On the heels of my annual physical, I had my annual heart checkup with my local EP on October 24, 2018. I’ve been feeling so good the past year that I was tempted to cancel it but I’m glad I didn’t. I got peace of mind and I learned some things that I’d like to share with you.
My morning started off with an echo. I have had an echo every year since my ablation three years ago. This would be my third echo. You might be wondering why I continue to have an echo every year when I’m perfectly healthy and free of afib.
I ask for one every year just for peace of mind. While it might be expensive, it’s a harmless screening that assures me that my heart is healthy and functioning properly. I’m convinced if my dad would have done the same he would be alive today. He died from heart failure that I’m 99% certain could have been avoided had he just had a simple echo done on a yearly basis.
My EP told me my heart looked perfectly healthy. My ejection fraction was a strong 60%. Last year it was 57% and the year before that it was 63%. It’s completely normal for your ejection fraction to vary from echo to echo so don’t look too deep into those numbers. The main takeaway is I’ve had a perfectly healthy ejection fraction since my ablation.
Side Note on Ejection Fraction
Ejection fraction is the percentage of blood flowing out of the two lower chambers of the heart (ventricles) with each contraction. A normal range for adults over 20 is 53-73%. If our ejection fraction is well below or above that range it can spell trouble.
My Heart Rate, Blood Pressure, & Heart Rate Variability
My heart rate was 55 bpm and my blood pressure was 106/80. My heart rate for the past year has been anywhere from 52–60 bpm, and my blood pressure has been between 100/70 – 110/80 so I wasn’t surprised by these numbers.
What I was surprised about, however, was my heart rate variability (HRV). I had heard about this term before but never gave it any thought. Heart rate variability is a measure which indicates how much variation there is in your heartbeats within a specific timeframe. High heart rate variability is an indication of good cardiovascular health and overall health.
My EP didn’t do any specific HRV measurements, but he listened to my heart with his stethoscope as I took deep breaths. When we take breaths in and out it changes the speed of our heart. Greater Heart Rate Variability (a higher HRV score) at rest is generally indicative of better health, a younger biological age, and better aerobic fitness. It’s a sign of great health!
Just by listening to my heart he said he could tell I have “great” heart rate variability. He said it, “sounded incredible.” He said it basically means my heart is working great and that such a “strong heart rate variability” is a great indication that my overall health is great!
Pill-in-the-Pocket + Beta Blocker – “Just in Case”
After my exam was over and I was given a clean bill of health, I decided to take advantage of the time I had with such a respected EP and ask him a handful of questions I had on my mind leading up to this appointment.
Every year during my annual checkup I always ask to have my flecainide and Eliquis prescriptions renewed. Again, you might be asking, why in the world would I bother getting prescriptions when I’m perfectly healthy and free of afib?
The answer is simple: so I’m prepared “just in case.”
Having battled afib for nine years and having had to go to the ER four times to be cardioverted, I am all about being prepared for the worst-case scenario. I hope I never have to deal with afib again but the reality is there is a chance my afib will return. It could come back tonight, tomorrow, or ten years from now. If it returns, I want to be ready for it. I don’t want to be caught flat-footed!
I always keep a month’s supply of flecainide and Eliquis in my medicine cabinet “just in case.” Fortunately, I’ve never had to take them since my ablation three years ago but if the beast returns I’ll be prepared!
While my EP was making a note to refill my prescriptions I asked him about adding another medicine to my arsenal “just in case.” I asked him about adding Bystolic to the mix.
Bystolic is a beta blocker. The reason I asked specifically for Bystolic was because I thought it had the least effect on your blood pressure. Beta blockers will usually lower your blood pressure so if you have low blood pressure to begin with as I do, beta blockers can practically put you in a coma. O.K. I’m exaggerating a bit, but the point is they can make you really lethargic and tired.
My thinking was I could pop the Bystolic along with the flecainide during an episode and the Bystolic would help keep my heart rate lower without lowering my blood pressure too much. We had a lot of back and forth conversations about this, but the bottom line was he recommended metoprolol over Bystolic.
His reasoning was that Bystolic stays in your system about twice as long as metoprolol. In fact, when looking up the half-lives of these drugs, Bystolic has a half-life of 12 hours while metoprolol has a half-life of only 3-4 hours. He was right. Bystolic definitely stays in your system much longer.
His concern was that if the flecainide converted me relatively quickly, say within 6-8 hours, I’d still be walking around with Bystolic in my system. In short, I may be one tired person until the Bystolic wears off. Instead, if under the same circumstance I took metoprolol, it would be mostly out of my system around the time I converted back to normal sinus rhythm.
