Overindulgence

Last weekend was my fortieth anniversary of leaving school.  A room was hired in a pub in the next village along from the school we went to.  Food was ordered and a mixtape of music from 1979 was prepared.

I arrived early to help the organiser set up the room, and was pleased to discover that the pub was selling a pleasant tasting beer.

It was a good evening, many former classmates turned up, including some that I had not seen for years and a couple that I had no memory of.

Unfortunately, the beer was too good and the night went on until the early hours.  I got a little carried away and drank too much (too much for a person without any health issues, let alone someone in my circumstances.  I realised quite late on that I was actually drunk, the first time in about four or five years.

I went to bed wondering and worrying what effect it would have on me in the morning.  I woke up fine, with no headache or noticeable ill effects.  I checked my pulse and it seemed fine.  I tried the Kardia and received a “normal” diagnosis.

This all compares favourably with the previous week when I had a mass of ectopics for no good reason.

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Ectopics

Prior to AF, I had a rock steady heartbeat.  It was very slow and even, I never experienced any ectopics.  After my ablations the p-wave returned, although it seemed quite suppressed and the rhythm was steady.  I experienced quite a few ectopics, so I recorded them and looked at the change over time.

Before the second ablation I had very few, this increased after the second ablation.  On average I was getting just over one a minute.  This calmed down early this year, to one every three or four minutes.  But I had a very strange reading one evening for no apparent reason.  Here is a Kardia trace.

19-05-29 HR AF

I think this is a huge number of ectopics rather than AF.  I took nine readings over the next hour, one more said “Possible AF”, one was “Unclassified” and the rest showed as many ectopics but were classified “Normal”

There was no reason whatsoever for this.  I was not particularly stressed, I had a relaxing couple of days teaching.  I had not been drinking, I wasn’t tired, and although I was in a hotel overnight, I hadn’t overindulged in expense account food either.

Everything was back to normal the following day.

No recent improvement

It is now 19 months since my hybrid ablation was completed and I am now way outside the blanking period.  Although this is generally agreed to last three months, I was definitely improving noticeably up to one year afterwards and arguably for another couple of months after that.  However, since December last year, I seem to have plateaued.

I have not tried to get back to my previous levels of exertion, I am cycling similar distances to before, but on flatter routes and 2 mph slower.  I have experienced the occasional high HR spike; it is possible that these are unrelated to my condition.  I didn’t dare risk ignoring it, because I delayed diagnosis for two year through thinking my HR meter was at fault.  I am deliberately remaining at a ceiling of 165 HR during rides, even though my previous healthy maximum was 185.

My resting heart rate is finally down to a reasonable level, 63 compared with a previous healthy rate of 57 (and 48 in my twenties when I was seriously fit).  I am guessing that this is not going to reduce any further.  I suspect that I am just less fit than four years ago, as well as being older and slightly heavier.

On Saturday, I tried the first ride in years with a ridiculous hill, one with a maximum gradient of 18% that was taxing when I was fit.  Even then, it used to take me 7 minutes, in contrast to my clubmate Danny, who held the local record of 4:53.  My fastest time made me the 148th rider out of 550 who had attempted it, so not good, but not actually that bad, really.

19-05-18 Bage hill

It didn’t go particularly well; it took me 8:41 (equivalent to the 350th rider) and although I tried to keep my HR low, I am not sure I could have gone harder.  On the plus side, I did feel good on the flat later in the ride and even felt a small improvement on the shorter, less steep hills, although I am still well below my peak.  Hopefully I am just a little out of practice.

Two years since ablation

It is now the second anniversary of my ablation: a Mini-maze procedure including a Left Atrial Appendage closure.  I also had a further RF ablation six months after this, which was always planned and completed the Maze lesion set.  Apart from a few dodgy Kardia readings, I have been AF-free since the Mini-maze and drug-free since November 2017.

Immediately after the Mini-maze, I was unsure whether it had been a good idea, my heart rate was still erratic and I felt like I’d been hit by a truck.  It settled down quickly and although I had a few ectopics and a few “Possible AF “ Kardia readings, I had no symptoms and my recovery seemed good.

