Quality of Life

[Crimson2020]

I frequently hear QOL mentioned on this site and am looking for your opinions.

I have had the symptoms of Paroxysmal AF for about 10 years but was only diagnosed 3 years ago. After my diagnosis I was put on Edoxaban 60mg and Bisoprolol 2.5mg, each one once daily.

In the early days I was only aware of palpitations after exertion or perhaps alcohol consumption, and this only occasionally, not every time. Perhaps once a month. Now I have episodes every 10 to 15 days and some of these have no obvious trigger.

Before Bisoprolol my RHR was 50 and now it is 44. However after each AF episode it jumps to 48. Then it gradually falls to 44 and this is when the next episode starts. This will last about 24 hours, but it’s only the initial hour or so that is slightly uncomfortable. The final 12 to 20 hours are virtually symptomless.

My palpitations and breathlessness are now much less noticeable and my quality of life is much improved.

I have suspicions that the Bisoprolol has increased my AF episode frequency but also reduced their intensity.

Should I just accept that the current position gives me a pretty decent quality of life and stop worrying that the Bisoprolol may not be the best option.

[BobD Volunteer]

It may be that sending your HR so low (normal is 60 to 100) is actually causing the AF events, Maybe discuss with your cardiologist.

[Crimson2020 in reply to BobD]

Thanks  BobD ,

I mentioned this to my cardiologist and he said he wanted to ensure that my HR did not go too high during an AFib episode.

He had seen the results of a recent 5 day Holter monitor which included an episode lasting about 24 hours. I did not ask to see this but I have seen that my HR swings between 35 and 170 during an episode. This was my second cardiologist consultation and 2.5 years after commencing Bisoprolol.

He did however suggest that if my RHR went below 45bpm that I omit the next day's Bisporolol. When I questoned the figure of 45 has said it could be adapted depending upon my experience. I am pleased that I have this in writing along with the rest of his recommendations.

[Cliff_G]

Try and figure out your triggers. If episodes start at night, or after a big meal, or when recovering after exercise, or when straining on the loo, or if you generally notice a low heart rate, especially of you normally have a low heart rate (sub, say, 60), these would be indicators that your AF may be of the sub-type called "vagally mediated" (VMAF). Some cardiologists and most GPs either don't know about it or don't recognise it, but I and many others in this group can absolutely confirm it exists (though it's not a black or white diagnosis). It almost made it into the international guidelines on AF, but what's there now is minimal. Anyway, the fact that you've noticed that your HR dropping to 44 is when it kicks of is, I would say, a very strong indicator.

There is good opinion that beta blockers can make VMAF worse, since what triggers an episode is a slowing of the heart rate which trips it into AF. The traditional view of AF is that it is triggered by the heart rate going faster, and it is this which leads to beta blockers being a med of first resort. Many vagal fibbers actually do not have a very fast rate when in AF, so the need to control that is not very strong. And AF symptoms can tend to reduce with time, regardless of drug - you often get the famous "big pee" which reduces your blood pressure and reduces symptoms. Flecainide is both anti-arrhythmic and slightly anti-vagal, and might help more than BBs. Diltiazem is another, which can help limit fast rates in AF but doesn't depress the normal resting HR so much. But of course everyone is different and you may need to do some experimentation with the help of your cardiologist.

Have a search around for vagally mediated AF, originally described bt the great French cardiologist Prof Phillippe Coumel. I think Dr Sanjay Gupta on Youtube has a video or two on it? Discovering my AF was vagal was a revelation. I could even terminate an episode with some gentle exercise (a couple of flights of stairs), with somewhat more reliability than Flecainide.

[Crimson2020 in reply to Cliff_G]

Thank you Cliff_G , this is very interesting.

Your gentle exercise solution is intriguing, but unfortunately I have lived in bungalows for the last 37 years. Do you have any other gentle exercise recommendations?

[Cliff_G in reply to Crimson2020]

Yes, just anything to get your heart rate up, a brisk walk, or sit-to-stand exercise from a chair, etc

[Crimson2020 in reply to Cliff_G]

Okay thanks, but do I want to raise my heart rate when in AFib? It feels counter intuitive.

My heart rate is plodding along at 45 and then the AFib hits. My heart rate becomes irregular ranging from 50 to 130 over a 30 second Kardia ECG.

Are you suggesting that increasing my activity to raise my heart rate could trigger a returm to NSR?

[Cliff_G in reply to Crimson2020]

Two things.

1. Raising your HR a bit before you go into fib, when you spot a slowing, may actually stave off a fib episode. It often used to for me.

2. Yes, if in fib, it is counter intuitive. I'm only talking about a gentle increase, firstly, but the heart's rate is set by the balance of vagal (to slow the rate) and adrenergic (to increase the rate) neural "drives" and their respective neurotransmitters at the sino-atrial node. This is happening normally all the time to adjust your rate to what is needed by what you are doing. Fib can be kicked off by an imbalance in these two drives, in the case of vagal triggering it's too much vagal drive which causes the imbalance. So gently increasing the adrenergic drive by gentle exercise, can re-establish a better balance. I can remember many instances where I terminated an episode - climbing stairs at our railway station, boarding a plane up the steps, going up a flight or two of stairs in the office.

It's not always reliable (as with all things AF) and if you find it pushes your rate up too much then obviously stop, but worth a try.

I eventually came to a point where my fib got too bad for this to work and I went for a successful ablation.

[secondtry]

I would get a second opinion.

[Crimson2020 in reply to secondtry]

To be fair, my first sentence is asking for others’ opinions.

Seriously though my last cardiologist appointment took 12 months, and how do I know if they are any better informed?

I am beginning to think that I should listen to my body more closely for answers.