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Atrial Fibrillation

 Poster: A snowHead
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I certainly didn't realise I had AF. I'd recently had a routine ECG which my GP had told me was fine (I suspect she was wrong). When I made a GP appointment because I didn't feel right the guy who saw me (a retired GP doing locums to buy a new suite of sails for his yacht) took two minutes with a stethoscope - to diagnose tachycardia, AF and fluid on the lungs and prescribe beta blockers and anticoagulants to be taken IMMEDIATELY. The cardios in Portsmouth wanted me in the next day and I was there for a week. The fluid took quite a lot of getting rid of - mainlining furosemide at one point. Now I take a furosemide every few days, when I feel the need. I have never been overweight - BMI 23 - 24 depending on how much fluid I'm carrying! I suspect a lot of cardio-vascular problems are genetically related - plenty of it in my family. But absolutely no dementia - so I'll take my chance with heart failure. With modern drugs the outlook is a lot better than it used to be and the community heart failure team was very good, when I eventually saw them (they were overstretched). They've discharged me, but I can contact them any time I feel the need.

My cardiologist specifically told me NOT to buy any fancy watches. Laughing
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@pam w, My cardiologist is very happy I have one and has asked me to ping him any ECGs if I’m worried. I have done occasionally but would never abuse that privilege!
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@genepi, sounds better than my consultant cardiologist at Tommy's who didn't bother reading my echoes over a few years. The valve consultant (and even my surgeon) at Guys took one look at 3 consecutive annual echoes and said it was perfectly obvious the first implant was failing. I'm glad I'm out of his clutches now and under the Valve Clinic. rolling eyes
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@Hells Bells, Thanks for that. The last time I spoke to a GP about my Warfarin, he told me the difference was that Warfarin had an antidote but the other drugs didn’t, so it was a balance on risks. That’s interesting that there are now antidotes to some of the others, so I might have to revisit sometime. @genepi, I’ve found my Apple Watch to be great for keeping an eye on it, but I’ve never detected any AF since I went on Bisoprolol and I have had an ECG which showed normal too. Obviously there may have been episodes when I haven’t monitored it.
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@geepee, the balance of risk changed quite a bit when Covid came along. It was riskier to bring patients in for warfarin monitoring than it was to switch them to a newer drug which might need kidney function checked every 6-12 months. As the newer (DOACs) drugs were safer than warfarin, many were changed over. As a pharmacist of a certain age, who first became interested in such things when I was just a teenager with an aunt taking warfarin every day, it is a big step change.
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@Hells Bells, Thanks for that. I had my Warfarin checks moved from a nearby GP surgery to another health centre due to Covid measures. I’d be happier on other drugs that don’t need regular testing, as I had to organise a test in Austria one year that cost me €70. Time to revisit options again. Thanks you for your advice. Much appreciated.
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@Hurtle, that sounds dreadful! I’m glad you’re in safe hands now. When I saw my cardiologist in Toulouse pre-op the other day, he asked to see what had been going on and scrolled through all my ECGs on my phone. A lovely man he is too.
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I had a really cheap heart rate monitor which really only measured bpm average, max and min over the exercise period. I found it useful to test out certain exercise routines like cycling, walking, running, hill climbing, cross trainer and see which were the most taxing. In the end I used this data to decide to concentrate on running as the other exercises never got my heart rate in the correct cardio zone for long enough. Running is fairly consistent and will get me in 70%-90% zone and above if I do some HiiT training mid run.

I also used it to monitor for changes. However, it eventually broke after 15 years.

This monitor was used to compare other readings from blood pressure monitor, and oximeter. (as well as a manual check)

I have never had reason to suspect any heart problems. Only that at rest, lying down my heart rate is 40bpm. Sitting at rest it is 40-50bpm.

I do not do stress testing anymore. I stopped doing that at about age 40-45, and focus on not putting too much pressure on my heart. Even so I still do running regularly, but never get out of breath and I am reducing distance sometimes to relieve pressure on muscles and joints which are recovering from injury.

Sometimes in the summer I will do some sprinting mid run to get me out of breath.

Never really liked smartphones, or apples. Not enough protection against viruses, and inadequate mobile signal where I am other than 2g.

