Anti arrhythmic medication

I have a long standing history of atrial fibrillation and had an ablation 5 years ago.  Did well with very few a fib breakthrough but had low pulse.  ( mid 40's).  Was on Eliquis but no need for antiarrynmics .  In October this year I had a watchman insertion with the goal of getting off Elizuis.  Well Atrial fib went crazy and I was very symptomatic.  Bradycardia got worse. Low 30's and November 15 I recieved a dual lead PM.  Now I am metropolol and Tikosyn.  I know it is early days but in the first 2-3  weeks I did have break through atrial fib which was not that symptomatic.  For the past week I would say that I have no atrial fib that I can detect .  I am pacing at 93% and my baseling heartrate is in the 60s.  Feeling pretty good now.   I am nervous about the Tikosyn and it is difficult to remember to take it on schedule.   Is it unrealistic to think that at some point I may be able to come off it?

 


9 Comments

Anti arrhythmic medication and Atrial Fibrillation

by Gemita - 2021-12-14 13:51:42

Hello Howickgal,

I also have a long history of Atrial Fibrillation (AF) but have not had an ablation, choosing instead to try a pacemaker and medication before considering a pulmonary vein isolation ablation or an AV Node ablation which may still be in my future.  I am now off all anti arrhythmic meds (Flecainide and Digoxin) which had become pro arrhythmic for me and I am now fortunately only taking low dose Bisoprolol for AF with a rapid ventricular response rate, as well as Edoxaban (anticoagulation) for stroke protection. I also have other arrthymias, both atrial and ventricular ones but like my AF, these seem to be well controlled with my current treatment.  Not everyone is as fortunate with their pacemaker and on minimum meds, but that has been my experience.

You did well to stay in sinus rhythm for 5 years, so your ablation was a success.  Unfortunately any trauma (like the Watchman) can trigger an arrhythmia like AF and it could be that that procedure, combined with your pacemaker implant have triggered worsening rhythm disturbances.  Hopefully this is only a temporary problem and that it will be controlled with Tikosyn, a heavy weight anti arrhythmic med and also with Metoprolol which will help keep your heart rate down and calm your AF at the same time. 

I am not sure that I would feel completely protected with a Watchman device alone. By closing off the left atrial appendage, blood clots that form within this area are prevented from entering the bloodstream but any clots potentially forming elsewhere due to the turbulence of blood flow during episodes of irregular AF, could still cause problems.

If you are feeling pretty good, I wouldn’t change anything right now.  Stay calm and continue to do what you are doing because it is clearly working for you.  If you forget to take Tikosyn, try to take it within one hour of your normal dosing time or if you are over the hour, skip the dose and then take the next dose on schedule as usual, but you will have instructions from your doctors.  You will be covered by the Metoprolol in any event which will control your heart rate which is probably more important.  A high heart rate for long periods will be more dangerous than an episode of slow AF.

No it is not unrealistic to think that at some point you may be able to come off Tikosyn, especially if you can keep the dose low (don't get to rely on it) and don’t go through any further heart procedures or trauma and allow everything to calm down.  Keep well hydrated and occasionally check electrolytes and do look after yourself.   I send my best wishes for a successful recovery.

Breakthrough

by AgentX86 - 2021-12-14 15:11:12

It's unfortunate that a Watchman disturbed your heart this much.  It might go back to "normal".  It seems that it's settling down.  You may need another ablation to touch things up but that's not the end of the world.

I understand your want to get off these drugs.  Antiarrhythmics are all toxic and Tikosyn is near the top of the list.  It's always a trade-off between the side-effects of the antiarrhythmic, liging with the arrhythmia, and the anticoagulant. Another ablation may be the answer but it'll have to wait until your heart settles down. Even then, it may be a year or two before your EP is confident enough to drop the Eliquis. As long as you're in AF or having breakthroughs an EP won't take you off the Eliquis.                                                           

Have you had TEEs to verify that the Watchman isn't leaking?

If you're having trouble remembering to take the Tikosyn, are you having the same trouble with Eliquis? BTW, I forget too but it certainly isn't good.

 

TEE and watchman

by howickgal - 2021-12-14 18:18:55

Thanks for your response.  I am scheduled for a TEE in February so I wont  be getting off the Eliquis til then.   I am in a clinical trial to compare the watchman to anticoagulants for stroke prevention.   Their protocol is TEE in four months after insertion.  Did not think that this procedure would have set off my a fib so dramatically but in the course of doing that my bradycardia became more profound.   Probably was a ticking time bomb that would have reared its ugly head eventually.. Who really knows. 

