Isolated Atrial Fibrillation Episodes: Is Ablation a Good Fit?

Love your response. I think I’ll go for Colorguard going forward. I’ve done two of those in the past, one is part of a Cancer Prevention program I signed up for over 12 years ago.

I wish for you a good meeting with your EP tomorrow! Keep us apprised of his decision, hopefully made in concert with how you would like to proceed. Incidentally, I also have the Kardia “tool” which is pretty cool although I didn’t need anything confirm that my galloping heart and runaway heart rate was abnormal.

Is it common to stay on Amiodarone, if having regular AF occurrences?

For some, only on the advice of a qualified heart specialist, yes. It depends on you, your particular case, and what the prescribing authority feels is best for your long term health. Amiodarone is generally considered to be the drug of last resort because of its toxicity and its potential to cause damage to organs, including to the heart itself. So, when a patient is placed on amiodarone, it is not done without a lot of consideration about several factors, not least of which is that none of the other widely used anti-arrhythmic drugs is suitable for one reason or another. This would mean that they considered Sotalol, propafenone, diltiazem, Multaq, and Tikosyn, as examples. Sotalol and Tikosyn are potentially dangerous and are often 'loaded' initially under supervision during a short hospital stay of two or three days. So it's not as if amiodarone is the lone bad boy in the group...others carry risks for certain cases as well.

This is just me talking to myself, but I would do whatever it took to get off amiodarone. If it means a pacemaker, so be it. I would also ask for a reasoned calculus as to why not Sotalol or propafenone. Chances are good, though, that the rationale is pretty darned solid, and amiodarone is all that is left. In fact, I was on it for almost ten weeks and did well by it. Luckily, I was told to stop taking it two weeks prior to the Holter monitor check to see if my heart was going to stabilize in normal sinus rhythm (NSR). The story from there is involved and I won't go into it since it isn't relevant, but I was grateful that amiodarone got me out of a horribly persistent AF with high rate and RVR (rapid ventricular response), and it kept me in NSR for weeks until I had to stop it.

This will probably be boring but I know I enjoy reading about other people's experiences, so I'll share mine. Nobody wants to go digging for my previous posts, so I'll just say that my first episode of AF was early last year and my second one was last week. Both were well tolerated and lasted only a few hours. Both times, I knew I was in AF - as a former ICU nurse, it is very easy to pick out AF during pulse evaluation by its completely erratic rhythm. I did purchase a Kardiamobile device for my phone after the first episode and have found it useful. The first time, I didn't go on an anticoagulant. The second time, I called my electrophysiologist's office and was given a one-week sample of Eliquis and an appointment for today. I went into the meeting with 3 questions: am I a candidate for pill-in-pocket arrhythmia management (answer: yes); am I a candidate for pill-in-pocket anticoagulation (answer: no); and is there any requirement to see a cardiologist when I have no signs/symptoms of coronary insufficiency or structural abnormality, such as a defective valve (answer: no).

The EP's recommendation was ablation. OK, sure, when your main tool is a hammer, everything looks like a nail. So I get that. On the other hand, this is, after all, his area of expertise, so I keep both these things in mind. He is enthusiastic about the development of pulse field ablation. As a candidate for the procedure, I have some things going for me that tend to lead to high success rates - I have only controlled hypertension as a co-morbidity, and I practice healthy lifestyle choices. I told him that I was surprised he suggest ablation after only 2 episodes, and I would need time to read and think about it. I joked (sort of) that I'm in denial and I'm never going to have another episode; he laughed heartily. I asked him if I was a pain in the ass as a patient and he expressed absolute tolerance for my viewpoint. So he's not one of these, "do as I wish or you're fired as my patient" kind of guys. And if he was, I would find somebody else.

In response to my request, he prescribed flecainide for me as pill-in-pocket arrhythmia management. I took flecainide briefly after my first episode of AF, so I know I tolerate it.

He would not agree to pill-in-pocket anticoagulation management. My CHADS score is 3 (1-age; 2-female; 3-hypertension) and none of these are reversible, last time I checked lol. Also, he says his professional society (I think he was referring to Am College of Cardiology) does not include pill-in-pocket anticoagulation in its standards of practice, so he just won't do it. I can respect that. So I will take Eliquis and we'll see how things go. He gave me a list of other anti-coagulants so I could see if I could find something more affordable - I don't see that I qualify for a low monthly payment for Eliquis, but I guess I will benefit from the $2000 out-of-pocket cap for 2025, like everyone else with Medicare Part D.

We had an interesting conversation about cardiologists. I wanted to bring up the topic because when I make appointments with him, the staff ask who I see for cardiology, and I don't see anybody. Not having a cardiologist definitely would not be the right way to go for some people, and there will probably come a point when I'll need somebody, but for now, I have no signs of coronary insufficiency, no structural defect, no reason to see that kind of specialist just because of an electrical abnormality. Long story short, he didn't make an argument to involve a cardiologist and we had an amusing conversation about the arrogance of cardiologists and these two specialties (EP and Cardiology) pi**ing on each other's territory.