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Atrial fibrillation Reflection

Atrial fibrillation strikes an electrophysiologist…

Middle age introduces itself in many ways; one is atrial fibrillation.  Youth, vigor and a medically-problem free life was seemingly right there in the recent past.  A rhythm doctor often hears this suddenness of onset described as “Doc, yesterday, I was fine.”  As is always the case for a first episode of an arrhythmia, yesterday, you were fine, but today is indeed a new day.

It happened during a bike ride.  However, the first chapter probably started a number of weeks before in the woods of North Carolina in which there was a terrible mountain bike crash. Ribs with cracks produce some of the most unrelenting pain a human can experience. Mysteriously, rib pain persists for weeks and since breathing is constant so is the pain.
Riding a bike requires heavy breathing and pulling on the handlebars which are both difficult when the ribs are cracked.  After two hours in the oppressive heat and constant pain we ride by the tiniest of country stores, deep in a hollow miles away from anywhere. Sitting down inside the store requires moving, and the associated pain combined with dehydration form the heat brings on a hot, sweaty and dizzy feeling. An electrophysiologist knows it is a vagal response. A bit of blurriness of the eyes and black and white vision comes over and I tilt the head down for a few minutes and it passes.
Moments later, back on the bike a glance at the heart monitor reveals irregular heart rates in the 120-140 range. Uh-oh. The breathing is labored and the legs have no power. A funny feeling in the throat appears, like a tickling thumping sensation that induces a faster breath. No, it couldn’t be atrial fibrillation? Every time the pavement rises the heart rate spikes and the usual power is absent.  A teammate offers the observation, “you don’t look so good.”
Finally, more than ninety minutes later on arriving home the chest still feels funny. What is this irregular floppy sensation in the chest? After years of hearing patients describe AF in many ways, I sit on the porch with the same symptoms as my patients.
To Staci, a wife and doctor, I proclaim, “it’s AF.” She feels the wrist and palpates the irregularly irregular pulse and shakes her head with acknowledgement.
I walk into the heart station at my hospital and am greeted in the usual friendly manner.  The face of the ECG technician gives the answer: yes, it is AF.  Within minutes another technician is there with the echo probe. The ER is calling and they have a bed for me. Word travels fast in the hospital.  Still, the rib pain is far worse.  The echo is normal and the heart rate is only 80 and so home is better than the ER.

My partner, another electrophysiologist, answers the phone immediately and it is nice to hear confirmatory words.  This AF episode is probably vaguely mediated. “Try some flecanide tonight and the AF will likely convert,” he advises.  

Even though one prescribes a medicine frequently, it is a different matter altogether when the time comes to ingest a drug that affects the action potential. But, the heart is still fibrillating and there are many cases to do the next day.  Surely, one cannot operate after a cardioversion, so I swallow the little white flecanide tablets before bed. Awakening a few hours later I immediately reach for the pulse as the chest feels normal and indeed the rhythm is regular.
For weeks later, there are annoyingly frequent palpitations. How many times have I heard from the patient with a stressed look on their face, “Doctor, the skip is every 5th beat.” Now, it is me holding the carotid pulse, feeling the premature beat that is known to be benign, but yet is persistent and representative of a chink in the armor of a middle aged bike racer.  An ECG suggests a right atrial origin to the offending beat while the 24 hour monitor revealed five thousand of them in a day.
Fortunately, the annoying beats have dissipated and a sense of normalcy has returned. After months, it is now increasingly less daring to have that extra cup of coffee.
Why did the atrium have this hiccup?  The arrhythmia passed as mysteriously as it arose and now an arrhythmia doctor stands educated and certainly more empathetic.  

Sometimes life can make one a better doctor.
JMM

23 replies on “Atrial fibrillation strikes an electrophysiologist…”

such honesty – is refreshing – am glad all is well – life brings us the lessons we need, when we need them

I'm glad the arrhythmia passed, Dr. John. Scary as it was, it has certainly given you a more empathetic take on your patients, and that can only be for the good. There have been so many times that I wished my doctor could experience the pain I feel when a joint is flared just for a minute or two. Perhaps it would move him to more understanding, compassion and aggressive treatment for me and his other patients with chronic RA pain.

I hope you're feeling well and treating yourself gently. Stay healthy, will you? I enjoy reading and learning from your blog.

-Wren

Thanks for sharing your experience. It must have been somewhat surreal to feel something you've spent so much of your life learning about in others.

You have described my experience exactly…..down to the flecanide which I take daily. What do you think would happen if I were to try "the pill in the pocket" approach since I hate taking drugs?

Hmmm . . . perhaps I should be prescribing more flecainide.

We seem to have a fear of it in my part of the country. I ran across a hospital pharmacist recently who wouldn't release a dose of it in the middle of the night unless and until a physician reviewed an EKG BEFORE EACH DOSE.