Certainly a second ablation is a possibility but not yet.  

Watchman

by AgentX86 - 2021-12-14 20:38:48

Ablations usually kick off bouts of Afib until the scar tissue forms.  PM implants often kick off a period of all sorts of arrhythmias (PVCs for me??).  It's not all that surprising that a Watchman would do its own number on the heart.  Time will tell.

Whether you can safely go off Eliquis with AF is something your EP can decide.  That was one of the purposes of the Watchman, so that an anticoagulant wouldn't be needed for AF.  It's why many insurance companies would pay for the procedure.  It's expensive but so is Eliquis!  My EP laughed at me when I suggested it, though.

Isn't a medical trial of the Watchman a little late?  The Watchman has been FDA approved for over five years and the Watchman FLX, a year and a half. I wonder who's sponsoring it and why.

Bradycardia shouldn't be a concern after your PM implant.  In fact, it'll allow more options to quash your AF.  Good luck and let us know how it's going.

 

watchman

by new to pace.... - 2021-12-14 21:24:04

I to would like to know how you are doing with Watchman.  As it was suggested i go that route.

Instead of anticoagulants.  But after implanted Watchman one has to stay on the anticoagulants for a year.  Which does not make any sense to me.

new to pace

Watchman trial

by howickgal - 2021-12-14 23:28:16

Agentx86. thank you for your kind response. the watchman did in fact set off my atrial fib   In fact it started during the procedure.   I had a cardioversion then and by the time i was in recovery I was back in atrial fib.  Stayed in recovery for four hours while they gave me multiple meds to try to convert it   Finally I converted on my own.   That was the beginning of my journey to the pacemaker.   My EP is very experienced and has put in many watchmans and he said he had never encoutered that in any of his patients.  Nice to be the first I guess

The study I am enrolled in is called the Champion trial  and it is comparing the watchman FLX to NOAC (non vitamin K antagonis oral anticoagulation. eg pradaxa,eliquis, xarelto,or savaysa) for embolic protection in patients with non valvular atrial fibrillation.  There have been other watchman studies , one inparticular with warfarin .  I is being sponsored by Boston Scientific

New to Pace. In this study you have to stay on NOAC for three months then plavix for six months. My atrial fibrillation has finally settled.  I am four weeks out from my pacemaker and 7 weeks out from the Watchman but of course I am on meds now too.  

Hopefully all will go well from here on out

tikosyn

by TLee - 2021-12-15 12:19:52

I am also taking both tikosyn & metoprolol for afib. I ask my doctor at every visit if we can cut the tikosyn--makes sense to me, as I didn't start to feel really well until the metoprolol was added (after pacemaker), so to me it seems that that is the "magic bullet". I am also bothered by all the cautions associated with tikosyn, although not so much now that I have actually missed a dose here & there with no disasters. My last remote report showed no afib, no unusual incidents at all, so something is working. My next office visit is in March, and I will probably ask again about the tikosyn. Pretty sure he will say it is the combination that is working so stay the course, which I guess I am OK with. I also wonder about dropping the eliquis if my afib is controlled, as I still feel that less medication is better I guess I'll find out in March. Really, we are all kind of medical of guinea pigs! Good luck on your journey.

T Lee

by Gemita - 2021-12-15 13:02:11

I am all for attempting to drop anti arrhythmic med Tikosyn, but Eliquis?  Not sure of your age but you would score 1 point for being female and 1 point for being over 65?  Okay see you are younger, so perhaps you are safe to come off with only one risk factor?   But you might like to check the scoring system clinicians use to calculate our stroke risk and calculate your risk, if you don't already know this.  

I was told it only takes a very short run of AFib to put me at risk of an AF related stroke.  A short run being around 11 beats and even if this is as infrequent as once a year, I would still be at considerable risk, so for me it is anticoagulation for life.  But really nice to hear your are doing so well

https://clincalc.com/Cardiology/Stroke/CHADSVASC.aspx

Risk factors

by AgentX86 - 2021-12-15 18:19:20

The risk factor for being female only counts if there is another risk factor.  IOW, if you have one, you get another as a bonus for being female.  At age 64 +364 days, that would be zero, a day later and it's two. ;-)  With a zero, anticoagulation isn't recommended (the bleed risk exceeds the stroke risk).  At one, it's dealer's choice (egualish risks).  Above and it's recommended.

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