Question For Cardiac Nurses

Dinith88 · Dec 3, 2003

JayJay, i wish you and your husband well!

As far as elective cardioversion is concerned, the WORST thing that can happen is ventricular standstill (asystole) from defribilator induced 'myocardial stunning'. HOWEVER, if this very rare side-effect were to occur, the treatment is pacing...and your husband already has a pacer! Should be no problem whatsoever.

The other issue is that there's a high incidence of recurrent atrial arrythmias in people who've had the problem for a long time. As you said, your husband gets long pauses as he converts to sinus...then will flip back into a-fib/flutter. Seems his problem is 'paroxysmal' arrythmia, and i wouldn't be surprised if he goes back into an a-fib/flutter down the road.

As far as not having an elective cardioversion and staying on meds, it'd depend on how well his rates are controlled and whether or not he's properly anticoagulated. If the current medications aren't working, have you, your husband, and the Doc discussed cordarone? Especially if his rates are refractory to all that other stuff?

Good Luck again to you both, and keep us posted!

BarbPick · Dec 4, 2003

Jay Jay,

If it doesn't work, your husband can be elected President. George Hurbert Walker Bush had atrial arrythmias his entire presidency, and still does today.

The fact that they didn't keep him and admit him right then should tell you they felt it could wait.

I also agree, no amiodarone?

Barbara

Jay-Jay, RN · Dec 4, 2003

My husband asked me to research amiodarone for him, and what I found scared the daylights out of him. Would you want to take a drug that has a 50% rate of side effects? Also, his opthamologist said, "I wouldn't take it if I were you. It builds up in the cornea, and can damage your eyesight."

He spent most of the day in hospital today. He's still in a-fib, but they got the rate down to the 60's-70's, using Rhythmol, plus a few other drugs.

The beeping of the machines, plus the nurses standing at the nursing station, gossiping, and TOTALLY ignoring him when he had an angina attack finally got to him. He signed himself out, and called me to come and take him home! I didn't try to convince him otherwise. If this can be controlled with drugs, that's FINE by me!

Ted · Dec 4, 2003

Jay-Jay:

So sorry to read about your husband's situation (both cardiac and hospital experience!)

Just want to wish your husband and you warm wishes as you tackle the a-fib problem together.

Understand I'm not an expert cardiac nurse. I learn more by reading this particular forum and rarely I contribute to it, sadly.

But I've never seen any one treatment work best for people who develop a-fib/flutter. This included electric cardioversion, beta-blockers, amiodarone (sp?), etc. Patients either convert and stay in sinus (if they convert at all), or convert and revert back to a-fib/flutter at some point in time. What I usually see, more often than not, is an attempt to convert back to sinus the patient who is a newly a-fib/flutter within a short period of time (

Usually . . . if it's realized that a person will probably be a "chronic a-fiber" the goal is rate control and therapeutic anti-coagulation.

And. . . people do convert on their own sometimes. Let's just hope that they've been adequately anti-coagulated during that time! :eek:

Again, warm wishes to your husband.

Ted

Havin' A Party!, ASN, RN · Dec 5, 2003

Agree with Ted.

Latest studies indicate rate control is where it's at (rhythm's not crucial).

Your hubby's right. Amiodarone is super scary.

Of great importance is anticoag treatment. Aspirin, if young (

Another option: If he's symptomatic and wants to stay off meds, look into an ablation.

All the best!

Ted · Dec 5, 2003

originally posted by larryg
. . . another option: if he's symptomatic and wants to stay off meds, look into an ablation.

all the best!

yep! i was thinking the same thing too. but i never see stuff like that in my small, my very, very small. . . my really freakin' very, very small hospital. if an ablation is done to one of our patients, it's after they're shipped to "teaching hospital general".

we had one patient specifically transported to one of those "teaching hospital general" type facilities for a possible ablation from an uncontrolled rate problem related to wpw thingy. of course no one really knows what happened to that patient; what type of therapy was provided, outcome, etc.

hippa is so not hip. . . .

but that's another topic for another thread for another time.

ted

testing edit function

Dinith88 · Dec 5, 2003

An ablation would be an option if this problem were 'ablatable'.

Unfortunatley, a-fib/flutter isnt 'ablatable' because there is no 're-entrant track' to sizzle. The entire atrium/atria are fibrrilating/fluttering...and sizzling the entire atrium would be detrimental to a patient's health

Also, it sounds as though his problem has a sick-sinus-sindrome/tachy-brady component (requiring a pacemeker)> In this circumstance, the problem is a malfunctioning sa-node. Again, sa-node ablations arent done....it'd ruin whatever intrinsic pacemaker a patient has. In fact, even in re-entrant svt, if the 'track' is close to the sa-node, ablation isn't done because of the risk of frying the node.

