CHA2DS2 VAsc score is a better score to use than CHADS score. The usual practice is to anticoagulate with a score of 2. We tend to use ASA with lower scores but the data on stroke prevention with ASA is not very robust. The newer anticoagulant drugs like dabigatran, rivaroxaban and apixaban have a better safety profile than warfarin. I use them in patients with score of 1 who are worried about risk of stroke.
Flecainide works well as an antiarrhythmic drug for paroxysmal a fib patients who do not have CAD. You should have a stress test done before taking it. I ask my patients to take the first pill in pocket drug in the ER or the office depending on when they have the episode. It can take 1-1.30 hour for its effect to work and should not be taken for shorter lasting episodes. You should tasking daily flecainide if you have frequent episodes and consider catheter ablation as it is more effective than drugs. I agree with early ablation as more frequent episodes of afib can lead to atrial remodeling and more sustained a fib.
Treatment of AFib can consist of an antiarrhythmic drug such as flecainide or propafenone if you have no serious structural heart disease, or sotalol or dofetilide if you have underlying coronary artery disease, or amiodarone if you have a significant history of heart failure. If medications fail to control the Afib, then catheter or surgical ablation may be effective. This is something you should discuss with your cardiologist or an electrophysiologist. Finally neither Viagra or Cialis are known to aggravate Afib.
There is no evidence that either drug causes AF to my knowledge, and it has not previously reported as an adverse effect. The use of Viagra or Cialis is of course contraindicated if you are also taking nitrates.
Catheter ablation or surgical ablation can be done for Afib, but it may be best in some situations to try an antiarrhythmic drug first to control the Afib. Ablation procedures can be done on Plavix if required because of a recent stent. In your area you can check with the following EP doctors regarding treatment of Afib.
In a small percentage of cases the frequency of episodes of AF may increase after ablation. These usually settle down after several weeks, but in some cases they do not, and a second ablation is necessary. I am not sure what ďinterval problemsĒ you had, but usually with dofetilide the QT is prolonged and with propafenone the QRS is prolonged, although the dose can be adjusted to allow continuation of the medication. The sharp chest pain could be due to a condition called pericarditis in which inflammation occurs around the heart after ablation. This is usually treated with ibuprofen 600 mg three times a day, but in some cases requires additional medication to control. If you continue to have frequent AF, especially if the episodes become more prolonged (>24 hours), it may not be safe to travel, unless you are taking an anticoagulant medication such as Coumadin or Xarelto to prevent a stroke, which I assume you are taking after ablation. I would certainly recommend you discuss these issues again with our EP doctor before travelling.
Restoring sinus rhythm before an ablation has been shown to improve long-term outcomes after ablation. So it was reasonable to get you in sinus rhythm first to see how you feel in normal rhythm and whether the medications will work. Amiodarone is our most effective drug, but it does have the potential for long-term side effects. Not knowing who your EP doc is, I canít predict if he will recommend an ablation. However, if you are now having symptomatic paroxysmal atrial fibrillation on medication, ablation may be a reasonable next step to try to eliminate the atrial fibrillation from recurring, either with ablation alone or in combination with medication. It may also be reasonable to continue the amiodarone, which sounds largely effective at this time, until it either stops working or you get side effects, and then consider ablation.
In most cases AF does not recur after an ablation, but it can in some cases, and rarely even be more frequent than before ablation, until it settles down permanently. There has been some research that shows that recurrent AF in the 90 day blanking period may predict a greater likelihood or recurrent AF, but we generally ignore AF that occurs during the blanking period. If you continue to have AF recurrences after the 90 day blanking period after ablation, this becomes concerning, and by 6 months a repeat ablation may be necessary.
Since I am not aware of your pacemaker programming, I cannot offer you much helpful advice. However, if the pacemaker paces and you have premature atrial beats in response, then reprogramming your pacemaker or adding an antiarrhythmic drug may in some cases help. The atrial fibrillation may be prevented by pacing in cases with sick sinus syndrome, but again in some cases addition of an antiarrhythmic drug may be necessary. I recommend that you speak with your EP doctor about adjusting the pacemaker or trying an antiarrhytmic drug to suppress the extra beats that are bothering you.
After two ablation procedures at one center, it would be reasonable to obtain a second opinion. A third ablation is sometimes warranted, if the AF recurs and is triggered by premature atrial beats on monitor, or if atypical atrial flutter occurs. If a third ablation is recommended it might be appropriate to ask for a referral to a center that does complex ablations or repeat ablations. Reconnection of the PVs is possible even after a second procedure, although it sound like testing with adenosive was done during the second procedure to demonstrate dormant (or as you put it \"minimal\") reconnections. A third procedure does increase the risk from fluoroscopy exposure, so you might want to have it done at a center that used 3-D mapping and minimizes fluoroscopy exposure. After a single or even multiple procedures, it is sometimes necessary to stay on an antiarrhythic drug to prevent AF recurrence. So that would also be an option in your case.