SVT and AF

[sparkywd]

I'm a 38 year old male with severe aortic insufficiency. I'm taking Prinivil 10 mg, Procardia XL 30 mg, and Toporol XL 50 mg all 1x day.  I exercise regularly and extensively - running up to 5 miles a day on the treadmill.  I've had regular echos, stress echos, and a TEE.  The TEE found a tricuspid valve and was reported as aortic prolapse (no kidding).  My heart was reported as slightly enlarged.  No other abnormalities were reported.

I'm writing because I originally went to the Dr. for "extra" beats and was put on a holter monitor - 209 PVCs a day.  I told the doctor I also got another rhythm that felt like my heart was beating backwards.  I was told - by three different Drs - it was probably nothing to worry about.  

So, I'm at my annual echo last week and sha-zam - I suddenly went into that "backward" beat which sent everybody around in a tizzy.   I was hooked up to a multi-lead ECG and they said it was SVT (219 BPM) but they needed more info to characterize the arrhytm.  My Dr gave me a cardiac beeper that I use to record any arrhythm.  It records for 60 secs and then you call in and transmit the results.

I was told that I had 2 types of arrhytm. - PSVT and then AF - the traces were taken roughly 10 minutes apart.  In addition I had numerous singlet PACs and PVCs.  I had the arrhythm for about 75 minutes.  My Dr. is increasing my beta-blocker to control these and says they are probably not serious (easy for him to say).  Historically, I've done this on my own and it has worked well to control the arrhythmias (PVCs/PACs and all).

And now for the question(s)....What does this all mean?:
1.  Are these arrhytmias life threatenting?  
2.  Will they progress (become more frequent/severe) over time?  
3.  What are the available Rx options and which are best?  
4.  Should I have any other tests - EP or whatever?  
5.  Can these arrhythmias be stopped with ablation and would that be wise?  
6.  Are these arrhythmias an indication I should have the valve replaced?
7.  Now that I have this smorgasboard of arrhythmias should I seek a second opinion on them?
8.  We like to drink wine with dinner 3-5 nights a week - should I stop all alcohol consumption?

Thank you.  Let me know if you need more info.

Best Regards,

Matthew

[Cleveland Clinic, MD]

1. Are these arrhytmias life threatenting? No.
     2. Will they progress (become more frequent/severe) over time? Afib is a chronic condition and may increase in frequency over time.  SVT tends to be stable.
     3. What are the available Rx options and which are best? Multiple treatments exist and your doctor can tell you which is best for you.
     4. Should I have any other tests - EP or whatever? An EP study may be a good idea.
     5. Can these arrhythmias be stopped with ablation and would that be wise? Depending on what type of arrhythmia it is it could be helped by ablation.
     6. Are these arrhythmias an indication I should have the valve replaced? No.
     7. Now that I have this smorgasboard of arrhythmias should I seek a second opinion on them?  Not if you're happy with the care you are receiving.
     8. We like to drink wine with dinner 3-5 nights a week - should I stop all alcohol consumption? Not necessarily.

[Matthew]

Oops - I should say the PSVT converted to AF in the last episode.  The PACs and PVCs were recorded at other times.  Also, I cut out caffine 16 years ago.  My cardio is Dr. Allen Johnson at Scripps Clinic in La Jolla, California.

[Cleveland Clinic, MD]

Here's some additional information on afib.

Atrial fibrillation
Definition:
A disorder of heart rate and rhythm in which the upper heart chambers (atria) are stimulated to contract in a very rapid and/or disorganized manner; this usually also affects contraction of the ventricles.

Causes, incidence, and risk factors:
Arrhythmias are caused by a disruption of the normal functioning of the electrical conduction system of the heart. Normally, the atria and ventricles contract in a coordinated manner. In atrial fibrillation and flutter, the atria are stimulated to contract very quickly. This results in ineffective and uncoordinated contraction of the atria.

The impulses may be transmitted to the ventricles in an irregular fashion, or only some of the impulses may be transmitted. This causes the ventricles to beat more rapidly than normal, resulting in a rapid or irregular pulse. The ventricles may fail to pump enough blood to meet the needs of the body.