I had a minor operation in 2018 to remove a non cancerous lump under general anaesthetic, during which my heart rate was monitored for the period under anaesthesia. I suspect if I had any unusual heart beats it may have appeared there. (a nurse mentioned afterwards that I must be very active, suggesting my heart rate was very low)
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Thanks for the fascinating thread, and all the stories.
Pro athletes get more AF because their huge hearts have more potential for crossed wires.
If I was the OP I might consider not taking anything.You obviously have some tendancy to AF but if it only comes on when hospitalized with pneumonia and shortly after, then I'm not sure lifelong meds are worth it. Stats apply to large groups of people and medicine inevitably involves increasing uncertainty when individual circumstances are considered.
If AF on and off in normal times I completely agree with the cardiologist.
Personally I'd have a chat with your doc and get a smart watch / Holter off the meds and see what happens. Risk of stroke per day is low, but over the years adds up. This clearly should be discussed properly in reality and this web post is not medical advice.
My 2p I'm a GP.
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Thing is, as I wrote near the top of the thread, AF is quite a common symptom. "What of" needs to be established for each individual before the optimum treatment can be identified. Then, when you have established that, you need to get on with it and not fret. One thing we CAN be sure of is that fretting/anxiety never did anyone any good.
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"Studies have demonstrated that athletes who engage in endurance sports such as runners, cyclists and skiers are more prone to AF than other athletes."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135187/

Many of my non professional exercise routines have been modified in my 40s as I became aware of the impact extreme exercise can have on the heart (particularly extreme weight lifting for the purpose of body building and endurance sports like long distance marathon running)

My modifications were because the primary purpose of the exercise was for good health. Consequently, if extreme exercise results in bad health I defeat the object.

Definitely one to watch out for, as you age if you are particularly sporty.

Another series of studies I examined looked at a reverse J shaped mortality curve improvement based on exercise from runners. In other words from no exercise up to a sweet spot there is mortality improvements in those who do running regularly. This improvement is lost gradually as the running becomes excessive. Further examination of the extra mortality in extreme runners suggests cardiovascular issues cause the excess deaths.

This sweet spot appears to be about 3 jogs a week which is my current target/average. (I was running too far and too frequently in the noughties, and so modified my behaviour)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431070/

"Conclusion

If one’s goal is to decrease the risk of CV events, and improve life expectancy, a regular regimen of moderate activity is adequate. Very high doses of strenuous exercise may attenuate some of the benefits bestowed by less extreme efforts.....
...... Even so, we should emphasize that the maximal benefit for CVD risk reduction occurs at much lower, safer and more moderate exercise doses."


https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.118.039461

A further article which puts it all in perspective for skiers.

"..Although very well-trained men have a higher incidence of atrial fibrillation than less trained men, the incidence is on par with that of the general population and not related to a higher incidence of stroke at group level. This indicates that exercise has very beneficial effects on other risk factors for stroke..."

https://snowheads.com/ski-forum/viewtopic.php?t=157109&highlight=

https://www.escardio.org/The-ESC/Press-Office/Press-releases/One-small-alcoholic-drink-a-day-is-linked-to-an-increased-risk-of-atrial-fibrillation

The other argument is that sporty people drink more alcohol. (see snowheads thread above) Perhaps this effect has not been removed from the interaction effects of the limited data on which the studies are based on? Interesting that there is another reverse J shaped cardiovascular event curve caused by alcohol consumption. So moderation with alcohol and exercise are advisable to avoid atrial fibrillation.

Reading the above article more thoroughly it actually says

"...researchers found that although low doses of alcohol were associated with a reduced risk of heart failure compared to teetotallers, a similar ‘J’ shape reduction in risk was not seen for atrial fibrillation. This suggests that the increased risk of atrial fibrillation among people drinking small amounts of alcohol was not triggered by heart failure....."

“....These findings are important as the regular consumption of alcohol, the ‘one glass of wine a day’ to protect the heart, as is often recommended for instance in the lay press, should probably no longer be suggested without balancing risks and possible benefits for all heart and blood vessel diseases, including atrial fibrillation.....”

In other words to avoid atrial fibrillation completely you should be t-total. Although, you are then at greater risk of other forms of cardiovascular disease.