The hybrid ablation seems to be gaining ground, particularly for treatments of Persistent AF; a meta-study edited by Katriina Aalto-Setala https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752005/ shows a success rate in cases of Long Standing Persistent AF  of 69% for single-stage treatments and 78% for the two-stage version I had.  (Success was defined as no episode of atrial fibrillation or atrial tachycardia lasting longer than 30 seconds without administration of antiarrhythmic drugs within the follow up period, which was at least a year, depending on study).  The success rate for PVI ablation was given as 70%, but only in the case of paroxysmal AF.  It was stated that it is much less effective in cases of longstanding persistent AF, but figures were not given.

It took me a while to get back to proper exercise (the probable cause in the first place) although this was deliberate rather than my inability.  I have lost a little fitness but hope to regain this during the year.  Prior to my AF, my resting heart rate was 57.  The beta blockers and ablations played havoc with it over the last couple of years.  The graph below shows my heart rate on a daily basis over the last few years.  This is not resting heart rate, but a regular reading taken in the evening when relaxing.  My actual resting heart rate is currently plateaued at 67, ten higher than before my treatment.

19-04-11 Resting HR

Odd heart activity?

I had a good start to 2019 with few ectopics, no arrhythmia and an apparently  recovered liver; things were looking good.

One morning (27th March) I woke and took my resting pulse as per normal; it was definitely not in sinus rhythm.  I went downstairs and used the Kardia.  I had a couple of “Possible AF” diagnoses, but these were actually high levels of ectopics rather than AF; see reading below.

19-03-27 AF

I took several readings over the next hour and had a few unclassified ones with unusual traces, looking a little like the strange one I had last June; example below.

19-03-27

After a few hours, everything went back to normal.  Hopefully these mean nothing; I have not bothered the Cardiologist, but will continue to monitor.

All clear?

For the last few years, I have had a couple of things going on healthwise:  AF and elevated liver enzymes.

The AF now appears to be under control; apart from the two weeks after my first ablation I have experienced no AF.  There have been a few ectopics, although these are relatively calm at the moment.  I am still pootling about on the bike, no racing no HIIT and no intention to risk anything by overdoing it.  I am scheduled to see the cardiologist at some point in the autumn of this year, but only because of the CEASE-AF research project.  If I was a normal patient rather than a participant in a clinical trial, I would have already been discharged to the care of my GP.

The liver enzymes were the second issue.  Originally several different enzyme levels were raised, and it is fair to say that self-medication with alcohol was likely to have been a contributory factor.  After these were discovered my alcohol intake was curtailed and I kept total abstinence between February and December 2017.  Since then I have kept faithfully to less than 14 units per week.  Binges have been few, but occasionally centered around celebrations.

19-03-18 GGT

The graph shows alcohol consumption against GGT.  The red line shows a fall in levels after I stopped serious drinking, with a little binge around the Xmas 2016/17 period.  It then fell quickly until I started amiodarone; it levelled off for a while until the majority of it was out of my bloodstream.  It then continued to fall steadily until now, when it has reached the upper level of “normal”.  My levels over the last year also gave no concern; although above the textbook normal level, they were described as satisfactory.    The Doctors comments this time are, “Satisfactory. No further action“.    I suspect that the GGT level will continue to drop very slowly, but it looks like I have no need for testing in future.

So, I have now effectively been signed off for both health problems.  I will not be able to increase my alcohol consumption in celebration but I am relieved and very happy.

Continuing improvement

derby-velodrome

Six months ago, I attended a skills assessment session at Derby Velodrome;  I was judged to be competent and so I received my velodrome permit back.  However, during the session I had a momentary HR spike of 201 for no obvious reason.  I had also seen a few spikes on recent rides of 170/180; I wasn’t sure whether these were problematic, i.e. a brief incidence of flutter or just a rogue reading.  I decided to leave the velodrome alone for a few months and monitor my HR.

I had experienced no recent problems, no HR spikes and the incidence of ectopic beats on my kardia is almost down to nil, so I decided it was safe to return to the velodrome last week.  As usual, I didn’t push too hard; on one exercise I decided to cut it short and recover; overall it was enjoyable and I think I could go a little harder.

In addition to this, I was on annual leave and drank more than I should; not really excessive, no binging, but 22 units over the seven days.  I am very pleased to note absolutely no ill effects.

I am beginning to feel almost normal.  I am a little unfit and a bit weightier: 2Kg more than when I became symptomatic, but I think this can be solved by a little extra exercise over the next year.

Three years since self-diagnosis

It is now exactly three years since I realised that my breathlessness and general lack of fitness was not related to aging, but due to a medical problem. I made an appointment with the Doctor, but could only get in to see a practice nurse, and had to wait four weeks. A few days prior to the appointment, I developed a noticeable persistent arrhythmia. I was referred for an ECG and told not to exercise.