It's probably universally true that physicians have more understanding and compassion after they've experienced some medical issues themselves. I think about that when I see physicians order very low doses of narcotics to young healthy people with major acute fractures. That doc's never been in pain!

-Steve

All,

So far the heart is fine, even whilst racing the bike, though I try not to tale it for granted,

Treating AF over the internet would border on reckless. I will say that the pill in the pocket technique is well established and (http://content.nejm.org/cgi/content/abstract/351/23/2384) I have recommended it for more than a few patients. You should talk with an electrophysiologist, preferably one who exercises.

Steve,

As a bike racer who has broken many bones and had multiple surgeries, I could not agree more with your sentiments.

Like any drug, flecanide has potential toxicity and adverse effects, however, for a young person with a structurally normal heart, its pro-arrhythmia risk is extraordinarily low. 1:1 flutter is the primary risk, which is very infrequent and can be averted by either adding an AV node slowing agent or a favorite of mine: during a paroxysm of arrhythmia, do no not exert yourself. It is a good idea to check an ECG after a few days of therapy to assess the QRS width, as pharmacologic effects can vary–albeit less than its cousin propafenone.

JMM

Dr John! My Afib was truly a shock to me! It was a 24/7 experience. Nights were the worst As I could not fall asleep with the constant pounding skipping. Flecanide had severe side effects on me, so I went for an outpatient cardioversion. Only lasted 2 months. Tried to reverse with other meds, went for 2nd opinion. New Doc suggested Ablation procedure at Duke would be the best choice for me. I made an appt for a consult there. However, I was anxious about it & had not yet tried the in patient cardioversion with Tikosyn load.. So I called my Doc could we try this first? He said OK if that's how you feel, it's worth a try. Everything went fine. That was back in July & I have stayed in rhythm since.

My Doc told me on hospital discharge "it worked, but it won't last." Let me tell you as a patient that was the worst thing he could say to me! His comment made me so anxious about a relapse & waiting for the shoe to drop! How about saying it worked, let's hope for the best?

Anyway, glad you are doing well & thanks for sharing your story!

Thanks for writing about your experience. I had my first and hopefullly only AFib and converted chemically within an hour but the iv 'shot' of Atavan 1 mg turned it around immediately. I who had natural childbirth and no drugs- never even took a Tylenol for a headache as possible side effects scared me. I spent three days stuck in bed afraid to turn over. Now it seems to be more a case of being used to having had this.However if/when I feel the feeling of fullness around my heart like a bubble or my heart misses a beat it scares me all over again. On Friday I will have a nuclear stress test and other tests.Not sure if I will lose my mind in the process of that test lol I am not sure what caused it. But am now on Metropolol and Aspirin. I am hooping it's a mineral deficiency or a thryroid problem and am scared again to know the results of my upcoming tests.
I hope you do really well and you've certainly brought a semblance of comfort to my shattered nerves. I could sense how it must have been to be in that little country store and to KNOW what was happening. Ignorance is sometimes bliss:) Thanks!

Thanks for writing about your experience. I had my first and hopefullly only AFib and converted chemically within an hour but the iv 'shot' of Atavan 1 mg turned it around immediately. I who had natural childbirth and no drugs- never even took a Tylenol for a headache as possible side effects scared me. I spent three days stuck in bed afraid to turn over. Now it seems to be more a case of being used to having had this.However if/when I feel the feeling of fullness around my heart like a bubble or my heart misses a beat it scares me all over again. On Friday I will have a nuclear stress test and other tests.Not sure if I will lose my mind in the process of that test lol I am not sure what caused it. But am now on Metropolol and Aspirin. I am hooping it's a mineral deficiency or a thryroid problem and am scared again to know the results of my upcoming tests.
I hope you do really well and you've certainly brought a semblance of comfort to my shattered nerves. I could sense how it must have been to be in that little country store and to KNOW what was happening. Ignorance is sometimes bliss:) Thanks!

ON 2/24/2010, Anonymous said that his Dr.at Duke stated that about the ablation he had had done on Anonymouse "it worked, but it won't last". Perhaps if I had known this to be the truth before my 3rd ablation (that has failed), I wouldn't have had it done and perhaps have asked for medicine instead. I don't know how much truth there is to the Drs. statement but now I would have hesitations about a 4th ablation. Yes, I too am anxious for relapses.

Nice account. I think that paroxysmal AF affects a good many endurance athletes….and the problem is just written off.

Thank you for sharing your story. I have been in A Fib since 98. I tried all meds. and several cardioversions. All seemed to work for a short time, then back to A Fib. I finally agreed to AV Node ablation with a good result. Finally in normal sinus rhythm, with a pacemaker of course. Thank you for this site, it was very helpful to me.

thanks for letting people know ,AF can affect anyone..even an electrophysiologist for Gods sake.I am an Anaesthetist in India been with Chronic Af since 2003 + Hypertropic Cardiomyopathy.Fairly comfortable with B and Ca channel blockers with anticoagulants.Truly hope things go well with you.
@anynomous.. if you've had av node ablation and now on a pacemaker .. chances are you are still in AF .Wouldnt hurt if you checked this out with your EP

John,

Thanks for the comment you left at my blog. I've had a chance now to look through your many posts here. I put up a permanent link to your blog.