"...Together with a recent randomized trial showing that a reduction in alcohol intake led to a reduction in AF recurrence, these data suggest that lowering alcohol consumption may be important for both prevention and management of AF. Importantly, any reduction in low-to-moderate alcohol consumption to potentially prevent AF needs to be balanced with the potentially beneficial association low amounts of alcohol may have with respect to other cardiovascular outcomes . . . The net clinical benefit of consuming low amounts of alcohol requires further study, ideally in adequately powered randomized trials. Until then, each individual has to make its own best educated decision as to whether consuming up to one alcoholic drink per day is worthwhile and safe...”

https://www.nhs.uk/conditions/atrial-fibrillation/causes/

It is probably worth looking at the nhs website as this should be the first source of information. Unfortunately, the NHS does not usually have a section on prevention. In this case it is because they do not know the cause

"..The exact cause of atrial fibrillation is unknown, but it's more common with age and affects certain groups of people more than others..."

https://www.escardio.org/The-ESC/Press-Office/Press-releases/fish-oil-supplements-linked-with-heart-rhythm-disorder

Latest study finds omega 3 fish oils can increase the risk of atrial fibrillation!

"Sophia Antipolis, 29 April 2021: Omega-3 supplements are associated with an increased likelihood of developing atrial fibrillation in people with high blood lipids. That’s the finding of a study published today in European Heart Journal - Cardiovascular Pharmacotherapy, a journal of the European Society of Cardiology (ESC).1....."

I wonder if runners, skiers and cyclists are more likely to fortify their diet with fish oils to extreme levels? (they probably do not as a group have high cholesterol levels though)

Further examination of pulse pressure indicates that high pulse pressure (above 60mmHg) can indicate a higher likelihood of developing atrial fibrillation. I know that I average a pulse pressure of about 50mmHg which is slightly higher than normal. However, I think this is because my pulse rate is lower than normal and so the stroke volume is larger in my heart than average. (which makes the pulse pressure higher: all other things being equal)

As we age pulse pressure naturally gets bigger, particularly for those over age 50 (like me). However, in my case the pulse pressure is not abnormal particularly as my pulse rate is naturally slow at rest.

https://www.aerjournal.com/articles/atrial-fibrillation-and-oral-health

This study suggests there is a strong link between AF and severe periodontal disease. Suggesting the bacteria in dental disease can cause AF (as well as CVD).

Flossing daily can be a particularly useful prevention method of dental diseases. In my personal experience, oral irrigators in addition to flossing and using an electric toothbrush are useful in improving gum health and eliminating plaque.
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And love to help out and answer questions and of course, read each other's snow reports.
We've come a long way since the original question in this thread which was specifically about possibility of skiing with AF.
I was diagnosed with persistent over a year ago and have since had two 'reboots' (cardioversions). The first restored my heart rhythm for 11 months and the 2nd for just 5 weeks. Further 'reboots' are not recommended (as my heart rate is slow - bradycardia) and I've now been referred for radio-frequency catheter ablation - waiting list 18 months (I guess that's what we get when a government neglects public services for 12 years).

The first thing I learned about AF is that it comes in a variety of 'flavours' and within each of these flavours there's an even wider range of intensities. The sheer variety of AF types and associated symptoms make it impossible to answer an apparently simple question, 'like can you ski if you have AF?' The range of answers is, literally, as long as a piece of string!

I'm not medically qualified, but I'm fast becoming what's become known as an 'expert patient'. All I can say with confidence is that the only people qualified to advise on the safety, or otherwise, of skiing with AF is the patient following consultation with their cardiologist (preferred), or GP. I can only describe my own circumstances and hope they may help to inform others in a similar position; I'm afraid those with different issues will need to find their own answers.

With huge sadness, I decided that I must cancel my skiing trips this year. MY AF is of the persistent variety (it's there all the time) and is only partially controlled by my drug regime. Moderate exercise (especially when it's cold) brings on breathlessness and chest pain (pain of this sort may be the prelude of something best avoided); the pain is caused by the heart not getting enough oxygen. Although I have a GTN spray which helps the progress of oxygenated blood, altitude (reduced oxygen) will inevitably compound my problems as will sub-zero temperatures. Fundamentally, my AF could increase my risk of a catastrophic heart event to an unacceptable level. Of course, there's only one way to really find out, but if a problem does occur I may only be aware of the answer for a few minutes!
Much as I love my skiing, I've decided to err on the side of caution and hope that my forthcoming ablation fixes me me for a few years (it's rarely a permanent solution for persistent AF). Perhaps, I'll get to enjoy a return to skiing next year and beyond...and at nearly 70 years of age who knows how many more years I'll enjoy on the mountain.
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To throw in my view..... age 76 in a couple of weeks, persistent AF and heart failure with severely compromised left ventricular function (ejection fraction under 30% when last measured by a cardiac MRI well before covid came along). Cardioversion restored sinus rhythm for 4 days.

