My previous cardiologist was an EP but she has moved to Amsterdam . My care in my local DGH has been transferred to an older cardiologist , late 60’s, now part time . He has just written to me copying in the guy whose waiting list I am on for the ablation telling me to take a larger dose of Flec as PIP and I might find I can manage it without an ablation . Previous one suggested an ablation straight away . Am just wondering if this is just a cardiologist with an old fashioned conservative attitude ? Has anyone encountered this kind of attitude before ?
Are old fashioned cardiologists again... - Atrial Fibrillati...
Are old fashioned cardiologists against ablation ?
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Peony4575
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As I understand it, you've only had one afib episode in 18 months, which did not terminate with 100 mg of Flecainide?
If this is the case, trying a higher dose of PIP Flecainide is reasonable and I don't think it has anything to do with being "old-fashioned", I would just call it a more conservative approach.
That said, ablations are being offered earlier and earlier, and there are arguments for that as well.
In the United States, under similar circumstances, it would be your decision. Not sure how much that holds through with the NHS. But certainly you could get a second opinion if you disagreed with your current EP.
Jim
Thanks Jim. He isn’t blocking it . The referral went from my GP ( At the EPs request ) as they are the budget holders . Am not sure he can block it , although he’s trying to pour cold water on the idea . I took 50 mg flex my HR decreased from 184 to 167. I took another 50 mg two hours later and my HR started to climb again and all the moisture was sucked out of my mouth for nearly 24 hours . Am not sure about doubling or tripling the dose
No one here can advise you on Flecainide dosing, but in comparison to others, that's a pretty low dose and may be why you didn't convert.
My instructions were 100 mg at the onset of an episode and then another 50 mg an hour later if I did not convert. And that is still considered conservative dosing compared to others.
On the other hand, you didn't seem to feel well on the Flecainide, which should be discussed with your doctor before increasing the dose.
How long does it take you to convert without the Flecainide? If you convert within a couple of days and the frequency is only every 18 months or so, then natural conversion with rate control is an option, knowing that at some point, there's a very good chance your frequency will increase and the episodes may get longer.
Jim
I have had 3 episodes all lasted 24 hours to the minute and I am not sure the drugs of which I have had variously bisoprolol , diltiziem, digoxin, I think amiodarone , had any effect . Its was two and a half years between the first two episodes and 22 months between the second and third . It is precisely because of the tendency for episodes to increase that I think try the ablation now rather than wait until I am older and have had a lot more
Given your infrequent episodes that terminate within 24 hours, personally, I wouldn't do PIP Flecainide, especially given your reaction to the drug.
In similar circumstances, many here might wait until your afib starts to progress more, but there's also a good case to do it sooner than later, especially now that pulse field ablation (pfa) is being more widely offered.
Jim
It's so hard to know. There is art as well as science in cardiology. In many ways, little has changed in the treatment of arrhythmias in the last several years (yes, ablations are safer, perhaps... but many online studies are US based where private medicine just could tend to favour ablation). So, your new doctor might not be conservative but pragmatic. I am, myself, wanting a review of my AF and palpitation treatment before I go ahead with my coming ablation.
The argument for ablation can sometimes seem clear enough from some on-line studies, but those who have had several ablations might have a different story. My son's teaching colleague has had five and can have no more because of the extensive scarring in the left atrium despite his AF (along with AFl) returning. It's easy to forget what "ablate" involves.
Steve
I was really reluctant to try ablation , I am not a stoical person . However this last was a bad do, and very inconvenient , cutting short the holiday , and I am so tired and washed out afterwards . I would like to give it a go . Am not sure about multiple ones at this point I will have to see how I get on . I don’t do well with drugs unfortunately, can’t take beta blockers .
It probably helps that the several people I have had contact with recently,including my 85 year old mother in law seem to have done well .
