate control drug. My resting heart is often in very low 50s but I am told by my EP that an extra 100mg as a pip is fine on top of my 100x2 daily. Riding it out is all well and good,but it's obviously better to be able to knock episodes on the head ASAP!
Hmm, a conversation with your consultant i think? X
Yes it is confusing for me as well, especially as the same cardiologist had agreed I could take the flec as a PIp before. I feel quite exposed not being able to use it now because I have nothing else!
First essential, don't panic as this always makes it worse, try your breathing, play some music, read a book all things to aid slow down but if it doesn't work then the Para Medics will attend, go through with tests etc., and either take you with them or reassure you that it is not. I didn't find the P/P any help but did take 375mg Soluable Asprin which helps to thin the blood I believe, advised by emergency doctor and then prescribed by Cardiologist rather than give me anticoagulants as I was only 54 at that time.
I have a low resting rate, too, perhaps caused by my LBBB. It is variable although often under 60, and sometimes under 50. I now take 1.25mg bisoprolol daily and when I was on 2.5mg, it would sometimes be under 40.
I have been prescribed flecainde 50mg after a cardiac MRI showed that it would be safe, but I was advised to take it regularly, not as PIP. That drug is said to work best in people with faster rates and with fast AF, I gather. It was prescribed for me but so far, I have only taken a single dose. It did keep me free of arrhythmias for several days, but on the first day, my heart beat became much more noticeable, or perhaps I was more aware of it. Anyway, I became reluctant to take more because of the potential and occasionally dangerous side effects that I had read of. My GP advised me to go back to bisoprolol, although the specialist insisted the flecainide would be safe. What a life?!
I currently take only 1.25mg bisoprolol but, last week my AF became faster than usual, (it is normally fortnightly or so, at 85-130, but last week was 130-160bpm). I though of starting the flecainide again but my wife was reluctant, so I I took an extra bisoprolol, instead. That eventually seemed to help, but only after a couple of hours, so it might have just been the AF itself naturally slowing..
That is the problem with AF, it's variability, making it hard to know just what the tablets are doing to help it, if anything at all. It can lasts for 10 seconds or a whole day, and there can be 2-3 weeks free of it.
Aren't you able to cope with the episodes you have? Luckily, so far, I am with the main problem being the anxiety it brings in its wake, and the sometimes slight light-headedness.
hi, thanks for your great post. I have found my episodes to be quite variable and try to use the calming techniques we have all been discussing here. I am interested in your experience with flecanide.
It is quite a journey we are all on with this thing. And it changes. Hard to know what to do sometimes!
I feel that it truly must depend on how you react to the episodes of AF. Drom my own experience, I realise fear, which is natural but must vary among individuals, pushes up the heart rate, and perhaps by a great deal. Since my MRI, I am much less fearful and, lo and behold, I am now much more comfortable when I have AF. It used to peak at about 180bpm, now it peaks at about 150bpm, and often a lot less.
I am hoping that I can press on just with the small dose of bisoprolol, and I sometimes wonder (given a recent post here from "CDreamer") whether I could stop that altogether, although I am not sure if the feelings I get are from the drug or my heart. An elderly friend, who's now 91, takes only his warfarin, and he has had AF permanently for years now. His heart rate, though, is lower than mine and rarely seems to exceed 90bpm.
I am sure that it’s a self generating circle, where small AF makes us anxious and stressed, which cause a bigger AF. I want to train my mind to calm down if I have AG, so that it stops ramping up, if nothing else.
Hi Steve according to my Fitbit and cardicolive my afib is peaking in the late 170s. My afib episodes are only lasting 2hours max, 1hour usually thankfully. How long would our hearts tolerate this rate before any damage is done.? Is it hours.days.weeks.? Iv got a cardiologist phone call coming up in the near future so I don’t know wether to wait until then or maybe try and get Intouch.