I did ski on a Snowheads bash (pre birthday) after my diagnosis. I was fine, but took it easy, and sometimes "sat out" a round and had a coffee when my companions continued to ski. Sometimes finished earlier than the others. I've not skied since - Covid - but I am skiing with my daughter at the end of February. We are both competent piste skiers but not up for big challenges. My key challenge is anything which requires me to get myself up hills - skiing or not! Walking with skis on shoulder up a long set of steps to a gondola would mean taking it steady. Dashing up would make be me breathless.

I take lots of medications (HUGE premium on my travel insurance) but they seem to be doing a good job and I try to do strength exercises and do 3000m on my rowing machine 3 or 4 times a week. If someone has health challenges other than AF then obviously it might make sense to decide not to ski any more. But I'd say that the mere existence of AF does not make that decision inevitable. Not for me, anyway.

The prospect of a "catastrophic cardiac event" doesn't bother me. Though it would be a bit of a bummer for whoever was skiing with me......
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You know it makes sense.
@Noeyedeer, that's a shame, but as you say it's a very personal decision and the more I learn and manage my own AF the more complicated it seems to be with no "right" or "wrong" way of doing things. Out of interest what drug(s) have they tried on you?

I'm on 50mg of Flecainide twice daily, that in itself seems to cause further issues, so also on bisoprolol. However this has a known side affect of cold extremeties which I seem to be suffering quite badly with, so after chatting to the specialised arrthyima nurses I am going to try a calcium beta blocker!

I continue to do sport, running, cycling and skiing...

Explanation from them on why a beta blocker is needed in additon to flecainide:

when on regular flecainide with organised atrial arrhythmias a beta blocker is indicated. The flecainide can organise atrial fibrillation into an atrial tachy but it has no effect on the AV node, therefore is no rate control.
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I take bisoprolol but no anti-arrhythmics. A calcium beta blocker sounds interesting - will look into that. I do get cold (white) fingers, but have never had good circulation, even before taking beta blockers.

My reading is that the key risk with AF is stroke, because of the pooling of blood in the left ventricle, caused by poor pumping. DOACs (direct oral anti-coagulants) are prescribed for that, and are probably the most vital of my medications. I'm not bothered by the prospect of a massive stroke, but the prospect of small, survivable, strokes terrifies me..... Skullie
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tarrantd wrote:
Does anyone have any experience of skiing with AF? I had a recent spell in hospital with a lung infection which seems to have triggered AF. I am taking meds but unsure what things to avoid other than alcohol and caffeine.
I have had one episode since which left me wondering about skiing. Internet research suggests altitude can be a trigger and obviously raised heart rate through exercise, can make it worse.
My take is that increasing my basic level of fitness will make me less sensitive but would appreciate any actual experience. I'm 69 and planning a trip to Val D'Isere in March.


I’ve twice had atrial fibrillation “reversed” through cardioversion. If you have it I think whether you can ski will depend on how you feel. First time I wouldn’t have been able - out of breath climbing stairs. More recent event triggered in New York but after day in ER was still walking 3 or 4 miles a day albeit fairly slowly. I think I could’ve skied gentle stuff. I skied 2 weeks last year after my first cardioversion and it didn’t trigger again.

So it should be how you feel that dictates whether you can ski. I’m on low dose of Beta Blockers which helps when you have it a bit. Caffeine and alcohol are best had in reduced amounts.

Any chance you could get a cardioversion done? I’ve had mine done privately on insurance. If you don’t have insurance I think it adds up to about £1500 or so. No guarantee how long it would stick (apparently 50% revert within a month) as it’s a reboot and the underlying issue can only really be fixed with ablation.
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pam w wrote:
I take bisoprolol but no anti-arrhythmics. A calcium beta blocker sounds interesting - will look into that. I do get cold (white) fingers, but have never had good circulation, even before taking beta blockers.