I think exploring all your options is the sensible and right way to go
I felt the same. My episodes were long at 36 hours but some would say infrequent at around every 4 months. I knew the likelihood of it progressing and it was ruining my life being scared to go on holiday etc in case it kicked off. I went for the ablation (waited 16 months), so far pleased I did, no episodes that I am aware of since.
Thank you so much for that Karendeena. That’s exactly how I feel it’s ruining my life . Although infrequent my episodes are long and very symptomatic and leave me feeling washed out for a couple of weeks. I won’t go abroad , I won’t travel any distance in my own in case I have an episode as I don’t think I should drive with AF at 180+ so need someone who could take over. Am so glad your ablation seems to have been so successful, fingers crossed I am as fortunate
I hope so ❤️ It is something I hope I don't have to have again but if I do I want a general anaesthetic, didn't like the sedation. I am pleased I had it done though. I went to Majorca at the end of August, first time abroad since before I was diagnosed. Going to Cyprus the first 2 weeks in November.
I hope it's successful for you too, it does give you some life back even though I don't like the thought of burning tissue in my heart. My EP says just forget about it now! I do think they have more success than failures.
Are you in the UK?
Yes I am. North West . Great to hear you have been travelling etc so happy for you. I would much prefer a GA and miss the whole thing but you don’t get that option do you ? Reassuring you are pleased you had it done, thanks
I wasn't given an option. I was told when I went for the pre op assessment that it depended on whether an anaesthetist was available....charming!
I don't think you will regret an ablation, you need some life back. I would go for it now. My EP told me that AF is like a 'jack-in-a-box' the more it pops out the more it wants to! Love his analogies 😊
I get the 'washed out' feeling too. The day after I had an episode lasting the usual 36 hours I went to Lincoln, felt awful especially when I was trying to walk up cardiac hill. I didn't really know much about it then as I was newly diagnosed.
I feel washed out for a couple of weeks ! Not sure if it’s the drugs the stress and anxiety or both . Disturbed sleep with vivid nightmares etc . Believe the EP is excellent . Prof Gupta , lead for the north west but I haven’t met him yet .
Don’t think I will be given an option on anaesthesia either . I wish someone else could go and do it for me 🤣 It really does affect my life because even travelling in this country it’s an added stress of wondering will it happen and because I can’t take beta blockers etc each occasion is a what will happen .
Yes everyone says it progresses and am 69 now , am not going to get younger and healthier !
Thank you for your advice and support, much appreciated !
Hi there, again, yes I have heard of that EP he's supposed to be excellent so you are in really good hands ❤️Without looking back on our thread did you say you were on Sotalol like me? I do think this is what disturbs sleep and gives nightmares. A friend of mine came off it because of that and she is under the same EP as me at Glenfield, he won't take me off it though, I don't like the drug at all.
How long do you think the waiting list is for ablation there? I waited 16 months on the NHS and even then I nearly chickened out, I was so scared. I did pay privately to see my EP though and told him I wasn't going to have it done if he didn't do it and he did. Someone else in the group had the same EP as me but has never met him in the years she has been under him so having a private consultation does help.
I must say though that Glenfield hospital really took care of me and I just stayed in one night. I didn't have any complications and even the groin wound wasn't a problem. The worst was lying flat for another 4 hours or so after lying flat for 4 hours in the cath lab. The day after I came out I had a short walk to Tesco cafe for coffee with my partner and did this every day for a week. At the weekend after the ablation I went to a garden centre for lunch!
The only problem I had was a strange type of indigestion where I kept wanting to burp. It was worse in the night. It did last a fair few weeks and I was worried because I read about damage to the oesophagus. I believe we are all prescribed PPI for 6 weeks to counteract this problem. ❤️
I am only on Edoxaban . I was on bisoprolol and had the withdrawal from hell, and that’s when the disturbed sleep and nightmares started. Now whenever I am stressed it starts up again .
