AF Burden

[Suny1]

morning I have had AF for 2 years and I am taking 5 mg Apixaban twice a day 80 mg sotolol twice a day and 2.5 mg ramipril once a day. I wear an Apple Watch which gives a weekly reading of AF burden this week it said the burden over 6 days was 26 percent. I just wondered if this was something that should be addressed? I get the usual side affects from the beta blockers tight chest breathlessness walking up hills and palpitations although this doesn’t happen all the time. I try my best to keep fit eat healthy food and I’m not overweight. I would really appreciate any advice you kind knowledgeable people can give me. Thanks

[BobD Volunteer]

It depends on how your QOL (Quality of life) is. Any and all treatment with AF is mainly about QOL provided rate is well controlled and you are anticoaguated.

[Suny1 in reply to BobD]

Thank you so much for replying Bob . At the moment I seem to be constantly tired and lacking energy. I know the medication has side affects so maybe it’s as good as it gets on it .

[CDreamer in reply to Suny1]

Those symptoms are affecting your QOL then yes, ask for alternative options.

[Suny1 in reply to CDreamer]

Thanks for replying CDreamer I’ve just taken a Kardia test and it showed heart rate 53 and possible AF. My blood pressure was normal 120/76. I’ve found most gp’s I’ve spoken to don’t seem too bothered as long as my BP is normal and heart rate low. I will follow it up as when I’ve been in AF in the passed my heart rate has been 150 to 178. Now it’s happening with a heart rate of 53. Sorry to go on . Thank you all again for replying I’m really grateful.

[JaneFinn in reply to Suny1]

Please don’t apologise, Suny, you’re not going on at all! We all learn something from these sort of conversations, and from the collective wisdom that is gathered. And often it’s when unpacking more detail that we get the most helpful advice

I’d agree with what Bob and CDreamer are saying about quality of life mattering. I do think that GPs can get very shruggy and dismissive about symptoms like tiredness and lack of energy, and it’s worth stressing how much it’s affecting your daily life when you talk to them. It may be the meds, but it’s worth them exploring if it’s something more. And if it is simply the meds, there must be alternative meds or treatment options to at least consider. Are you under a cardiologist? I’m guessing not an EP, they are like gold dust! Jx

[mjames1]

Newer research shows that being an Afib overtime, can weaken the heart and sometimes lead to heart failure. Given this and your symptoms, I would speak to your doctor about a rhythm control control strategy, using either daily antiarrhythmics or getting an ablation.

Jim

[Suny1 in reply to mjames1]

Thank you for your reply Jim I will speak to my gp.

[JOY2THEWORLD49 in reply to mjames1]

Hi Jim

Caution is needed here.

An abnormal structure to the heart would render that neither cardioversion, ablation or anti-arrhymnic med can be used.

As you might remember I was told NO to these and rely on meds.

Diltiazem CD 120mg was the saver which is a CCB Calcium Channel Blocker but this med cannot be used if one has ventricle chamber adnormality.

cherio JOY. 75. (NZ)

[wischo in reply to mjames1]

Mostly when your heart rate is not controlled and blood pressure drops too low does heart failure rear its ugly head. Otherwise I think HF is unlikely.

[mav7]

Is your heart rate and blood pressure controlled ?

As mentioned, best to consult with your doctor. And ask for an echocardiogram (if not recently done) to assess overall condition of your heart.

[Buzby62]

Others have given you good advice about your condition, I would just add that the Apple Watch AF history figure is very much an estimate from occasional checks the watch does when you are at rest, really not a reliable figure but more an indication that you are having some AF. It won’t capture it all and if you have none the lowest report will read as “Less than 2%” but never reports zero AF. I learnt to ignore the figure as it was quite meaningless really.

See towards the bottom on this Apple support page “Things you should know”

support.apple.com/en-gb/108375

Best wishes

[Cabinessence in reply to Buzby62]

I'm part of an Apple Watch study with Barts and can't understand how it can give an estimate of the time I've been in AF, because to take an ECG measurement you have your keep your finger on the watch winder for 30 seconds? So the figure it gives must be an average of all the readings you've taken during any given week surely?

[wischo in reply to Cabinessence]

Can it not read your HRV and heart rate average?.

[Buzby62 in reply to Cabinessence]

It’s from occasional background checks where the optical heart rate sensor detects irregular beats that shows signs of possible AF which is also detection of excessively high HRV (Heart Rate Variability) as wischo mentions. As you correctly say the only way to confirm that variability is AF is with the ECG app electrically but you have to do that manually. It’s an estimate based on the fact that you’ve already been diagnosed with AF and the variability is likely to be that. As I said, I learned to ignore it.

Best wishes

[Cabinessence in reply to Buzby62]

Aaah right. Thanks for clearing that little mystery up!👍

[KentAndrew in reply to Cabinessence]

Hi,

I took part in a previous Apple Watch study with St Bart’s.

As I understand it, the Apple Watch performs background scans whenever you are still. This can either be recorded as %time in AFib or instantaneously reporting every incident.