Ablation is a wonderful option for those who have abalatable problems. Unfortunatelty, not all (the majority) of atrial arryhtmias cant be fixed this way.

The classic rhythms that can be ablated are WPW and SVT's caused by a re-entry track (WPW is ALWAYS caused by a re-entrant track)

Dinith88 · Dec 5, 2003

LarryG,

Just read your comment about being

The risk for developing a clot is very real in a-fib. Coumadin is a standard treatment for prevention of a-fib associated thrombus.

Aspirin is less effective but will occaisionally be given as a substitute for coumadin in very elderly patients (at increased risk for falls, co-morbidity/bleeding issues, etc.), or those who are unable to tolerate it (for whatever reasons).

A person with a-fib who is less than 65 and is on aspirin rather than coumadin is rolling the dice and flirting with stroke. Although i'm sure the chance of clot would be lessened with aspirin (minimally), coumadin is the treatment of choice and would provide much better protection.

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Dec 5, 2003

Originally posted by Dinith88
An ablation would be an option if this problem were 'ablatable'.
Unfortunatley, a-fib/flutter isnt 'ablatable' because there is no 're-entrant track' to sizzle. The entire atrium/atria are fibrrilating/fluttering...and sizzling the entire atrium would be detrimental to a patient's health

Also, it sounds as though his problem has a sick-sinus-sindrome/tachy-brady component (requiring a pacemeker)> In this circumstance, the problem is a malfunctioning sa-node. Again, sa-node ablations arent done....it'd ruin whatever intrinsic pacemaker a patient has. In fact, even in re-entrant svt, if the 'track' is close to the sa-node, ablation isn't done because of the risk of frying the node.

Ablation is a wonderful option for those who have abalatable problems. Unfortunatelty, not all (the majority) of atrial arryhtmias cant be fixed this way.

The classic rhythms that can be ablated are WPW and SVT's caused by a re-entry track (WPW is ALWAYS caused by a re-entrant track)

They are doing ablation therapy to both AFib and Flutter now at the Mayo clinic. I have had several patients that were referred to Rochester for persistant Afib despite attempts at Cardioversion, Tikosyn and other anti-rhythmics. Another thing that is big is the MAZE treatment that has a high success rate. I have noticed though that both groups (ablation/MAZE) usually end up with pacers eventually.

http://www.mayoclinic.com/invoke.cfm?objectid=CB7DC907-CA64-499D-B8B4C9F9BF3C2F9F

Dinith88 · Dec 5, 2003

Moonshadeau,

I skipped to the link and glanced at it. It did state that ablations arent as successful in a-fib.

The idea of ablating a-fib is VERY new(and very wierd!) and must be experimental???

I'm wondering how an a-fib could be ablated? Are you familiar with the techinique? We've never had a patient thats been ablated for af (we have a fairly busy ep-lab that does lots of ablations)

I work with a couple hot-shot electrophysiologists...and i'll get their 2cents.

I'm wondering What would be ablated????

Again, i'll ask them and get back to this board (probably on mon. or tues. when i see them next.)....?

Thank you very much for the info!...

Dinith88 · Dec 5, 2003

moonshadeau,

It just dawned on me that sometimes our EP dept. does ablations for patients with refractory a-fibs...but they don't exactly stop/cure the a-fib. ...and they arent ablating an atrial focus..but rather wiping out the AV-node. These people are ALWAYS given a pacemaker, as their subsequent underlying rhythms will be junctional.

The AV-node can be considered the ventricles' "ears". The ventricles normally beat when the AV node 'hears' the impulse (sent by the sa-node via the atrial tracts). In A-fib, the atria are quiverring, and all the AV node 'hears' is a bunch of 'static'. It's because of this that the ventricles beat irregularly and rapidly.

So, in essence, with AV-node ablation, the ventricles become 'deaf' to this atrial activity and will beat to their own tune. (junctional rhythm)...and will require pacer implantaion.

This procedure is uncommon, because the patient then becomes completely Pacer dependant. And because the a-fib isn't 'cured' these patients will still be at risk for thrombus formation and need to be anticoagulated even though their pacer rythm will be regular.

I'm guessing these are the type of patients you're familiar with??

After looking at the Mayo-site, i think the 'new' procedure they're speaking of is a curative ablation of an atrial focus that's triggering the a-fib???

That has never been done where i work and i would bet that the patients that qualify for this treatment are rare. (but again, i'll ask the EP doc's at my place of employment)