Am waiting to see when my clinic appointment is , if it’s ages off I will pay to have an appointment privately to just have a good chat . He actually works at the local private hospital although Liverpool Heart and Chest where his nhs clinic is . It would help to have some sort of relationship with him ahead of the big day . His PA told me his waiting list is 7 months , I assumed it was for the ablation now am wondering if it’s for the appointment
Gosh that’s quick being out and about the next day . Some people seem to bounce back and others seem to struggle . The information you are giving me is so helpful thank you so much ! I will take my earphones and listen to an audiobook for the lying flat bit, I don’t do well flat 🙄
Yes! Not just older ones either. Last time the word ‘ablation ‘was used to me it was an older cardiologist who first of all said it was too late for an ablation and when I said I didn’t want one anyway he said ‘Very wise’. But when young ones mentioned it I had the feeling they didn’t rate EPs very highly. I think I understand why but it is confusing for the patient when the cardiologist wants to try everything before reluctantly passing you on to an EP who (generally) is eager to perform an ablation asap and more than one if necessary.
I would love to know how NHS budgeting works. Because if money is going on ablations for people who could ‘take extra Flecainide’ at the expense of those who need heart valve repairs (say) I can understand why there could be negative feelings.
The budget is held by your GP. I don’t think you can say for example that ablations are carried out to the detriment of people needing heart valve repairs. The list of procedures carried out by the NHS are reviewed and increasingly procedures , you will be aware varicose vein removal has been taken off the list as have many other minor procedures. In fact in my case I have been admitted in all three occasions I have had an AF episode. The private tariff is I believe about £14000 so the money spent ablating me would be very cost effective . I think there is always tensions between physicians and surgeons/interventionists with the former generally thinking the latter are too scalpel happy . It’s a difficult area
Your meds will come out of your GP budget but if referred to secondary care for a procedure, it comes out of the hospital budget. Either way it should not influence clinical decision making but lack of specialist knowledge often does and at the end of the day, doctors are people and tend to have bias based on their own experience - just ask two doctors if they think taking a daily aspirin is a good thing or not!. My experience is the doctors who don’t perform Ablations don’t really understand them very well or how to assess a patient’s suitability.
It depends on the contract CDreamer . For example . When I worked in musculoskeletal we had a block contract . They paid so much money and they could send as many patients as they like . Other places charged per item. Am not going to argue with you because at the end of the day it’s something none of us have control over so it doesn’t really matter
Buff - I have been trying to work out the how NHS budgeting works for about 40 years, the goalposts change endlessly, the acronyms constantly change, each region seems to have completely different rules - hence the PostCode lottery often referred to. The number of different bodies all with different boundaries and rules is breathtaking.
Whoever pays for treatment, in the end it is a decision that should always be made jointly between doctor and patient. In your case I think it is more about a conflict of views of clinicians than about the money. Thankfully, in the NHS EPs are salaried so that does remove any monetary incentive.
Hi, yes, when I first started on my AF journey I was seen by a cardiologist who was about to retire and he said “he didn’t want the electric people to get hold of me”.
After he retired I was seen by a series of locum cardiologists all giving me information but not taking responsibility for action. I reluctantly saw an EP privately having worked all my life in the NHS. I’m was fortunate in being able to afford to do this. I didn’t have a regular ablation but I have had an AV node ablation which the private EP arranged through the NHS. I haven’t looked back, my quality of life is transformed.
I am not advocating for ablations but pointing out that you can ask for a second opinion or to see an EP through the NHS if you have doubts.
Hope this helps.
Thanks Singing T that’s useful . My previous cardiologist was an EP who recommended ablation after my second episode . I haven’t seen this new one but he still felt empowered to write to me, my GP and the EP I have been referred to for the ablation with recommendations on the basis of having read my discharge letter from the last episode from another hospital , and having looked at my last echo . I am going to politely respond copying in the others as he did . I don’t feel he should have done this without at least a conversation with me but heigh ho . I don’t think his letter can have derailed my ablation , but it does show how your path can be altered by who you see .
Delighted to hear that you are doing so well!