I also saw that Gordo Byrn, a former world champ at UltraMan triathlon and founder of EnduranceCorner, retweeted the link to your blog last night to his many followers, so perhaps you've had some additional triathlon readers as well.

I don't know many EP folks who are also athletes, so I've enjoyed reading your take on things. As a surgeon, I see virtually NO patients who are athletes…..and my interest in heart disease in athletes is rather a hobby. I'm struck, though, by the number of inquiries I get from local athletes about heart-related issues.

BTW, I agree with you that a disclaimer is always needed when providing medical info (that can be construed as advice) over the internet. And I wholeheartedly agree that not everything you read online is true!

Glad to have "met" you….

Is there anyone out there that has hypertrophic cardiomyopathy and was told to have an ablation? Any problems??? My husband of 45years and I believed that his cardio doctor would not put him in harms way by letting an associate/dr. perform this procedure which was nothing short of a disaster.After he came out of surgery dr.said he would be in recovery room for two hours and go home….. We couldn't even get him up in two hours….. I asked the nurse to get him some jello so I could get something in his stomach when we got him up…. When she helped get him up and I fed him a few spoonfulls he laid his head back on the pillow a few seconds later blood was coming out the sides of his mouth….. The 5 family members ran in the hall to get the nurse, she started phoning doctor,,, He answered page after two hours then told her he would be down in a few minutes …She came back in the room 45 minutes later and sadly told us Dr……. went HOME….. anyhow things got worst….The two hour procedure plus two hour recovery room wound up being six days the doctor never stepped foot in my husbands room all the days he was in that hospital. The day he left that doctors assistant brought in an appointment for 3 months later…. My husband was never the same again….He passed away 5 weeks later.

I just want to correct a misrepresentation that Anonymous said on Feb 24th @ 1:03 pm in response to my comment Feb 24th @ 10:18 am.

Please reread my comment. I never went for an ablation @ Duke nor did I see any DR. there. I opted for instead to stay local and had inpatient cardioversion & Tikosyn Load. It's been 8 months in rhythm. However the medications make me tired & headache never leaves.

I am a 55 year old Olympic Rower (1976) that still constantly trains and races. I blew out a leaf in my mitral valve in 2005 and had open heart surgery to install an annuloplasty ring and stitch up the leaf. I felt great and was racing again in four months. It wasn't until eight months after my surgery, when I suspect the Ameoderone finally washed out of my system, that I fell into chronic afib. My thought is that when my valve failed my heart became engorged with blood, stretched, and broke up the normal electrical pathways. I went through a couple of years of coumadin, cardioversion, and beta blockers. I've been drug free and symptom free for periods of time but haven't been able to shake it. A year ago I was doing a rigorous endurance lifting workout and experienced near syncope. I wondered if it was venous pooling. A full battery of tests and heart MRI did not seem to reveal a definitive spot to ablate. My cardiologist agreed not to treat me with a beta blocker but instead chose a calcium channel blocker (verapamil 100 mg long release). I am doing fine until I really go all out. If I slowly build through my aerobic/anaerobic threshold I am fine – if I sprint through it I go into afib – quit the piece – and drop back into sinus rhythm. My doc deferred when I suggested increasing my dosage.

I would like to race as hard as I can. My problem is that I feel selfish seeking treatment so I can row at 40 strokes per minute when I will probably be fine at 30.

I guess I wonder if I am patient will my heart heal itself or will it require intervention. I don't want to quit racing but don't want to be foolish either.

Thanks for listening.

I have heard that there is a link between AF and the Helicobacter pylori bacteria. If this is the case it may be treated with antibiotics. I would imagine that if you are susceptible to AF triggered by inflammation at the PV's then eliminating H Pylori might be an option.

Gary,

You need an opinion from an electrophysiologist skilled in ablation. Maybe a couple opinions are necessary. You are not selfish.

Anony,

I have not heard of any relationship between AF and H. pylori.

JMM

I am glad you are better!.. I unfortuanately am not. I really don't understand you doctors and they way you treat this disorder. I am miserable when I am in afib. My temples pound my chest pounds the throat thing, and so on. The heart does not pump effectively thus creating an inability to be active.

Drugs which slow the heart down and mask the effects don't make me more able to function!

Come on folks why is an ablasion not a front line technique?

A cure instead of a semi effective treatment…

there is a real head scratcher..

So, can you tie your rib trauma to getting afib?
I discover that I have afib 2 months after the broken rib accident, been all that time in pain, weak, head aches, chest and back pains.

Yes I believe so. It is not uncommon for AF to occur after trauma. Post-operative AF is probably an example of this phenomenon. So far the AF has not recurred. JMM

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