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Major Coumadin Problems, on Sotalol For 8 Years, Then Cryoballoon Ablation at Age 74

By Larry Stichweh, Lacey, WA, August 2017

Larry Stichweh, Lacey, WA

Many of the shared personal A-FIB experiences on describe a long and complicated path to a cure. But mine, not so much.

But it did involve these issues: a bad experience with Coumadin, effective long-term use of Sotalol (Sotalol becoming an important component of my blood pressure control), significant congestion side effect of Eliquis, and a single successful cryogenic PVI ablation with no complications.

I hope my story is more typical of those who experience A-FIB (except for the Coumadin issue).

High Blood Pressure for 20 Years

My story begins at age 66 in 2008. I am a retired chemical engineer and was living in Pensacola FL. I had been successfully treated for high blood pressure for at least 20 years, working progressively through many hypertensive drugs and drug combinations. Up to this point my blood pressure was controlled near 120/80.

Urology Test Led to A-Fib Diagnosed at Age 66

It was taking an increasing level of meds to keep my blood pressure in check. At a routine office visit, I suggested to my doctor that we should look at possible causes of my high blood pressure.

He took one look at my ECG, took me to his office, and said he was admitting me to the hospital right then and there.

My doctor agreed, and as a starting point, sent me to an urologist to look for a kidney stenosis problem. The ultrasound proved negative, but the urologist listened to my heart and noted an irregular beat. I had no known prior history of heart problems.

The urologist sent me down the hall for an ECG with instructions to have the technician give the chart to me to take back to him. He took one look at it, took me to his office, and said he was admitting me to the hospital right then and there. He put me in a wheel chair (even though I felt no symptoms) and off I went.

He said I had no “P” wave and was in A-FIB. Thus, began my A-FIB history.

Hospitalized 6 Days: Started Arrhythmic Drug

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue. My best guess was less than two weeks prior to discovery. I spent 6 days in the hospital while I was introduced to the arrhythmic drug, Sotalol, which requires a few days of monitoring at the start to watch for undesirable reactions.

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue.

I also began anticoagulation therapy which starts with injected heparin and then migrates to Coumadin.

After 6 days in the hospital I was feeling well (though bored) but still in A-FIB. I requested a electroconversion. During the prep and anesthesia, I self-converted [back into sinus rhythm] and was sent home to begin adjusting the Coumadin level.

Weeks Spent Adjusting Coumadin Dosage

Now the “fun” begins.  I left the hospital taking 160mg Sotalol/day and 5.0 mg Coumadin with an INR of about 2.5 on April 29, 2008.  I had to report to a “Coumadin lab” every few days while they adjusted the Coumadin dosage to the target INR level.

Here is the history of the adjustments, as prescribed by the clinic technician, working toward a target INR of 2.5:

Date    INR    Adjusted Coumadin mg/day

4/29     ~2.5     5.0 as discharged from hospital
5/2       4.1       4.0
5/8       4.3       4.4 I do not know why this increase was prescribed
5/16     3.8       4.0
5/30     3.6       3.0

[SSR: These INR levels are too high for someone on Coumadin.] I spent the better part of a month above the target of 3.0.

On June 3, 2016 I was sitting at my computer in the morning when I noticed my blood pressure increasing rather rapidly from my normal systolic of about 130mm to 200mm.

I had my wife drive me to the emergency room where I was monitored due to the high blood pressure, and they noted I had been taking Coumadin.

Back to Hospital with High Blood Pressure Crisis

By midafternoon I was sitting in the ER and noted my vision was fading out to all white. The dropping blood pressure brought the staff in to put my head down and feet up which brought back my sight and consciousness.  At this point the ER doctor said he had no idea what my problem was, and I was admitted to a hospital room. I seemed to be somewhat stabilized at this point but very weak.

That night a bowel movement was very large and resembled fresh asphalt which I informed the attendant of the next morning [sign of intestinal bleeding]. This information apparently did not make it into my record, a major oversight. No one ever asked about this possibility while I was there, and I was in no shape to think clearly.

The next three days I did not have the energy to sit up or eat any solid food. They ran many tests including a CT scan and frequent blood tests.

None of these produced any clue as to my problem.

