Hello all, hope all is well, I have a question about flecainide for afib, I went to see an EP about 5 months ago who suggested I have an ablation for my paroxysmal afib and at some point remove my pacemaker because of my low percentages which was very much concerning to me so I opted for a second opinion. This other EP from the boston location came highly recommended and said ablation would be a last resort so he put me on this medicine and lowered my pacing rate to 45. He also stated to leave the PM in  case I should need it down the road. My question with flecainide is how low it makes my heart rate. When im at the gym before the flecainide I could raise my hr up to 125/130 and now maybe at the highest 105. Also, ill be sitting at my desk and notice my apple watch  reading around 47-54 which makes me somewhat nervous. Are the low rates a concern? I am also one day left on my 2 week zio patch my EP had me wear just . Im just a little nervous it gets that low. Be well


Heart Rates

by Penguin - 2023-10-01 04:11:41

Hi Athena, 

With one day left on your 2 week zio patch I'd wait to see the results before you (or we) second guess the reasons for the heart rates you describe. The zio patch and pacing %s now that your pacing rate has been reduced to 45 bpm will help you decide whether or not you are comfortable with your pacemaker turned down and how you might feel without it.   The flecainide muddies the waters a bit. I'd have preferred to see the effect of a lower pacing rate without rate lowering drugs (if that's what flecainide does?)

Re: Heart rate of 105 exercising at the gym (cardio?)  How do you feel exercising at that heart rate and are you getting the reading from your Apple watch?  Is it accurate?

Re: Heart rates of 47-54 at your desk. This may show that your own heart is managing a resting rate of 47-54 bpm on it's own but again, that depends on the accuracy of the apple watch. It will be interesting to see how much pacing you are receiving with a lower rate of 45 bpm. 

I don't know whether your h/rates of 47-54 (if accurate) are a concern or not.  People I know who are athletic and super fit boast about resting heart rates in this range.  Are you super fit and how do you feel at these heart rates when working and exercising. Do you feel any different?

The AF and how flecainide potentially controls your susceptibility to an AF attack and protects you would be my primary concern for now, along with the frequency of any AF attacks.  That may be difficult to determine with a drug for AF prescribed during the period of Zio patch testing! Will you get a true reflection of your underlying AF issue and it's frequency with flecainide in the frame?

 It's not a drug I have any experience with, so I can't comment, but I'm sure other AF sufferers will chime in. 


Paroxysmal AF and Flecainide

by Gemita - 2023-10-01 13:30:52

Hello Athena, nice to hear from you again.  I can imagine your concern when you were advised to have an ablation for your paroxysmal AF and then at some point to remove the pacemaker because of your low percentage of pacing.  I am glad you sought another opinion.  It was certainly the right thing to do.

I am unclear why you were told an ablation would be a last resort.  Today, an ablation (a regular ablation around the pulmonary veins) is often a first line treatment for Paroxysmal AF although our symptoms usually have to justify such a procedure.  In other words we usually have to be so symptomatic, having tried and failed other less invasive treatments first, like medication, before we are offered an ablation (at least that has been my experience in the UK).

Treating an arrhythmia like AF often requires powerful medication to try to stop it completely.  I see you have had a Zio patch for two weeks and this will help you and your doctors to know how frequently you are getting AF and how symptomatic you are, although sometimes paroxysmal AF can often be less frequent than every two weeks.

I am unclear why your lower rate is now set at 45 bpm.  This does seem rather low, unless your own natural heart rate is well above this level and your new EP from Boston wants your own heart to do more of the work to assess just how much you are using your pacemaker.  I agree that leaving the pacemaker in place is the best policy because treating AF may uncover other difficulties, like another arrhythmia.  Using powerful meds that could reduce heart rate is much safer when a pacemaker is in place, hence your EP’s comment to leave it in, in case he should need it down the road.  

Now on to your main question, Flecainide.  Flecainide is a popular, first line anti arrhythmic treatment for many arrhythmias, providing we do not have any structural heart disease (heart failure, CAD, reduced ejection fraction) when it would be contraindicated.  Pro arrhythmic effects can occur unfortunately with many anti arrhythmic meds.  For example I developed Atrial Flutter as a result of treating my AF with Flecainide.  My fault because I failed to take a low dose rate control medication (like a beta blocker) at the same time, to help prevent this from happening.

Flecainide for the first couple of years worked well for me without any real symptoms or side effects, apart from a bit of blurry vision. I remember when it was first tried I met many patients on it and they reported similar success with it, especially on lower doses.  Try it and see.  You might find it works well for you and won’t lower your heart rate too much.  If it does, you have your pacemaker which can then be re-set to support you more, by raising your lower rate limit to say 50-60 bpm.  I always found my AF and other rhythm disturbances were less noticeable when my heart rate was running higher.  Personally I found Flecainide was more inclined to trigger tachycardia than bradycardia but we are all different.

Finally can I ask how symptomatic you are with your AF?  Sometimes AF cannot be stopped “completely” and it might be futile to even try.  I was told a rate control medication like a beta blocker or a calcium channel blocker to treat any high heart rates during AF episodes might be all that is required to calm AF down and a safer option than moving towards anti arrhythmic meds or an ablation which are clearly not always effective either.  But you are younger Athena and I can understand your desire to stop/find a cure for your AF.  Also if you have risk factors for an AF related stroke, you might need to consider an anticoagulant at some time in the future.

Good luck, as always

paroxysmal afib

by athena123 - 2023-10-01 16:35:31

Thank you both for the response, I had afib feb,march and april only for a short time which i was then put on Eliquis. Maybe a adjustment on my pacemaker woulld make me less tired but for now it seems to be working on 100mg 2x dailey. Maybe when i see my EP again he could lower the dose to 50 mg and see if its tolerable. I think the zio patch will let him see how my heart has performed for the last two weeks and may offer any insight. I also, Gemita experience a little blurry eye from time to time and will report that as well. Thank you both for yopur valued imput. I always feel at ease on this platform. 

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