My reading is that the key risk with AF is stroke, because of the pooling of blood in the left ventricle, caused by poor pumping. DOACs (direct oral anti-coagulants) are prescribed for that, and are probably the most vital of my medications. I'm not bothered by the prospect of a massive stroke, but the prospect of small, survivable, strokes terrifies me..... Skullie


I certainly had cold extremities when I was in AF and on Bisoprolol. After cardioversion I am still taking them as cardiologist said can be slightly preventative and when it triggered when I was on them it wasn’t as bad. Circulation a lot better but still not quite what it was..

Yes, blood thinners as you state very important. When it triggered in NY I went to emergency doctor to try to get thinners but they sent me to ER. They prescribed 10 Apixoban to get me home… $110.
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geepee wrote:
@Hells Bells, Thanks for that. I had my Warfarin checks moved from a nearby GP surgery to another health centre due to Covid measures. I’d be happier on other drugs that don’t need regular testing, as I had to organise a test in Austria one year that cost me €70. Time to revisit options again. Thanks you for your advice. Much appreciated.


I believe Warfarin is old school now. Apixoban and other thinners don’t need monitoring. (Anything ending in ban is in that group)
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@buchanan101, FWIW I'm not on blood thinners at the moment, needs reviewing as I get into my 60s apparently. Read back on page 1 for some very detailed info on blood thinners from an expert!
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@pam w,
Quote:

The prospect of a "catastrophic cardiac event" doesn't bother me. Though it would be a bit of a bummer for whoever was skiing with me......
+1 wink

I hope you have a great time - I've just had a brilliant time in Alleghe, behaving exactly as you did a few years ago, it was fine. But of course I don't have AF (except briefly after my aortic valve re-do and again when I got Covid for the second time, but short episodes in both cases). I am, however, worrying just a little bit about the walk to the Burz lift on the BB.
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kitenski wrote:
@buchanan101, FWIW I'm not on blood thinners at the moment, needs reviewing as I get into my 60s apparently. Read back on page 1 for some very detailed info on blood thinners from an expert!


I Know I've just read back - it's good stuff!

Didn't appreciate how many skiers have AF. or are prone to it. and how it's so very different.

I thought blood thinners if actually IN AF were essential for the stroke issue?
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@buchanan101, your stroke risk depends on more than just being in AF, and your risk can be calculated using a CHA2DS2Vasc score which takes into account all the risk factors (gender, age, AF, hypertension, heart failure, previous stroke, diabetes, etc) before recommending anticoagulation.
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There's a big NHS push to get everyone on DOACs on to Edoxoban, which is significantly cheaper than the likes of Apixaban (my current one). A group of us with AF was invited to our GP surgery on Saturday to get a presentation on the subject and indicate our agreement to switching.

As I am in permanent AF I don't have to worry about whether alcohol might be a "trigger". wink
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Hells Bells wrote:
@buchanan101, your stroke risk depends on more than just being in AF, and your risk can be calculated using a CHA2DS2Vasc score which takes into account all the risk factors (gender, age, AF, hypertension, heart failure, previous stroke, diabetes, etc) before recommending anticoagulation.


Ok, just googled a link.. I can only assume my cardiologist has done this in his head without telling me because I think I'm 0 (https://clincalc.com/cardiology/stroke/chadsvasc.aspx). Not sure about C but I've had an echocardigram that picked up nothing

I'm only on thinners when in AF and for a month after Cardioversion. But this is interesting, thank you - if and when my AF triggers again, should I be on thinners given low or very low CHA2DS2Vasc score

There's also the new NICE guidelines in UK for stroke risk and statins for stroke risk over 5% in 10 years...


Last edited by You'll get to see more forums and be part of the best ski club on the net. on Mon 16-01-23 15:43; edited 1 time in total
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pam w wrote:
There's a big NHS push to get everyone on DOACs on to Edoxoban, which is significantly cheaper than the likes of Apixaban (my current one). A group of us with AF was invited to our GP surgery on Saturday to get a presentation on the subject and indicate our agreement to switching.

