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Suggest Treatment For Persistent Tachycardia

Posted on Wed, 22 Mar 2017

Question: In 2015 I experienced two episodes of tachycardia lasting several hours and was diagnosed with aFib. An EP did not believe the dx and felt I had SVT, which he ablated. Several months later, the tachycardia returned and I was properly diagnosed with aFib. While awaiting an ablation for this, I was found to also have aFlutter. Shortly thereafter, I had an ablation for the flutter and, shortly after that, had an ablation for the aFib. I was without arrhythmia for about 6 months before I again started having brief episodes. Typically, though not exclusively occurring while resting, my heart rate would elevate to about 150 bpm before eventually returning to normal. The longest such episode lasted about an hour (although my heart rate was still around 90 for several hours) while most lasted seconds to a few minutes. In my follow-up visits with my EP, he has been unconcerned about the episodes. After the last episode, I chose to resume my beta blocker but my EP said there is no reason to be on the beta blocker. Since resuming the beta blocker, I had no episodes for several weeks until yesterday. At the gym, engaging in an exercise that usually elevates my heart rate to about 100-115, it elevated to 150 bpm per my heart rate monitor. I then used the exercise machine's heart rate monitor to get a second reading and it read 140 bpm. I left the elliptical trainer and began lifting weights and my heart rate was bouncing between 70-95 bpm, often from second to second and unrelated to the intensity of the exercise. When it returned to about 70, I went back to the elliptical machine and while exercising at a very light pace, my heart rate shot up to 120 within less than one minute. For the next several hours, it bounced between 60-90 at rest. This morning, it is back in the low 60s and responded appropriately to exercise. While I trust my EP, I must admit I am more concerned than he is about these episodes. Could the aFib have returned? Would an event monitor be a good idea?

Answered by Dr. Sagar Makode (51 minutes later)

Brief Answer:
See the description

Detailed Answer:
Hello,

Firstly, the ablation procedure for atrial fibrillation are not always successful and recurrences are quite common. So nobody can say for sure that you'll not have any episodes. As far as rates during exercise are concerned, they do not appear like atrial fibrillation episodes. They are more kind of sinus tachycardia, for the two reasons, one it started on exertion and relieves with rest which is unusual for atrial fibrillation, although rate was little higher. The reason for higher rate may be you were on Beta blockers and they are the rate controlling drugs so when one stop it, heart rate tend to be bounce back. Also, if you would have not exercised since long, it may lead to deconditioning, that may be a other reason. Now, you would ask why during lifting heavy weight it didn't increase that much, because lifting weight increases vagal reflex which tend to keep heart rate under check.
Secondly, your doubt regarding event monitoring, I would say yes you can certainly undergo it. Even routinely to look for a success of ablation one can have it. Or else you can also undergo holter monitoring and exercise with it, that will also clear the doubt.
I guess you must have been assessed for anticoagulation and don't have any heart failure, hypertension, diabetes, history of stroke or tia, if none is present then there is no need for anticoagulation. Ablation will not nullify the need for anticoagulation.
I hope this helps you and get back if you have any further doubts. All D best.

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Sagar Makode (37 minutes later)

Thank you for the very quick response. So, if sinus tachycardia, anything I should be concerned about? Should I continue exercising since I had no other symptoms, such as shortness of breath, dizziness or feeling faint? Should the sinus tachycardia be evaluated?

Also, what about the non-exercise related events? Most have occurred while resting and 2 or 3 occurred right as I awoke from a nap, with a heart rate as high as 150. What may these be attributed to?

Finally, my normal heart rate is in the 60's. What could account for it elevating to the 90s and remaining there for several hours despite the fact that I'm not engaging in physical activity at the time?

Answered by Dr. Sagar Makode (28 minutes later)

Brief Answer:
See the description

Detailed Answer:
firstly, you can certainly continue despite sinus tachycardia and you should resume your exercise gradually and increase it gradually over a period of few days so that heart would adapt and heart would not rise this much. There is no need of evaluation for it.
Episodes at rest in 150 are likely to be a fib episodes, heart rate will not rise this much without any reason. For these, I would say, it's better to be on beta blockers especially if symptomatic. Considering the risk and associated failures with the procedures, there is no point in going for re-ablation. Your episodes of 90 could be sinus or a fib. Since these are persisting for hours they are also likely to be afib and it could be sinus because it's not very high and heart rate is highly variable parameter and there are multiple internal and external which can modify heart rate like anxiety etc. So confirming these to be afib will only put you on beta blockers and not change management significantly. so either you get ecg done during episodes or holter or event monitors.

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Sagar Makode (4 hours later)

Since it appears the aFib is still present, does that present any restrictions on physical exercise? I exercise regularly several times per week doing both cardio and weights and, with very few exceptions, such as the one I mentioned earlier, I have no problems with my heart at all (except for some PACs). Since the aFib is paroxysmal and usually lasts no more than an hour, do I need to be on an anticoagulant stronger than baby aspirin?

Thanks so much for your time and feedback.

Answered by Dr. Sagar Makode (3 hours later)

Brief Answer:
No restrictions

Detailed Answer:
There is no restrictions on the physical activities and exercise. You can have it till you symptoms allow.
Regarding, anticoagulation, it is not dependent on how long the episodes persist, even if someone is having for a minutes then also he may be a candidate for anticoagulation. Anticoagulation depends on chadsvasc score, if 2 or more then one will need anticoagulation more than baby aspirin. This score has various points like history of heart failure like shortness of breath, hypertension, age more than 65, diabetes, history suggestive of stroke like weakness of body part, sudden onset loss of consciousness or facial deviation etc. If you any of these positive then let me know. Some of the parameters have two points. I guess this must have been calculated for you by your EP.

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Sagar Makode (1 hour later)

My CHADS score is 0, so guess I'm good on the baby aspirin.

Answered by Dr. Sagar Makode (2 minutes later)

Brief Answer:
Yes, it's good

Detailed Answer:
So you don't need anticoagulation at this stage. Aspirin is enough.

Note: For further queries related to coronary artery disease and prevention, click here.

Above answer was peer-reviewed by : Dr. Remy Koshy