That all made perfect sense, but I was still concerned about metoprolol having more of an impact on my blood pressure than Bystolic. He said he didn’t have the same concern. He said the Bystolic was more likely to negatively impact my blood pressure than metoprolol. This didn’t make any sense to me as it was completely opposite of everything I had heard from other afibbers, but he’s the doctor so I wasn’t going to get into a debate with him about it.
He agreed to give me a prescription for a very small dose of metoprolol to take if my afib returns and I need some relief from the episode. However, he told me not to take it right when I take the flecainide. He said I should take the flecainide first and then wait. If I didn’t convert in 6-8 hours and was miserable, then I could take the metoprolol to take the edge off.
If my afib returns, my “emergency only protocol” is to pop 300mg of flecainide and 5mg. of Eliquis. I’ll ride it out for 6-8 hours and see how I’m doing. If I convert, life is good. If I don’t and I’m just miserable, then I’ll pop 25mg. of metoprolol and go from there. Hopefully, I’ll never have to engage the “emergency only protocol!”
Side Note on Preparing for the Next Attack
Being prepared for an afib episode can go a long way in giving you peace of mind and helping you get through an episode with much less stress and anxiety! It took me a long time to figure this out. Don’t wing it! If you have paroxysmal afib, have a game plan so you’re ready for the next attack! Take control of your afib. Don’t let it control you!
When Is It Time to Go to The E.R.?
I’ve been asked this question so many times from afibbers and I’ve never had a good answer. I always assumed the answer was a technical one, that if your heart rate was over X beats per minute you had to go to the E.R. My assumption was wrong.
My EP said the answer wasn’t a technical one at all. He said it varied from person-to-person, but it was based strictly on your symptoms. If you’re having obvious, or “scary” symptoms, then it’s time to go to the E.R.
If you’re having an afib episode and you’re feeling really faint and practically passing out, or if you are having extreme shortness of breath, these would be considered obvious, or “scary” symptoms. You should go to the E.R.
On the other hand, if you’re doing o.k. and managing, you probably don’t need to go to the E.R. He said we all know when something just isn’t “right” so he said we just have to listen to our bodies. He said most of us will know when it’s time to go. He also said that some people will go to the E.R. regardless just to be safe and that’s perfectly fine too.
When I look back at the times I went to the E.R. during an afib episode, I definitely went prematurely. I didn’t know any better at the time. I just assumed an afib attack automatically meant a trip to the E.R. I also panicked a lot back then during my episodes so that only reinforced the idea that I had to go to the E.R. immediately.
Looking back, I probably could have avoided all those trips to the E.R. and saved myself thousands of dollars in the process! My episodes back then were never insufferable. Miserable, yes, but never too extreme to bear.
The Cardioversion Window
Speaking of going to the E.R., I talked to him about the “cardioversion window.” This is the window that doctors will do a cardioversion without requiring you to have a TEE first.
A transesophageal echocardiography, or TEE, is a test that produces pictures of the heart. While painless, a TEE is not the most comfortable procedure and one that you’d like to avoid having if you can. A TEE is done by placing a tube down your throat and into your esophagus. Sounds fun, right? It’s especially fun when you’re in a full-fledged afib episode – NOT!
The cardioversion window is 48 hours. Let’s say you have an afib episode at noon on a Monday, doctors in any E.R. will do a cardioversion “on the spot” without requiring any further tests as long as the cardioversion is done by noon on Wednesday – 48 hours from the time the afib episode started. If you walk into the E.R. at 3 pm on Wednesday, most doctors won’t do the cardioversion. They’ll require a TEE first.
The reason a TEE is required after 48 hours is because there is the possibility that clots can form in the heart after 48 hours. The concern is if you have a clot it can dislodge after the cardioversion and travel up to the brain and cause a stroke!
The exception to the cardioversion window is if you’re on an anticoagulant, or blood thinner, such as warfarin, Eliquis, Xarelto, etc. If you’ve been on a blood thinner since the afib episode started, most doctors will do a cardioversion without any further testing.
I asked him if I took the Eliquis right when an afib episode started if that would count as being on a blood thinner so I could avoid having a TEE in the event I needed a cardioversion after 48 hours. He said as long as I was on a blood thinner during the entire 48-hour period I would not need to have a TEE. What he did not say was that I would beprotected from clots. That’s an entire article for another day.