Progression of AF is the reason to have an ablation. The first cardiologist I saw was not EP and was against ablations, he was pro medication.
My understanding is AF (the errant electrical signals) are subdued by medication, the medication does not stop the progression of AF. This is why you hear the term "Break Through', and then the dosage of meds is increased.
The latest advice is to medicate and ablate as soon as you can to stop the progression of AF.
Thank you Rob that is my understanding . My Dad progressed to HF due to his medically managed AF ( managed by GP) . Helps to hear that from another source , thank you . I intend to go ahead with the ablation if I can. I have poor tolerance of meds which doesn’t help
I am having a Pulsed Field Ablation on the 12th of November. Meds have controlled my AF well over the 2 years or so, I have had zero episodes on a low dose Flecainide twice daily. I could bury my head in the sand and think the meds will work forever, I read a lot and have been following the PFA trials so feel very comfortable having an ablation.
Sounds like you have had good advice.
Rightly or wrongly I have always been sceptical of EPs who almost always (from reports here) suggest an ablation. Yes the earlier ablations are probably more successful (and therefore look good on the EP's record) but I would advocate a more cautious approach starting with some medication.
Incidentally, after 9 episodes in a month my cardiologist did not favour PIP as too much of a roller coaster for the heart. In my case I think he was right as I have grown to understand that my heart behaves best with an even keel on all matters. My medication was and still is 200mgs Flecainide daily and was successful for 10yrs but that period included a lot of lifestyle changes as well.
hi, I had an ablation 4 months after I went into permanent AF. The very wise experienced consultant, at London Bridge private hospital, was very honest, which I greatly appreciated. I had two failed Cardioversions and wanted a permanent solution, if possible, rather than continuing on the meds. He said if I did nothing, my heart would become “saggy”. The chance of a successful ablation for me would be 70%, if I had it asap, but he could not guarantee that I would feel better. So, the cryoablation worked and I’ve been in sinus rhythm for 2.5 years. Post op, my local cardiologist was reluctant to let me off Bisoprolol, so after 18 months ( I had been lightheaded etc for over a year, I changed cardiologist and he let me off Bisop and I feel so much better. Shame it took so long to get off it, I also came off Apixaban and now only take Ramipril and that’s just 1.25mg, every few days….
Hoping this helps…..
He's probably a cardiologist(plumber) and not an EP (electrician).
I had an ablation 7 weeks ago so am still in the blanking period and getting quite a few ectopics though very rare short afib bouts which I an told is normal and should subside. the only reason I went for an ablation is that all the antiarrythmic drugs I researched are quite toxic and not as simple as taking a paracetamol for a headache. Also long term afib usually causes other serious problems which can be irreversible so its a big no from me for the long term medication route. Good luck with your decision.
Thank you for that . I can’t tolerate beta blockers , diltiziem dropped my BP into my boots , and I had side effects from the first dose of flecainide. Drugs don’t agree with me and I think the chances of me being medically managed successfully are slight to non existent . Also agree re long term consequences of AF. Am frightened but going forward for ablation, irritated that this cardiologist I have never seen tried to muddy the waters. Thank you for your response it’s very helpful to have your perspective and I agree with you
I suspose it can apply to any discipline, but I worked for a professor of Oral Rehabilitation = his field covered both periodontics and prosthodontics. In the field of periodontics we divided practitioners into 'knife men' and conservatives.'. My boss was a knife man, but his much younger associate was a conservative - so I don't thinks it's age dependent!
Thank you ! I think this man is definitely conservative ! But look how people managed the old way frequently end up. My father had AF derived heart failure and isolated systolic hypertension . I think you are right, the conservatives always think interventionists are too keen to get stuck in
Hi Wischo , I'm not sure what the long term consequences of permanent AF are. I've had it (diagnosed) for about 7 years. Take Apixaban and small dose of Losarten.
Did have heart valve replaced 3 years ago but Drs were vague about the cause of it, and whether AF could have been responsible.
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