I opted for the instantaneous reports.

[JOY2THEWORLD49]

Hi

Near your age, I too have an issue with BB Bisoprolol. 2.5mg reduced 1.25 in the last week Night.

My BP seems to dip and still is . I though a change to sotalol but it is contradictary .. forgotten

so I have left that out and decided to reduce BB. Bisoprolol had a change of manufacture.

I've asked for an ECG at the Drs 28th November.

Meanwhile BP dips. I notice at Table Tennis picking up a ball. It did take me 5secs to get my head right. !/2ing tablet has improved.

Walking is easier but having to stop to regain energy although improved its still there.

I take 120mg Diltiazem CD for heart rate control AM and this med is the most important.

Neither Metoprolol 186 or Bisoprolol 156 controlled my heart rate.

What is your issue? Heart Rate or BP uncontrolled? Heart Rate under 100 at rest and BP 120-139 / 80. also at rest.

We need to stay alert to the control of heart rate and BP.

I had a Stroke Embolic (stray clot to my left frontal lobe) September 2019 but found to have AF Rapid and Persistent and then the Carotid Scan showed a shadow on my Thyroid. Yes papillary carcinoma cancer. Thyroidectomy plus in Feb 2020.

Do speak out with side effects and/or symptoms.

cherio JOY

[JezzaJezza]

hi Suny

The Apple Watch is accurate at capturing the equivalent of a 1 lead ecg ie using 1 finger but not so accurate at interpreting the results. It often reports any possible arrhythmia or palpitations as ‘possible AF’

See if you can get a 24 hour ecg holter from your GP or alternatively use an app called Qaly. Qaly takes the ecg and then uses either AI or actual cardiologists to interpret and report on the trace.

Best wishes

Jezza

[Alphakiwi]

Hi Sunny1was diagnosed with paroxysmal atrial flutter 6 years ago. Considered permanent 3 yrs ago. Anticoagulation rivaroxaban 10mg was 20mg. Significant left atrial dilitatian I take a beta blocker. Metoprolol 47.5 mg. I also have a dual chamber pacemaker with the intention of having an av node ablation.The beta blockers have all been tried and im so over them,having never been given the ablation possibly due to the hospitalsbeing semi closed at that time.

Could anyone explain to me how AF burden is worked out and meaning. Please

Regards and bestest ,

Colin nz

[Twosumsmum in reply to Alphakiwi]

Hi Colin

I have atrial Flutter all the time and also paroxysmal AFib and sick sinus tachycardia/ bradycardia syndrome . I initially had cardioversions for the flutter, then a dual chamber pacemaker that constantly got confused by rate changes caused by the ratio of atrial rate that affected the ventricle rate . So now I have had an av ablation and a CRPT pacemaker that is now in full control and helps my heart failure symptoms .

I am still aware when A fib is happening although my heart rate no longer gets affected.

[babs1234]

is 26% unusually high for you? My highest reading was 19% which concerned me but since has gone back down to between 4/8%

[oscarfox49]

I take both apixaban and sotalol (half a 80mg tablet twice a day) and have done so for many years. I too take daily exercise in physical work and daily walks of up to 45 minutes and I am finding slopes ever more taxing at 78 with the symptoms you describe. It has been recommended to me to replace Sotalol with something like Nebivolol which is far more cardiac specific although I have not tried it fearing to change medication which has helped me for so long (since 1995). Has your doctor suggested any alternatives such as this or Bisoprolol which might help and are more commonly prescribed nowadays compared to Sotalol?

[Auriculaire in reply to oscarfox49]

I thought Sotalol had an anti arrythmic effect. Nebivolol does not and is just a rate control drug with a better side effect profile than Bisoprolol. I find it does not control heart rate as well when in afib. So if you switch you might have to take Flecanaid as well.

[oscarfox49 in reply to Auriculaire]

That may well be the case, and apart from the predictable effects of Sotalol I have found it without any real problems. The last cardiologist I saw however said it was 'old fashioned' and 'we don't use it any more'. As he refused to even tell me what Nebivolol was (only mentioning the generic brand name) and said he had no time to discuss it, I didn't take his advice anyway and from you say I probably did the right thing. Sotalol does however have more of a systemic impact so I wondered if the poster was impacted by this in terms of breathlessness and so on.

[Suny1 in reply to oscarfox49]

Thanks for responding it’s good to hear from someone taking the same meds. I was originally prescribed Bisoprolol but they didn’t work for me. I have found sotolol effective perhaps too effective in one way as my heart rate sometimes drops too low and the dose has to be adjusted. I think your correct in saying their side affects can be quite profound ie breathlessness and tight chest.

[Ppiman]

That's quite a lot of AF but will vary, I suppose, according to how many episodes you had, and their length? I only set my Apple Watch to measure this last week for that, although I didn't wear it overnight, and it showed 6% (despite my not having had any known episodes). The week before, I had had quite a lot of AF, but wasn't measuring it then. I know that my ectopic burden would likely have been higher, even though it was an unusually good week for that, too, but the watch cannot measure that.

