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Forum Name: Cardiology Diagnostics

Question: Multiple arrythmias


 fyrmnk - Mon Sep 27, 2004 12:02 pm

Hi, I am a 30 yom. I am a firefighter in good shape, running and working out regularly. My heart itself is in great shape physically (pass stress test yearly with good scores), but my electrical system is pretty mixed up and seems to be stumping my docs and me.

Since I was 19, I've had PVCs and PACs (on stress tests too), no big deal. Then a number of years ago, I had an episode of A-fib (not known then what it was). Event recorder for a month, no repeat so not diagnosed. I ignored it for several years to prevent risk of it affecting my job.

Finally the last couple years, A-fib began lasting up to 8 hours at a time. After an hour, dyspnea and fatigue would start. These episodes were sporadic, lasting between 1-8 hours a few times a year, then every couple months, mostly at night while trying to sleep. Still didn't want to go to the doc for fear of my job.

Then last year, I had a near black out while driving. I can usually always feel every beat every day. It was beating normal, then I suddenly felt it stop, began to black out, got to the side of the road, hard thump, then very tachycardic. Dizzy about a 1/2 hour after. This got me back to the doctor. Captured A-fib on event recorder couple weeks later, but no more pauses (felt same as when I noted a-fib above, which is why I figure above noted items [exc. blackout] was a-fib).

EP study and attempt ablation scheduled. Was in a-fib as soon as medication started, so determined no ablation could occur. Finally diagnosed as vagal a-fib. Various med combos tried, all made arrythmias significantly worse. After several attempts, I elected not to try more.

Was selected for ablation by Dr. Jackman in OKC. At this point having a number of rate changes for no reason. Normal resting for me about 60, will jump from 60-120+ at rest for no reason, sometimes gradual, sometimes instant. Dr. on staff there and a 2nd here stated appears more going on. OKC doc stated needed to get electrodes placed inside near nodes (I think) to determine what else was going on due to so much elec. activity? Anyway, thanks to insurance, procedure fell through.

Now, having very frequent (daily) episodes of sporadic chest pain. Also multiple rate changes and occasional SOB. Just completed additional monitor hard wired that takes recording from 1 min. prior to when I press the button. First sending, receiving company stated dangerously fast (moderate physical activity for about 5 min.) at around 180. Was back fine after 15 min. Another sent after chest pain and company stated a wave change was noted that I needed to talk to the doc about, but still within normal levels. (Also, last stress test for job 6 months ago, computer flagged a problem before starting, but I denied to them any cardiac issues due to job. They allowed stress to continue believing it was a computer glich. I was on meds then, thouhgt maybe related to them). A-fib hasn't been an issue last several months, only lasting 1-5 min. when it happens, but everything else is.

So here I am. Just wanting other ideas as to what's going on. Thank you for reading the long winded post.
 Dr. Yasser Mokhtar - Tue Oct 26, 2004 10:50 am

User avatar Dear Fyrmnk,

i am sure that before you were labelled with the diagnosis of vagal atrial fibrillation, all other causes of atrial fibrillation were excluded, such a hyperactive thyroid gland among others. This is very important.

i am sure that you had a not at all good experience (i don't want to say painful) with the medications combination trials and that is why you decided not to try anything else. But what are the medications that you tried?

Your chest pain episodes from what i understand seem to be associated with the rapid heart rate that you get. You having chest pain means that your heart rate is so fast that the coronaries don't have time to fill with enough blood (to supply the heart) and then the heart muscle starts to complain by giving you this chest pain. You have to contact your cardiologist with these symptoms as soon as possible. You have to be evaluated.

i am not sure what other options your electrophysiologist discussed with you regarding how to deal with the atrial fibrillation. In my opinion, remember i am not an electrophysiologist, you have a few options.

1. To have good heart rate control and never mind about whether or not you are back in normal rhythm and have blood thinners, i hope you are on them now, because patients who have atrial fibrillation have a significantly higher incidence of stroke than people who don't.

2. Have an ablation of your atrioventricular node, the passage that conducts the electrical impulses from the atria (where the atrial fibrillation starts) to the ventricles (the actual heart rate is not the one that the atria produce but the number of impulses conducted to the ventricles). And after having ablation have a pacemaker implanted. i am not sure what is the ablation that your electrophysiologist deemed unfeasible. i think that this might be a too of a permanent solution as you are young as is but there are many young patients as you are who have had this done.

3. Have what is known as an anti-tachycardia device. This is basically a device that will give a shock every time you have one of these episodes. It is not a comfortable thing and i am not sure whether the fda approved it for use in atrial fibrillation or not.

In any case, i think it is very important that you be on anticoagulation (blood thinners) as long as you continue to have these episodes of atrial fibrillation.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 fyrmnk - Wed Oct 27, 2004 4:15 pm

Hi Doctor, thanks for the reply. Yes, all other forms were ruled out. I had to stop meds because of multiple side effects with each, including various other arrythmias.

In addition to the a-fib without meds, I also have other arrythmias, including occasional slight bradychardia, tachycardia at rest (normal resting is 60 for me, hits 120+ at rest on occasion), SVT w/o a-fib, pvcs and pacs, and pauses.

Can't do option 2 or 3 because I will lose my job if either are implanted. Can't do Coumadin or related because of risk due to job and active lifestyle. I do take a full strength aspirin a day though.

Have discrepency on when I should go get cardioverted when in a-fib. Had one cardiologist (heart failure prevention spec.) say no longer then 6-8 hours. My current one says he thinks I can make it 24 hours w/o stroke risk, so I'm planning on cardioversion if I stay in over 12 hours. They do say staying in for a length of time is hard on the muscle.

Thanks again.
 Dr. Yasser Mokhtar - Sat Oct 30, 2004 6:12 pm

User avatar Dear Fyrmnk,

Thank you very much for the update.

Having pauses and getting fast heart rate at the same time has always been a tough situation. The treatment is obviously something to treat both but the dilemma is if something is given to treat the tachycardia, it will worsen the bradycardia and if something is given to treat the bradycardia, it will worsen the tachycardia. So, usually, and once more, a pacemaker is inserted and medications to prevent tachycardia from occuring are usually given. But, obviously this is not going to be the case in your situation.

Regarding how long would you wait before going in for a cardioversion, first of all, the longer you wait, the harder it is to cardiovert. The consensus is never to wait more than 48 hours otherwise there is a big chance that a blood clot has formed inside the cavity of the heart and if cardioversion is performed, this clot breaks and goes wherever in the body causing a variety of problems, the commonest of which is a stroke. That is why, if 48 hours pass and a patient is in atrial fibrillation, the patient is not cardioverted, placed on blood thinners and comes back later may be at 3 weeks or so to have cardioversion and then remains 3-4 more weeks on blood thinners before the danger of embolization is gone.

You never mentioned anything about the results of an echocardiogram but i am sure that several were done. If the size of the left atrium is bigger than normal, some cardiologists let the patient remain in atrial fibrillation and start anticoagulation because if the left atrium is bigger than normal the chances of atrial fibrillation coming back are really high.

Continuous tachycardia does cause the heart muscle to be weaker.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.

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