Causes of atrial fibrillation and flutter include dysfunction of the sinus node (the "natural pacemaker" of the heart) and a number of heart and lung disorders including coronary artery disease, rheumatic heart disease, mitral valve disorders, pericarditis, and others. Hyperthyroidism, hypertension, and other diseases can cause arrhythmias, as can recent heavy alcohol use (binge drinking). Some cases have no identifiable cause. Atrial flutter is most often associated with a heart attack (myocardial infarction) or surgery on the heart.

Atrial fibrillation or flutter affects about 5 out of 1000 people. It can affect either sex. Atrial fibrillation is very common in the elderly, but it can occur in persons of any age.

Prevention:
Follow the health care provider's recommendations for the treatment of underlying disorders. Avoid binge drinking.

Symptoms:

     sensation of feeling heart beat (palpitations)
     pulse may feel rapid, racing, pounding, fluttering,
     pulse may feel regular or irregular
     dizziness, lightheadedness
     fainting
     confusion
     fatigue
     shortness of breath
     breathing difficulty, lying down
     sensation of tightness in the chest

Note: Symptoms may begin and/or stop suddenly.

Signs and tests:
Listening with a stethoscope (auscultation) of the heart shows a rapid or irregular rhythm. The pulse may feel rapid or irregular. The normal heart rate is 60 to 100, but in atrial fibrillation/flutter
the heart rate may be 100 to 175. Blood pressure may be normal or low.

An ECG shows atrial fibrillation or atrial flutter. Continuous ambulatory cardiac monitoring--Holter monitor (24 hour test)-- may be necessary because the condition is often sporadic (sudden beginning and ending of episodes of the arrhythmia).

Tests to determine the cause may include:

     an echocardiogram
     a coronary angiography (rarely)
     an exercise treadmill ECG


Treatment:
Treatment varies depending on the cause of the atrial fibrillation or flutter. Medication may include digitalis or other medications that slow the heart beat or that slow conduction of the impulse
to the ventricles.

Electrical cardioversion may be required to convert the arrhythmia to normal (sinus) rhythm.

There is not a consensus on the best long term management  of atrial fibrillation but many doctors feel it is important to try everything, including cardioversion (shock) to try to get the heart back into regular rhythm.  The risks of staying in afib are stroke (if not on anticoagulation) and decreased heart heart function (tachycardia induced cardiomyopathy).  Not all afib can be maintained in regular rhythm and those patients must live with the afib and take chronic anticoagulation (blood thinners).


Expectations (prognosis):
The disorder is usually controllable with treatment. Atrial fibrillation may become a chronic condition. Atrial flutter is usually a short-term problem.

Complications:

     incomplete emptying of the atria which can reduce the amount of blood the heart can pump
     emboli to the brain (stroke) or elsewhere--rare


Calling your health care provider:
Call your health care provider if symptoms indicate atrial
fibrillation or flutter may be present.

Q: Are there other safe drugs I could take at home to avoid cardioversion?
A: There are many different drugs that are used in the attempt to keep the heart in sinus rhythm (SR) but as with any medication they all have various side-effects.  You doctor can work with you on finding the best drug for your case.

Q:  What are the side effects to Toprol.
A: Toprol XL is a long acting version of metoprolol.  This drug is a beta-blocker.  Potential side-effects of beta-blockers include fatigue, problems with diabetic control, and impotence.

Q:  It seems that the better physical shape I stay in the less I have a problem with A.F. Could exercise have an impact?
A: There is no known effect of exercise on atrial fibrillation (AF).

Q: Is a pacemaker an alternative?
A: In some people who are unable to be controlled with drugs the electrical connection between the atria (upper heart chambers) and ventricles (lower heart chambers) is electrically severed and a pacemaker is placed to control the ventricles.  The atria remain in fibrillation but the side effect of the rapid heart rate is eliminated.  Chronic anticoagulation is required, as there is a risk of blood clots forming in the atria.

Q:  I have an uncle that was diagnosed with IHSS. Are IHSS and Mitral valve prolapse related problems?
A: No.


The links below are good sources of information about atrial fibrillation.

http://www.med-edu.com/patient/arrhythmia/atrial-fib.html
http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/afib.html
http://www.merck.com/!!vDXoe16kTvDXpz08Of/pubs/mmanual_home/chapt16.htm