You out your symptoms down to the bisoprolol but are your episodes themselves symptomatic? I have an elderly friend with long-standing permanent AF and those are the only symptoms he has, and he takes no medication. I can get mildly "breathless" (like an air hunger) but put mine down to the left branch bundle block (LBBB) and the bradycardia that this causes, although it could be the bisoprolol, I suppose (1.25mg daily, occasionally 2.5mg). If I try walking at all quickly when I have AF, however, then the rate shoots up from its typical 100-130bpm to an uncomfortable 180+bpm.

I am on a waiting list for an ablation. Has this possibility been mentioned to you?

Steve

[wischo in reply to Ppiman]

Apple watch will frequently report PVCs or PACs as possible afib as all it detects are irregular beats. Its not that bright in all fairness.

[Ppiman in reply to wischo]

That’s a good point but I still feel it is an unusually useful and clever device in the round given its out and out overall usefulness. I didn’t know it had a reading of “possible AF” only “AF” or “Inconclusive”. That’s interesting.

An ECG does need at least two points of contact but I gather the Watch uses an algorithm that relies on its heart rate monitor to look for AF-like activity such as “irregular irregularity”.

I’ve never used the AF burden app until this last week and can’t see much use for it really except for interest.

Over the years I’ve had this device, it’s the one I wouldn’t want to be without. For home ECG checking, I’ve also now come to admire the new Emay / Contec 6-lead devices for their sharp screen, no monthly fees, and instant feedback of a wide range of arrhythmias without any need for an app.

Steve

[Buzby62 in reply to Ppiman]

I’ve never used the AF burden app until this last week and can’t see much use for it really except for interest.

Exactly Steve, the only way to confirm AF on the watch is via the ECG manually. The background checks in either Alert mode or History/Burden mode will not pick up all your AF and Apple state this on their support pages.

Best wishes

[Ppiman in reply to Buzby62]

If you are on an anticoagulant, though, with that specific AF risk covered, then whether the arrhythmia is AF or other multiple ectopics makes little difference, I suppose? It is still worth knowing about as a "burden". I have a feeling that my own AF is just my atrial ectopics "joined up" (i.e. they get into a circular firing mode somehow).

I am hoping that Apple will extend their app at some point to cover other arrhythmias as the hardware seems to have that capability. It's been shown to be very accurate. I suppose Apple is reluctant to do that as the cost of getting FDA / EU approval must be very high.

Steve

[Buzby62 in reply to Ppiman]

I guess the ECG function which uses the electrical sensors via a circuit across your body made with your finger on the other hand may be able to be extended to spot other arrhythmias but the optical heart rate sensor used for background checks is much more restricted and is just an indication really. It’s the optical sensor data that the AF burden figure comes from which is pretty meaningless in my opinion but is a good indicator that you’ve had some irregularities and definitely of interest. Anything above 2% means your background checks have picked up irregularities.

Best wishes

[Ppiman in reply to Buzby62]

Yes - they’re very good conclusions! Thanks.

Steve

[wischo in reply to Ppiman]

Sorry possible afib is only on my Kardia mobile?? too many gadgets.

[Ppiman in reply to wischo]

I haven't had a Kardia for a couple of years but that rang a bell with me.

Steve

[Auriculaire]

If you are aware while awake of when you go into afib (either through symptoms or taking your pulse ) it might be better to invest in a Kardia which will give you a more accurate idea of your rate both in afib and in NSR. If you are getting such a low heartrate when in afib compared to how it was before then you might be overmedicated by the beta blocker and have an even lower heart rate when in NSR which would explain why you feel so tired and breathless.

[Suny1 in reply to Auriculaire]

Thank you all for your wonderful advice I feel less isolated being able discuss worries with people who understand and are very knowledgeable. I had an ablation that lasted 7 days that was 2 years ago been on ramipril sotalol and apixaban ever since. I’ve seen an EP twice last time in Feb. I’ve had a few breakthroughs of AF with a heart rate of 160 which took 3 days to subside and I found it exhausting. Hence sotalol increased to 80 mg twice a day this has lowered my heart rate to 50 to 60 so I was surprised to still have an AF burden of 26 percent I thought AF only occurs with a high heart rate.

[Buzby62 in reply to Suny1]

No, AF is an irregularly irregular heart beat and can be high or low rate. For most I believe it does cause high rate and that’s why beta blockers are prescribed to manage the increase in rate while in AF but you can still be in AF.

AF Fact sheet link api.heartrhythmalliance.org...

Best wishes

[wischo in reply to Buzby62]

My heart rate as I sit is now 56bpm and on Edoxaban, Ramipril and 2.5mg Bisoprolol,I have both an apple watch and a Kardia and find the kardia more specific. I think if your rate is low it is much better than a racing heartbeat so control and anticoagulation are mostly what medics strive for. Apparently the Afib itself is relatively harmless if rate and BP are ok? though I stand corrected on this. Quality of life always suffers but to varying degrees and luckily mine is rarely affected. Blood pressure now is 122/69.