A Visit from My Friend A-Fib

I almost didn't realize, but this is my first Christmas with a-fib.    Cozy !

              


    I have been doing so well.  Although I accept that I will likely need a cardiac ablation for my paroxysmal atrial fibrillation eventually, my cardiologist who is a world expert in electrophysiology is not in a rush.  I never had atrial fibrillation before this year, and then in February, during a cold with chest congestion, I laughed during a movie, and pop, I was in a very uncomfortable heart rhythm, which as a nurse I recognized instantly. A quick assessment of my pulse yielded a probable atrial fibrillation.   In all, seven episodes of this happened this year, before this one,  and many of them necessitated hospitalizations until an effective home plan for conversion could be crafted.
                   All a-fib is not alike.  Mine is particularly erratic and does not result in good perfusion to my brain and organs. I cannot walk, and I feel faint, as my heart does a dance like a large flopping fish. I have a monitor which I put on, and it tells me what is going on in terms of rate and rhythm.  Then I take two Flecainide, and sometimes an extra beta blocker and extra potassium.  Then I wait the hour or so that it usually takes to convert.  This almost always happens at night during dreams, and I wake up immediately. This leaves me not feeling well for a couple of days after such episodes.
                  An acceptable first line treatment which is gaining ground for some types of even initial a-fib is cardiac ablation, or in my case, a type of cardiac ablation called PVI or pulmonary vein isolation. The short version of what an ablation is, is a procedure in which multiple catheters are threaded through the groin and other arteries which map the interior cardiac conduction system.  When the problematic collection of nerves is isolated, and arrhythmia is intravenously induced, it is burned, as if cauterized.  The procedure can take many hours and benefits most patients with this issue..   My cardiologist has not made the jump to this because he thought that control of my new onset asthma in February, and supplementing my perennially low magnesium and potassium levels might do the trick all by itself.  He also thought that since I take both types of thyroid supplementation, both liothyronine (T3) and synthroid (T4) that it made sense to send me back to the endocrinologist and see if some adjustments in these drugs would stop the a-fib, so that perhaps it will not be seen until my seventies or eighties. (I am almost fifty and as yet, pre-menopausal, and this is important because there can be a hormonal interplay in causation.)
                  In a-fib, an extra collection of nerves in another region of the heart is sensitive enough to episodically spur an additional heartbeat which occurs in addition to the normal and expected one. This syndrome can be familial.   The result is a heartbeat which is double or more your normal one, and is irregular and erratic.  In addition, the heart is beating at times when it is not full, and the result is pumping at least to some degree, poorly oxygenated blood.  Additionally, erratically pumped blood leads to potential blood clots forming in the heart and resultant strokes, although I have been told that this is unlikely during episodes of a couple of hours or less.  And yes, they have me on an enteric 325 mg. aspirin daily.
                 The odds are actually against me here though.  My father passed in his eighties from atrial fibrillation which occurred in his fifties.  At first, it could be converted to normal rhythm, and as time moved on, it could not. Eventually, over time, it caused a remodeling in his heart and the cardiac damage which eventually brought heart failure and his passing.   My youngest son died suddenly at 12 1/2, and with a clean autopsy. The teams which did and redid the autopsy believe he had a spontaneous heart rhythm disturbance which could have begun with a-fib and moved quickly to a fatal ventricular arrhythmia.  He may have died the very first time he has a heart rhythm disturbance.  After that, a decision was made to look over our other children with a fine tooth comb.  Although the others seemed fine, our eldest son was referred for an ablation at age 25.  The procedure was difficult, but he is without a-fib now.
                  I was content to let this play out for awhile, and see if this could be brought under control with some medical management strategies.  Like any good critical care RN and college instructor, I did my research, but I do not like the results. Most people, after about  a year of a-fib, don't respond to episodic medications anymore. The disease moves on, and becomes resistant to conversion.   Women with a-fib fare far worse statistically than do men.   Women with a fib are much more likely to have strokes and much more likely to die of sudden arrhythmias than their male counterparts.  The long term result of being stuck in a-fib may also be dementia, especially for women.  So, I am unlikely to do as well as my father did, and he was severely limited by this disorder in the last twelve years of his life or so. Cardiac ablation statistically improves those odds substantially, especially for women.
                 With eight episodes of erratic paroxysmal atrial fibrillation, one of which cancelled my trip to our other home in Canada and left me unable to fly for the rest of the year, it looks like I am going to have to cough up the big bucks and have the procedure and the aftercare done.  This cost my son 67K.
                  Tonight, I went to bed perfectly happily.  I had not had any a-fib for a couple of months, and I passed right by the November date in which my youngest son died, without falling into it.(It's forever a difficult day emotionally.)    I love chocolate, but don't eat much anymore because the methylxanthines in chocolate are known to cause arrhythmia in some. (This is the chemical which can kill dogs or cats if they ingest chocolate.)    Late this afternoon we had some Cadbury chocolate, my favorite.   I ate a fair bit, but having cut out any other caffeine from my diet, no tea, coffee, or brown sodas, I thought I would be fine.   I was fine when I went to bed.
                   Around one am I began to have an elaborate dream.  I had two friends, a man and a woman who were both becoming physicians and were in medical school.  The woman had a lovely voice and perfect pitch.  I encouraged her to enter a contest in which the prize was a job as an opera singer.   She wondered if perhaps she should give up medicine and let her husband amass the med school debt rather than both of them.   I went with her to the contest.  The contest was not just about subjective singing and sightreading.  There were difficult and complex exercises and the contest tested her ability to sing a particular note on demand.  She was doing very well.    During a break she told me that she was nervous, and said "feel my pulse".   She was in a-fib !  I told her that we would deal with this right after the contest.  A few minutes later, she won the contest.  Then, I awoke to find that I was the person in a-fib !
                     So here I sit, in the middle of the night,  waiting for flecainide to do it's magic as I shiver at the computer with rain dancing on the skylight above.