That is until day four. After I had been drinking only water, my morning hemoglobin results came back at 7.0 (normal is 14) now that my blood volume was back to normal due to the water intake. I had lost 5 pints of blood.

My Small Intestine Bleeding Linked to Coumadin

At this point the several doctors on my case knew what to do, and three units of blood brought my hemoglobin up to 11.5. They concluded that the intestinal bleed had stopped on its own with the discontinuation of Coumadin and that I could be discharged.

With the discontinuation of Coumadin, the intestinal bleed had stopped on its own.

Poor Opinion of Hospital Care: This sequence of events does not reflect well on the hospital and staff and their record keeping. My wife was also not happy with the lack of communications with the cardiologist managing my case. I do not remember any discussions with any of the doctors.

A follow-up colonoscopy and endoscopy eliminated the back and front end leaving the small intestine as the default source of the bleed. At this point it was concluded that I should avoid Coumadin until such time as this problem in my small intestine is identified and corrected, if ever.

Switched to Aspirin: The newer anticoagulants, not requiring INR monitoring, were not yet available [in 2008]; so I was left on 81mg aspirin for anticoagulation.

Next 8 Years: Paroxysmal A-Fib Gets Worse

As time progressed my A-FIB was clearly paroxysmal with episodes lasting between 1 and 2 days with 8 episodes over the next 8 years. The interval between episodes ranged from 0.6 months to 22 months. This calculates out that I was in A-FIB only 1% of the time.

Symptoms were minimal, consisting of slight fatigue with the loss of the atrial pumping action and the noted irregular heartbeat.

I could not identify any thing that triggered or ended an A-FIB event. I always self-converted and had to pay attention to even note when the sinus rhythm returned.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation.

Arrhythmic Drug: Sotalol dosage was adjusted between 160 and 240 mg/day with reductions when needed to increase the resting heat rate or increased as the A-FIB frequency and duration eventually began to increase.  Fortunately, this A-FIB frequency meant that anticoagulation therapy was likely of little value in my case. [Some say that clots can form and cause an A-Fib stroke in only 24 hours.]

A-FIB Frequency and Duration Increase: Sotalol and other antiarrhythmic drugs typically are effective for only a few years at most, but in my case, Sotalol worked for 8 years before the A-FIB frequency and durations began increasing.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation at age 74.

Elects CryoBalloon Ablation at Age 74

By this time [2016] cryogenic balloon ablations had become readily available in major medical centers in the US, and I was now living in the Seattle area. This was a major improvement over the RF burning ablations for the Pulmonary Veins, the most common sources of A-FIB.

My local cardiologist referred me to Dr. Derrell S. Wells with the Swedish Heart and Vascular Clinic at Cherry Hill in Seattle. (I had noted his listing on the directory of doctors.)  My local cardiologist had an echocardiogram done and forwarded it to Dr. Wells who reviewed my echocardiogram and medical history. He concluded I was a good fit for a cryogenic PVI ablation.

My EP Skilled in Both CryoBalloon and RF Ablation Techniques

My left atrium was enlarged but still within the acceptable range. He could also do RF ablations at the same time if other active electrical sites were found.  Dr. Wells looked at my Coumadin adjustment experience and commented that it was no wonder I had a bleeding problem.

My EP could also do RF ablations at the same time if other active electrical sites were found. 

Surprisingly, there was only a 6-week waiting time between the initial appointment and the ablation procedure. The day before, I reported for x-rays and an MRI to create a three-dimensional model of my heart for use in the procedure. The clinic had at least two MRI units and at least one was a 3 Tesla unit.

Stopping Sotalol Causes Problems

Three days before the ablation I was to stop the Sotalol. (During the procedure, they do not want a drug suppressing any A-FIB tendency.)

Stopping the Sotalol proved to be a significant problem for me. Two days after stopping the Sotalol, I reported for the MRI and a checkup by Dr. Well’s nurse practitioner.

My heart rate was above 100, blood pressure was high, and I had the “shakes” so much that I could not sign my name in a recognizable script.

The nurse said if I thought it necessary, I could take a Sotalol which I did.  One hour later I was back to normal.

CryoBalloon Ablation: Successful 2.5-hour Procedure

The next morning, I was prepped for the catheter procedure.

