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 flecainide 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 flecainide 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
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