As I am in permanent AF I don't have to worry about whether alcohol might be a "trigger". wink


Guessed it was cheaper! OH's step Dad had Edoxoban but that resulted in blood in his urine so he's on Apixoban
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@pam w, there is also a big safety study that suggests that apixaban is the safest and most effective DOAC. Surgeries are being pushed into switching patients to Edoxaban, simply becaust the NHS has got into bed with the manufacturers to secure a cut price deal. The surgery will hit a target and get a payment for dwitching their patients to Edoxaban. Apixaban is about to come off patent very shortly, and price will drop.Hence, in a couple of years time we (and yes it is usually the pharmacist in the GP practice doing this) will be being asked to do the opposite.
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That's interesting, @Hells Bells. I did wonder about that. When does Apixaban come off patent?
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@buchanan101, do you mind me asking how old you are? And do you therefore take a thinner for the hours you are in AF and then stop when the episode stops?
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Can't see any mention of the Valsalva maneuvre so far, so thought it was worth flagging for anyone with paroxysmal AF, as a possible route to self-cardioversion after discussion with a medical professional. https://www.webmd.com/heart-disease/atrial-fibrillation/valsalva-maneuver

Also if you want more data on your heart rhythm, the Fourth Frontier HR monitor provides realtime ECG monitoring during exercise, without the need to hold your apple watch in a funky way while trying not to fall off your bike Happy As with the Kardiamobile device, there is apparently some "AI" involved that can help spot various arrhythmia.
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Breathing is certainly important. There are relationships which are only just beginning to be understood between breathing and heart rhythms. Long slow breathing out is also helpful - and not only for AF. Also for panic attacks or general stress. My cardiologist advised me not to bother with trying to monitor my heart rate. He said the important thing was how I felt, and advised me to do whatever exercise I felt comfortable with.
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kitenski wrote:
@buchanan101, do you mind me asking how old you are? And do you therefore take a thinner for the hours you are in AF and then stop when the episode stops?


61. I am currently on until I see cardiologist next week at follow up for Cardioversion just before Xmas. I will stop then. I did last time.

(His mantra is you have to be on thinners for a month before and after Cardioversion)

When I've been in AF I am permanently in AF... my watch keeps telling me
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Quote:

my watch keeps telling me

that's why it might be best not to bother with gadgets and apps. I rarely think about it.
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pam w wrote:
My cardiologist advised me not to bother with trying to monitor my heart rate. He said the important thing was how I felt, and advised me to do whatever exercise I felt comfortable with.


I suspect that's because you have permanent AF so an HRM wouldn't tell you much incremental.

With paroxysmal AF the advice I've had is that "AF begets AF" and it's best to drop out of it where that's in your control (i.e. exercise induced). A monitor helps identify asymptomatic AF and also provides much more data to a cardiologist, where your heart might behave normally during a check-up.
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pam w wrote:
That's interesting, @Hells Bells. I did wonder about that. When does Apixaban come off patent?


It has already, but the manufacturers are appealing the decision not to allow them an extension.
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Hells Bells wrote:
pam w wrote:
That's interesting, @Hells Bells. I did wonder about that. When does Apixaban come off patent?


It has already, but the manufacturers are appealing the decision not to allow them an extension.


The price I paid in New York - $10 a tablet, two of those a day - shows the cost of Apixoban.

However, if Pharma weren't protected by patents, they wouldn't do the research. Worked on inhalers for AZ a few years ago, and someone said that something like 1% (or at least a very very low %) of drugs in development get to market; that's what costs the money
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How long will that take? I don't mind switching to a lower cost DOAC but if it's not likely to be for long, I'd probably opt to stay with apixaban. I take six prescription drugs and as the cocktail seems to work OK there's some argument to leave it as it is. Does edoxaban use the same mechanism?
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Then you can post your own questions or snow reports...
@buchanan101, thanks, I was on thinners for 3 months before my ablations so that makes sense.

@snowdave, my cardiologist said something similar along the lines of the heart "likes" being in AF and will stay in that state if it can!!
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 After all it is free Go on u know u want to!
After all it is free Go on u know u want to!
pam w wrote:
Quote:

my watch keeps telling me

that's why it might be best not to bother with gadgets and apps. I rarely think about it.


Learnt to ignore it.

It was very useful first time - I didn't know what the heck was going on, just felt really weird...
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@kitenski cardiologist thinks I will need ablation eventually - determined to beat 15 months for this Cardioversion (sudden extreme heat entering a non ventilated ticket machine area beneath Times Square triggered this relapse, so I need to manage the triggers). He says I will need 2 ablations, one for flutter, one for fib! I'm not keen...
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Much more interesting thread than all that guessing and hoping about snow...
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