My AF has been in progress since 2.30pm today. The rate has been around 90-130bpm in general, but giving my grandson a piggyback ride after dinner this evening was not the best of things to do, and it rose to well over 180bpm for rather too long, bringing on the need to sit down and with somewhat stressful but mild chest discomfort; added to that, I went momentarily very light headed when I tied my shoes up. I got what I deserved but I was pleased I had coped okay..
I have been reassured by my own experiences and by my specialist that the ventricles can cope well with this kind of thing. After all, they do so in athletes, although in their cases, their hearts are pumping efficiently. At such a fast rate, in our cases, the opposite is the case, and the pumping is far from efficient. However, our hearts are not at 180bpm all of the time, whatever the ECG reads: it is an average. I gather all ECG / heart rate apps struggle to know quite what to count when there is an arrhythmia. What can happen during AF, also, is that the valve can leak a little, and added to the poor filling, the EF (ventricular ejection fraction) can drop somewhat from its norm (whatever that is for you - mine is low 50s%).
I took an extra 1.25mg bisoprolol this evening, a few hours later than I ought to have done, but I was feeling okay and forgot. It worked within two hours and the rate is now about 80bpm average. I do have some flecainide tablets (50mg), but I am reluctant to take one as "PIP" (I nearly did, however).
I started this "journey" in 2019 with persistent atrial flutter (with so-called "2:1 conduction", which has a heart rate of exactly 155bpm. This was constant and for quite a long time, then with Bisoprolol 5-10mg, exactly 105bpm for some weeks, finally ~50bpm once digoxin was started, then ablation in June and a cure for all that. Those "exact" figures are typical of AFl, by the way - the ventricles react is a fixed ratio to the atrial beat of ~300bpm.
What was the effect of those many weeks of fast heart rate? Well, I had two echocardiograms as I was lucky back then to be able to use my wife's private healthcare plan (we've retired since and lost that as it became too pricey). The pre-ablation echo showed permanent AFl and a reduced EF, with some mild valvular regurgitation. Both returned to normal on an echo after my ablation, confirmed by a cardiac MRI. In 2022, with increasingly common ectopics and AF (not AFl), a further MRI revealed no deterioration and a structurally "sound" heart.
So - I think you, too, are as safe as I seem to be. We are both worriers, I suspect. What can happen in a very few people, however, and that isn't us as we would surely know it, is that, during AF, the atria prevent the ventricles from filling efficiently, and the output (EF) falls too far risking not to keep the major organs perfused with oxygenated blood. That results in feeling like you will faint (pre-syncope) or fainting (syncope)... and a hospital visit. How near are any of us to that? I think we are all a long way from it, except the few that already know that is the way their AF goes. That said, I think by far the majority of AF sufferers who take themselves to A&E / ER soon recover with the comfort of care relieving their stress and lowering their heart rate, and, likely, an extra dose of something like bisoprolol. The few who need more urgent care will get something like IV amiodarone or similar and all is well. Anticoagualtion is the key to heath for all since micro blood clots can easily form in some people in a small atrial "sac" called the left atrial appendage ("LAA"), when their AF is on.
While finishing writing that reply, the AF stopped and perfect NSR resumed - the neatest 30 seconds I have seen since the last time. Why the heart reverts so well to ideal NSR is a mystery, given that, in the many days before it, I have multiple and frequent ectopic beats with small AF periods of maybe 10 seconds to 2 minutes.
I still have "chest ache" but otherwise can tell it is now NSR, but no great change as a few others do report.
Here is the Apple Watch ECG some time after the 180+bpm rate when the average was lower. I was too sweaty for the watch to record the fastest rate. I haven't had that for maybe a year. I shall take more care next time, but still - I am here to tell the tale and think the heart is well able to cope.
The wide peaks are caused because I also often get unsynchronised left ventricle conduction from my "LBBB" (left bundle branch block), as this time. Even the NSR graph shows this a little.
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