The skeptical cardiologist has just updated his page on atrial fibrillation. I’ve updated the sections on medical management of AF and on AF ablation and included the relevant sections at the end of this post.
I’ve had a lot of reader AF questions by emails and comments and I’ve addressed three that are likely of general interest below
Beta-blockers, Sotalol, and Exercise
A half year ago I experienced atrial fibrillation (at 57), with a heart rate of around 100 beats per minute while resting. Sotalol (2x40mg/day) didn’t fix it, but a cardioversion did and I stayed on the same amount of Sotalol. I have discussed the usage of Flecainide with my cardiologist. He described the risk of flutter, as I am quite active in sports (swimming, running and cycling), and would only prescribe it with an additional bètablocker. I was satisfied with that explanation. Last week I was allowed to stop with the Sotalol, but needed a cardioversion within 10 days. Now back on the same amount of Sotalol (no Eliquis, as the cardioversion was within 24 hours and my risk for a stroke is low).
Question: is Flecainide without a bètablocker an option? I quite liked being ableto run the last week without the effect of Sotalol.
Since my first experience with atrial fibrillation I have reduced the intensity and durations of my workouts, as I favor being healthy above athletic performance
Sotalol is an antiarrhythmic drug that has beta-blocking properties and which must be started in the hospital under ECG monitoring for 72 hours in order to monitor for QT prolongation and possible ventricular tachycardia.
I’ve written about flecainide for suppression of AF here and emphasized that concomitant use of a rate slowing drug (beta-blocker or calcium channel blocker) is highly recommended.
I’ve been thinking a lot about beta-blockers and exercise performance in the last year and will post soon on that topic.
I think the reader is wise to cut back on “the intensity and durations” of his workouts as there is evidence that excessive exercise is associated with AF and a higher cardiovascular risk compared to moderate exercise.
A review of the mechanisms for AF with exercise contains this graphic
and another review on the management of AF in athletes contains this table on treatment
To the comments on catheter ablation, I would add that the risk of complications includes pulmonary vein stenosis which can lead to markedly reduce functional capacity and that there is a good chance of needing multiple procedures if lifestyle isn’t moderated. Any discussion of ablation should mention the possibility of death from esophageal-atrial fistula.
Ablation versus flecainide in Masters Bicyclist
I was diagnosed with AFIB in June and had a successful cardioversion in September. I am on 50mg of Flecainide twice per day. I am still in rhythm.
Long term if I am able to stay in rhythm, would you recommend staying on the Flecainide or going off of the Flecainide and having an ablation if the AFIB comes back..
I am 73, was training fairly hard as a masters bicyclist but have cut way back on that. Also, I was diagnosed with sleep apnea and have addressed that.
Basically, do you see an advantage for ablation over a successful cardioversion plus flecainide?
As indicated here I am a huge advocate of AFibbers doing everything in their power to modify lifestyle to reduce or suppress recurrent AF. I congratulate this reader on addressing the overexercise factor and the sleep apnea.
For many patients following weight loss, reduction of alcohol, modifying exercise and addressing sleep apnea SR can be maintained without drugs or ablation.
My approach to patients who are successfully maintaining SR on low doses of flecainide without side effects (which is the norm for flecainide) is to continue the drug unless the patient wants to stop it. If so, we warn them that stopping flecainide does increase chances of AF recurrence but that if AF recurs we can easily deal with it.
If AF recurs off flecainide quickly I typically advise resumption of flecainide over ablation but always mention the patient has this option.
If AF recurs late (>6 months or so) off flecainide, a repeat CV without flecainide is reasonable with close attention to lifestyle factors that may have contributed to recurrence.
Long Term Implications of Holiday Heart: Alcohol and AF
My usually extremely healthy husband who has been battling a nagging cough, had a brief episode of A fib on Wednesday morning after having 7 beers, cough syrup w/ codeine, and inadequate water the night before. ER doctor stated that heart was strong, echo revealed no regurgitation by any valves, no bloodwork evidence of heart attack. He had no shortness of breath, pain, nausea, etc. He has exercised strenuously all of his life (nationally ranked swimmer age 12-25, now weight training + cardio 3-4x/week). His slight HTN is well-controlled by rxs. He has no lipid profile concerns. Question to you: Any chance that this episode was a one-time thing assuming he is mindful of alcohol’s/dehydration’s role in arrhythmia issues? We were in the midst of trying to secure lower cost health insurance when this occurred. Now he will be saddled with “pre-existing” A-fib which will kick him out of all but ACA, which is not affordable for us. And more importantly, we hate the thought of life-long meds which may not be necessary and possibly harmful. It seems that you are the only one who has a fresh perspective on these issues. Thanks so much!!
This AF episode was clearly triggered by alcohol and testing as described indicates no structural heart disease. It could be a one time thing but in general when AF occurs under a particular trigger it tends to recur at some point down the line even without the specific trigger.
For patients with structurally normal hearts and one episode of AF clearly triggered by excess alcohol (so-called holiday heart) my approach is to emphasize lifestyle modification. I don’t start antiarrhythmic drugs for first episode and definitely wouldn’t look at ablation. I would have long discussion with patient on stroke risk and I would recommend they obtain a Kardia ECG monitor or an Apple Watch to monitor their rhythm.
It’s also possible this is another case of overexercise and exercise modification may be in order.
and here is the excerpt from my updated AF page:
Posts About Treatment Of Atrial Fibrillation
How Obesity Causes Atrial Fibrillation in Fat Sheep and how Losing Weight can reduce the recurrence of atrial fibrillation.
Drug Therapy: Rate Control and Anticoagulation
Foxglove Equipoise. When William Withering began treating patients suffering from dropsy in 1775 with various preparations of the foxglove plant he wasn’t sure if he would help or hurt them. After 240 years of treatment, we are still unsure if the drug obtained from foxglove is useful.
Should Digoxin Still Be Used in Atrial Fibrillation? Recent studies suggest that we should not.
Why Does the TV Tell Me Xarelto Is A BAD Drug? Anticoagulant drugs that prevent the bad clots that cause stroke also increase bleeding risk. A bleeding complication is not a valid reason to sue the manufacturer. The lawsuit are strictly a money-making tactic for sleazy lawyers.
Drug Therapy: Antiarrhythmic Drugs for Maintenance of Sinus Rhythm
If lifestyle changes alone can’t control atrial fibrillation, I am an advocate of enlightened use of medications (antiarrhythmic medications or AADs) that can safely restore and maintain the normal sinus rhythm long term.
My three-part series on “enlightened medical management of AF”:
Cardioversion and Ablation
We can shock (cardiovert) the heart back to normal rhythm with little risk and very high success rate when performed by experienced and enlightened cardiologists. Keeping the rhythm normal after successful cardioversion is a bigger challenge (see above) and when medications and lifestyle changes fail an invasive procedure (ablation) is an option for some patients. Ablation should not be considered a cure for AF as recurrence is common and successfull ablation has not been shown to lower stroke risk thus anticoagulants are still recommended lifelong after the procedure.