Hello Ms XXXXXXX

Thank you for your query.

I was not able to download or open the pdf file (shows 0 bytes, corrupted file). Can you upload that file once again? Can you also upload the ECG as an image file?

I understand that your father, aged 77 years, from Macedonia who is a hypertensive patient with BP well controlled on medication, is now diagnosed with Atrial Fibrillation (? not fibrosis, I think. Correct me if wrong) and flutter. Cardioversion is being contemplated.

There are two types of cardioversion - electrical and pharmacological. In electrical cardioversion, a controlled electric shock is administered by means of paddles placed on the chest with ECG synchronization to convert the rhythm to normal sinus rhythm. Sedation is given to the patient so that he does not feel the shock. Full anaesthesia and muscle relaxants are given in special circumstances only.

In pharmacological cardioversion, an intravenous drug is administered to achieve the conversion to normal rhythm. Subsequently, oral drugs may be given to maintain the sinus rhythm.

Many a time, an initial electrical cardioversion may be followed with intravenous/oral drugs to maintain the normal rhythm.

The success of the procedure depends on the technique, the underlying rhythm, the duration of the arrhythmia, the presence of underlying heart disease, the size of the atria, presence of any electrolyte disturbances, etc. It is also essential to ensure that there are no blood clots in the chambers of the heart which could embolize to different organs during the cardioversion.

The maintenance of sinus rhythm and risk of recurrence would depend on the cause(s) of the arrhythmia, the atrial size, the medications that are given and the presence of any other triggering factors.

If a patient has had one episode of atrial fibrillation/flutter, there will always be a risk of recurrence. However, that risk can be minimized by using appropriate drugs to prevent the arrhythmia, controlling the BP well and avoiding any other precipitating factors.

Under controlled circumstances, cardioversion is quite safe. The maintenance of sinus rhythm has a lot of advantages in an elderly male with hypertension who will depend on normal atrial pumping mechanism to achieve a good cardiac output, especially when the ventricles may be stiff. The complications are rare and include problems due to the sedative drugs, local pain/burn marks, precipitation of other arrhythmias including fatal ventricular fibrillation, thrombo-embolism, rare incidents of myocardial damage, and recurrence of the arrhythmia later.

The risks of a continuing arrhythmia include serious risks of thrombo-embolism (when blood clots form in the cardiac chambers due to stagnation of blood and these clots may get embolized to different organs resulting in stroke, gangrene of limb, splenic infarcts, damage to gut, etc). Also, the heart rate becomes fast and may precipitate ischemia in an elderly individual with co-existing coronary artery disease. The overall pumping of the heart also reduces over time.

Since the arrhythmia has been present for a month, it is essential to do an echocardiogram and/or a trans-esophageal echo to ensure that there are no clots in the heart already. Also, it may be better to put him on anti-coagulant drugs.

In the absence of any specific contra-indications for cardioversion, and considering the fact that benefits far outweigh risks, and that risks due to continuing arrhythmia are quite significant, I would recommend that you go ahead with cardioversion followed by medication.

There are other treatment options for a recurrence of the arrhythmia including specific drugs, certain types of pacemakers, atrial defibrillators, radio-frequency ablation, etc.

I hope this clarifies some of your doubts. Feel free to get back to me for any further issues and of course, I will get back to you after you upload the file once again.

With regards,
Dr RS Varma

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Hello XXXXXXX

Thank you for the clarifications.

I was able to open the files and see all the reports.

I could not understand the descriptions in Macedonian language. But the ECG confirms a diagnosis of atrial fibrillation. Also, the echo report shows mild stenosis (blockage) of the aortic valve along with mild regurgitation (leak). There is no need for any active intervention for this age-related mild valve disease. The underlying function of the heart appears to be good.

Atenolol, Enap and Enap H are for the blood pressure. In addition, they are beneficial for the heart also. Sincum is an oral anti-coagulant given to prevent blood clots from forming within the cardiac chambers. Propafenone is an anti-arrhythmic drug given for the atrial fibrillation. Atoris is atorvastatin for reducing the cholesterol levels. It may also help in preventing worsening of the aortic valve disease.

"I think that, given all the data, there should be one good attempt at restoring normal sinus rhythm with the help of electrical cardioversion".

The drugs can be continued to try and maintain sinus rhythm. If this is successful, it will be very good for the patient. In case it does not succeed, then there is no option but to accept the arrhythmia and continue the medicines at optimum dosage.

The anesthesia required will be decided by the treating doctor according to the protocols in that particular hospital. Sedation is usually adequate, with precautions taken for airway support, resuscitation and ventilation in case of any emergencies. Some cardiologists prefer full anesthesia with muscle relaxants. It would depend on the personal preference of the cardiologist and the protocol followed in his/her institution.

I hope this answers your query. Feel free to get back to me for any further clarifications.

With regards,
Dr RS Varma

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Hello Ms XXXXXXX
Thank you for follow up query.

As regards your first question, the answer is yes, there are patients controlled with medication. Atrial fibrillation can be of different types and can have varied presentations. If one sincere attempt at conversion to sinus rhythm fails, then the best course would be to manage with medicines. Instead of electrical cardioversion, pharmacological cardioversion with drugs like Ibutilide can be tried also.

Yes, I do think that, despite symptomatic improvement, there should be at least one good attempt at attaining sinus rhythm. This assumes, of course, that the symptomatic improvement is due to spontaneous or drug-related correction of the arrhythmia, and that AF is still persistent.

A full month of oral anticoagulants are advised because, the atria can harbour small blood clots since the chambers do not contract because of the arrhythmia, and stagnation of blood can lead to clot formation. When the atria resume their normal function, these clots can get dislodged and can "embolize" to different parts of the body and cause obstruction to blood flow.

Travel is usually safe, if the usual precautions are followed and the arrhythmia is well controlled. He will need to continue his medicines at the proper times and have food/fluids at regular intervals. He will also need to do some walking along the aisles every two hours or so, to prevent blood pooling in the legs and XXXXXXX vein thrombosis. Depending on the customs regulations of the countries involved, he may need to keep a copy of his medical reports, doctor's prescriptions and bills for the medicines that he is carrying. A break for a day in between may lessen the strain of the journey, but that depends on the individual concerned and your father may be the best judge of how he wants to travel.

For the last question that you asked, the answer is yes, there can be chest pain during the arrhythmia in selected cases.
1) Due to the fast rate of the heart, when the heart does not get adequate time to relax in between two beats.
2) In patients with obstructive coronary artery disease, the arrhythmia can precipitate unstable angina.
3) Persistently rapid heart rates can lead to a fall in the pumping efficacy of the heart.
4) Mild age-related leaks from the valves may be exaggerated during arrhythmia.
5) Certain arrhythmias may cause fall in blood pressure to low levels and produce ischemia.

The presence of chest pain during arrhythmia is usually a good indication to do an electrical cardioversion at the earliest possible time.

I hope I have been able to clarify all the issues that you have raised. Please feel free to get back to me for any further questions that you may have.
With regards,
Dr RS Varma

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