UPDATE:   I converted to regular sinus rhythm at 4:10 am.   This means that I was in atrial fib for a total of 2 hours and 20 minutes.  It looks as if part of my readiness and preparedness plan should be an ablation in 2013.    Are there any dental or medical procedures that you need and have been putting off, for good or not-so-good reasons ?






More information on atrial fibrillation courtesy of Healthline

What is Atrial Fibrillation ?

 
         We hear this phrase a good deal, and yet most adults have no idea what it really means. Atrial fibrillation is the most common of heart rhythm disturbances. A heart rhythm disturbance is also known as a type of arrhythmia or most correctly, dysrhythmia.   "A-fib" as it's often abbreviated, can occur suddenly and can be experienced in a variety of ways.  Most people with "a-fib" experience a sensation of either fluttering in their chests or the sensation that their heart is flopping around.  This may come in tandem with the sensations of being slightly breathless and also anxious.  Most people feel an energy drain and may even be a little lightheaded.  A few people with atrial fibrillation have odd sensations in their throats and a very few complain of unusual sensations in their left arms or even in their deltoid muscle of their left arm.
          Some people develop an episode of atrial fibrillation during a period of acute stress. Some develop it after getting insufficient sleep or after too much caffeine. People can be in atrial fibrillation for a few minutes, for an hour, for several, and some, for years.  Beside the obvious discomfort and the feeling of general unwellness, there are other reasons that atrial fibrillation should not be allowed to continue.  A heart beating irregularly and inefficiently can allow clots to form. These clots can later be liberated and can cause a stroke.  Therefore the rapid diagnosis of actual atrial fibrillation, and the treatment of such is important.
          Atrial fibrillation can run in families.  My father believes that he had brief episodes of a-fib all the way back to grade school. He was not diagnosed with atrial fib. until he was in his fifties and on a business trip out of town. His initial diagnosis and treatment occurred in New York City.   Both his mother and his father were diagnosed with a-fib in their fifties.  My grandmother, after diagnosis and treatment, lived well with this tendency, until she was 96.   My father was challenged by recurrent atrial fib. from his fifties periodically until his eighties, and at times, his energy levels were impaired.   One of my children has been treated for a-fib and is currently stable.  My son who died of an acute rhythm disturbance, believed to be Long QT syndrome, was not felt to have had a-fib.    The development of atrial fibrillation at some point is therefore very likely for me. I have a cardiologist lined up, ready to treat me for this eventuality.
           Atrial fibrillation is usually diagnosed when the patient himself complains of feeling an "odd heart rhythm".  On taking their pulse, they have a clearly irregular rhythm.  Anyone of any age, who has an irregular heart rhythm should be taken to a competent emergency room at once.  Once they are there, an EKG will be taken in an attempt to document the type of rhythm disturbance.  A rhythm strip showing atrial fibrillation is immediately obvious and is easily diagnosed.

This is an enlarged view of a rhythm strip, a portion of an EKG, showing atrial fibrillation.  In this strip, the heart is beating inefficiently and irregularly, and there are opportunities for clots to form and be thrown throughout the body.

I have added a normal tracing here for comparison.  This tracing is of a normal sinus rhythm.

