2020 AF Symposium: AF Management 

Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause

by Steve S. Ryan

One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.

While several cases were discussed, here I summarize just one case.

Dr Eric Prystowsky 

Patient History: 75-Year-Old Female

Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN

Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.

She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.

Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.

Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.

Treatment by Dr. Prystowsky

Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).

The patient had repeatedly been offered a catheter ablation, but she declined each time.

Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).

Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.

She felt better for 5 days.

Moderate Pericardial Effusion; Medications Adjusted

The patient then developed a moderate (“significant”) pericardial effusion.

Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.

Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”

She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.

The patient had repeatedly been offered a catheter ablation, but she declined each time.

Minimizing Pacing; Medication Adjusted

The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.

A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.

He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).

Dr. Prystowsky’s Lament

He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”

One Year Later and Lesson Learned

A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”

Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.

He wrote me that it’s been over a year, and the patient is doing great.

If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2021

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