Dr. Wells used conscious sedation, but I was totally unaware of anything during the 2.5-hour procedure. All four pulmonary veins were ablated using two freeze-thaw cycles for each vein.  Electrical isolation was confirmed.

No Significant Bleeding/No Complications: No other A-FIB sources could be identified, and an arrhythmic event could not be chemically induced. Total fluoroscopic time was 11.5 minutes, a relatively low time. No significant bleeding issues were experienced at the catheter insertion point. Dr. Wells said that my case was a “text book” case with no complications during the procedure.

Blood Pressure/Heartrate Alarm: Later that evening my blood pressure and heartrate increased significantly as I had not taken a Sotalol for 30 hours. I asked the nurse to give me 120mg of Sotalol which he did after consulting the on-call doctor. Again, that solved the problem within the hour.

I was discharged the following morning.

Most Patients Not on Sotalol for 8 Years: Dr. Wells said he had not seen a case where Sotalol had provided a significant contribution to blood pressure control, but then most patients have not been taking it for 8 years.

Recovery―Replacing Eliquis with Pradaxa

Over the next several months the Sotalol was gradually replaced by another blood pressure medication (Carvedilol added to Losartan and Torsemide).

Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no issues.

Eliquis was prescribed for at least three months after the ablation to avoid blood clots while the heart tissue healed. Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no further issues.

I should also note that I had been taking 20mg/day of Omeprazole for 6 years for gastritis which may have helped me tolerate the Pradaxa, but this is pure conjecture.

After One Year Still A-Fib Free

During the three months [blanking period] following the ablation I experienced no A-FIB events. But I did observe a few missed heart beats ranging from 1 to 10 that gradually diminished to zero.

There were no irregular heartbeats as experienced with A-FIB. After three months, I was given a wearable battery powered cardiac monitor for two weeks which was then mailed off for analysis.

Off Pradaxa: The results came back in a normal range, and Dr. Wells gave me permission to discontinue the Pradaxa. Almost one year later I continue to be A-FIB free.

Self-Monitoring of Blood Pressure & Pulse: I monitor my blood pressure frequently, and the unit I use will also detect an irregular heartbeat. I can also feel the pulse in my wrist. This takes about 5 seconds to do, requires no equipment and can be done anywhere and at any time. It was obvious when I was in A-Fib.

Lessons Learned:

I guess the point of my story is that even if your symptoms are minimal and paroxysmal, do not hesitate to consider an ablation if you begin moving toward persistent A-FIB.

Success Rate diminishes: As your A-Fib becomes more persistent, the lower your success rate of a permanent cure.

Don’t Delay Too Long: The rapid advances in ablation procedures over the last 20 years suggest delaying if possible, but not beyond the point of a diminishing probability of a successful cure.

Larry Stichweh

Editor’s Comments:
Larry’s Easily Cured Case: We’re grateful to Larry for sharing his A-Fib story of being cured by a single, short CryoBalloon ablation, which is similar to the experience of most A-Fib patients (unlike many of the stories in which tend to be unusual and often heroic).
Success with Sotalol: Larry had remarkable success with the antiarrhythmic drug Sotalol which also has beta-blocker properties.  But don’t count on any antiarrhythmic drug to control or eliminate A-Fib for 8 years. Most antiarrhythmic drugs tend to lose their effectiveness over time, as Sotalol eventually did for Larry.
Anticoagulants are Considered High Risk Drugs: Coumadin and all anticoagulants are considered high risk medications. They work by causing or increasing bleeding. Even though they are certainly preferable to having an A-Fib stroke, they carry their own set of risks.
Larry could have died from his internal bleeding. He will have to monitor and watch out for GI bleeding probably for the rest of his life.
But on the other hand, Larry was having A-Fib episodes longer than 24 hours which can cause clots and strokes. One of the most difficult decisions you and your doctor have to make is whether or not to be on an anticoagulant and which one to take. And that decision may change as you do.
Continued Monitoring: Larry will see Dr. Wells or his colleagues for at least once a year (but, like me, probably for the rest of his life).
He may want to make sure he doesn’t slip back into silent A-Fib, so he may use DIY monitors at home to check himself regularly.

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