            Once a physician has diagnosed atrial fibrillation, they usually obtain some labwork.  This is done to rule out other issues and to check fluid and electrolyte balance.   Having low amounts of any blood electrolytes,  particularly potassium can cause many patients to descend into atrial fibrillation.   Then an intravenous line is started.  In many places a cardiologist is called, although most board certified emergency room physicians are fully capable of treating atrial fibrillation.   The patient will also need an echocardiogram, an ultrasound exam of the heart which helps to rule out a number of potential causes of atrial fibrillation which could need to be addressed.

               The potential causes of atrial fibrillation are many.  This arrhythmia can occur in tandem with coronary artery disease, or completely independently of it, as it appears to do in my family.   For some people , another illness has depleted their electrolytes and the atrial fib. is simply a symptom of another poorly controlled disease process.  For others, too high a dose of another drug given for another issue, has been administered for another problem, and has caused the a-fib. For a few, they have ingested too much caffeine in the form of soda, tea or coffee, and this has caused a fib.  Excessive use of alcohol, college parties with excessive alcohol ingestion, or tobacco can also cause this.  Excessive thyroid hormone from either your own thyroid gland, or from excessive thyroid supplementation from your physician can also cause atrial fib..   Excessive asthma medication can also cause atrial fibrillation, but then so can poorly managed asthma.

  This is a listing of some of the additional causes:

     

• High blood pressure
• Heart attacks
• Abnormal heart valves
• Heart defects you were born with (congenital issues)
• Sick sinus syndrome — improper functioning of the heart's natural pacemaker (failure of sino-atrial node)
• Emphysema or other lung diseases including asthma
• Previous heart surgery, including cardiac bypass graft surgery
• Viral infections which can lead to cardiomyopathy with arrhythmia
• Stress due to pneumonia, surgery or other illnesses
• Untreated sleep apnea

    Once echocardiography, an ultrasound examination of your heart is done, many of the issues above can be ruled out.  Some people simply have atrial fibrillation without any of the issues listed above.  These are people who may have additional nerve pathways in their cardiac conduction system which periodically trigger a competing rhythm.

This is a person receiving an echocardiography exam.

      

This is one view of an echocardiogram. A great deal of information can be obtained by looking at the measurements as determined by this machine.

                      In my family, no particular cardiac abnormalities have been found that were felt to cause a-fib. Still, this can be a serious and potentially life threatening issue if not addressed.    Once controlled, it can simply be monitored.  My grandmother for example, had a-fib in her fifties, and it was controlled using a very small dosage of medication, until she passed of something else entirely at 96.   For others, there can be a more frustrating course.   Treatment can include medications, surgery to correct abnormalities found, or something called cardioversion, in which a very slight shock is delivered to a sedated patient to correct a rhythm disturbance. This is not anywhere near the magnitude of the shock delivered during a code situation.  A few people with recurrent a-fib will not respond to drug correction or to cardioversion, and their best option for complete recovery will be cardiac ablation .    One of my sons had a cardiac ablation in his twenties and is living and well today.

In cardiac ablation, the cardiac conduction system of the patient is mapped using a catheter which enters the patient through a small opening in the groin.  When the focus which is causing a competing rhythm is identified, it can be burned slightly as if done with a cautery. For many patients, this ends their proclivity for a-fib.  A few need to have the procedure performed once again.

                 Atrial fibrillation is the most common of the cardiac conduction disorders.  It is a fairly common disorder and occurs much more often as we age. It does run in families. There are multi-factorial causes, and therefore a multitude of treatments both available and necessary to restore the patient to a regular sinus rhythm.  Returning the patient to a regular sinus rhythm is necessary because their energy level, general function is impaired while they remain in atrial fib. and because their chances of having a stroke are greater, the longer they remain in it.   Even when a person converts to a regular sinus rhythm following a period of time in atrial fibrillation, they likely remain exhausted and feel "spent".    People in atrial fib or who have recently concerted are often given anticoagulants in order to prevent their formulating clots in the period of time following the correction of their rhythm disturbance.

               This is a common cardiac disorder, and under todays diagnostic and treatment capabilities, this disorder can be controlled for many people.

              I mention this, fourteen days before Valentine's Day, because in a survival forum, this is indeed something that we can do something about.  The person for whom atrial fibrillation is diagnosed early, has an excellent chance of living a normal lifespan and living through other health challenges or challenges in our world.  Continued atrial fib. and heart failure from longstanding a-fib. can be avoided.   Strokes from untreated a fib can certainly be prevented.  This month, I am seeing a friend who is a cardiologist, and getting a new baseline EKG and a new baseline echocardiogram done.  This might be the best Valentine's Day gift I can give my husband, and the rest of my family.