The point is if I wanted to avoid having a TEE after 48 hours I had to be on a blood thinner – period.
Side Note on Taking Eliquis “As Needed” to Prepare for a Cardioversion
You’ll note that my EP did not say if I would be protected from clots if I took Eliquis “as needed” when I had an afib episode to prepare for a cardioversion. I have no idea if you’d be fully protected or not. You’ll have to do your own research on this topic. I’d start with this study.
He confirmed what I already knew, that it was the most effective antiarrhythmic drug available today. When no other drugs will work, amiodarone usually will (at least in the short-tem). However, he also confirmed it has the potential to be the most toxic antiarrhythmic drug. It can become toxic for just about every organ in the body but especially the lungs and thyroid. Even your skin, hairs, and eyes are vulnerable to its toxic effects.
When you’re on amiodarone it’s imperative to be monitored. He said his group is very diligent about monitoring their patients who are on it. They also do regular testing and monitoring after their patients are taken off of the drug for a period of time. The reason being, the half-life of amiodarone is measured in weeks and months! This drug stays in your system for a very long time so you need to be monitored for a while after you’re done taking it.
My primary question for him was, given its potential toxic effects is there even a reason to prescribe it? I was expecting/hoping that he would say he’s not a fan of it but instead he seemed somewhat enthusiastic about amiodarone. He said it has been a “very successful” drug for many of his patients. And even more surprisingly, he said very few of his patients suffer any harsh side effects from it. He said instances of toxicity are also very rare in his experience.
I was glad to hear, however, that he doesn’t use amiodarone as a first line of treatment, nor does he use it as a long-term solution for younger patients. He said he uses it very strategically and typically reserves its use primarily for patients with life-threatening arrhythmias that don’t respond to other drugs and treatments.
He didn’t seem to be as “scared” of amiodarone as I am. His general take was that it can be a highly effective and successful drug for some patients and that all the “hype” about its potential toxicity and side effects were overblown. By that I mean, the instances of patients experiencing severe or life-threatening side effects were rare in his experience. His general belief was that as long as you do regular monitoring while you’re on it, it’s o.k. to take amiodarone.
He put my mind at ease a little about amiodarone, but I will still avoid it like the plague. I will only allow a doctor to give me that “poison” if all else fails and my life depends on taking it. Otherwise, I will always look for other options, but that’s just me.
I ended my appointment discussing digoxin. My interest in this drug is a personal one. My dad was taking digoxin for his afib. His doctor put him on it in the late fall or early winter of 2014. He would die just months later in June of 2015 from heart failure.
I have no way of knowing if digoxin played a role in my dad’s death but the sad irony is, just a few months before his death I shared this article about digoxin with him as a warning to get off of it. I was concerned this drug would do more harm than good.
My dad shrugged my warning off and gave me crap for being so “positive.” His words to me were something like, “Gee thanks, son, for cheering me up. Don’t worry about me right now. Just focus on your ablation and after that we can talk about my heart issues.” I wasn’t trying to be Debbie Downer, nor was I trying to scare him. I was just concerend he might be taking an unnecessary and potentially dangerous drug.
My EP said digoxin has very little utility today. It’s a very old drug whose day has come and gone. There was a time when it was a mainstay drug for the treatment of heart failure and afib, but not anymore. He said there is a very small niche of patients where digoxin makes sense. The example he gave me was patients with permanent afib. He said he has patients in this group who take a very low dose of digoxin and a low dose metoprolol and they do “extremely well over the long-term.” He said there were other, “small niches of patients,” where a low dose digoxin makes sense but it’s very small. In general, however, it is not a drug he uses that often today.
I asked him about its potential role in my father’s death. He said it was unlikely it caused my father’s death, but it very likely didn’t help any. In other words, there was no reason for my dad to be on it. My EP didn’t say this, but I’m convinced that the digoxin only made his health worse.
Here’s why I say that. Digoxin is primarily eliminated by the kidneys. If you have bad kidneys you can become toxic on it because the kidneys can’t eliminate it. When my dad was in the I.C.U. guess what else was failing besides his heart? His kidneys. In fact, he had ZERO kidney function by the time he was admitted. How long had his kidneys been failing prior to being admitted? My guess is in addition to suffering from heart failure by dad was also experiencing digoxin toxicity to some degree.
I’m praying for continued good health and a relatively calm heart for the next year. I’m so grateful to God that I’ve been afib-free for over 3 1/2 years now. I’m praying for at least another 3 1/2 years of afib freedom!