After a month (and some considerable chasing) it was confirmed that I had AF. I was called in for a full blood count and put on the waiting list for an echocardiogram. This took place in June 2016 and confirmed that I was in AF and that my left atrium was significantly enlarged (37 mls/m2 compared with a healthy max of 28)

Another month and I saw the cardiologist (luckily, he was an EP). I was put on Bisoprolol and Rivaroxaban. At this point, my symptoms worsened; I suspect the Bisoprolol was the cause, rather than any progression of my AF.

I had a successful cardioversion in October 2016, although it only worked for a couple of weeks; it felt marvellous while it lasted.

In November 2016 I saw the cardiologist (not the EP this time). The treatment plan was to be another cardioversion, this time supplemented with flecainide, followed by a referral to Sheffield for an ablation. I was more than happy with this.

In January 2017, I met the EP who suggested that I was a suitable candidate for a medical trial. The treatment was in two stages: First a Mini-maze; entry made through the chest wall, the atrial appendage clamped off and a scarring pattern made on the outside of the heart. This was followed six months later by a catheter ablation on the inside of the heart that completed the maze box set, a CTI line for flutter and cleared up any rogue signals. In between, I was amiodarone for six weeks to stabilise me.

The Mini-maze, in April 2017 was rough; it took me quite a few days to get over and three weeks before I was able to go back to work. It was pretty successful, My Kardia said I was in AF for a lot of the following week and I had some minor arrhythmia over the next few months and ectopics which are symptomless; I took regular Kardia readings, but the cardiologist said they were nothing unexpected or untoward.

The Amiodarone caused no problems except for a scorching summer clad in long clothing, hats and factor 50.

The catheter ablation in October 2017 was a doddle: it was done under GA and I missed all of it. Immediately afterwards I was full of life and felt 100% recovered. I came off all medication in November 2017.

I took it easy throughout 2018; I exercised, but kept to sensible limits. I returned to club cycling in September, but with the beginners’ group rather than the racers. I am still taking it steady with the social group, not wanting to risk my recovery.  I am definitely enjoying life.

I still have a few bouts of ectopics; some of which confuse my Kardia into unclassified and the occasional AF diagnoses, but generally I have been in good health and I have been in NSR 99.99% of the time. The cardiologist in charge of the trial suspects a 80% success rate over 20 years (i.e. no significant AF in that time) I think this is probably overoptimistic, but am very pleased with the treatment.  

See below for my current ECG.

19-01-30

Rogue beats

On four occasions over the last few months, I have experienced a few rogue HR peaks during a ride; these are only momentary and don’t show on the Garmin until I download the data.  I am not sure whether this is a fault of my HR meter or my own internal wiring, but I have been monitoring every ride recently.

The first instance was on 25th October; one spike of 173 for a split second while on the rollers. This was a strange session, there were also dropouts so I think that this was possibly a sensor error.  On 4th November, I experienced a spike of 169 for a split second on a road ride while not making any particular effort. On 2nd December there was a spike of 167 for a split second while climbing; however, this was close to the top of the climb and my HR was actually falling at that time.  On 28th December I had the most worrying one; an instantaneous spike of 181 during a steady flat ride on the trails. 

I have been very patient and have not attempted to recapture any former glories; half my rides are still flat, and in spite of that, my average over a year is 1.6 mph lower than it used to be on rides through the peak.  It looks like I will have to continue steadily, monitoring what is happening, hopefully, it is not serious, but it has put a damper on what was a much better year than I could have expected after the two ablations.  Here is my annual Strava summary.

Back with the Cardiologist

This was my regular six-monthly review as required for the clinical trial.  Today there were worse than usual traffic and parking problems getting to the NGH so I arrived a couple of minutes late for my X-ray.  No problem and ECG and BP were all taken before my actual appointment at 9:30 a.m.  I had a nice chat with the Arrhythmia nurse about how my recent work stresses were affecting me.   I was finally invited in to see him at 10:20 a.m.

He seemed quite happy with the ECG and X-ray.  I showed him a few Kardia readings since the last visit; he was pleased I was keeping records and said that he had just ordered twenty for the use of patients in monitoring their AF.  He said that every reading I had taken was relatively normal, except for one.

18-08-12 HR

This was taken in Florida, on a day when I had drunk a lot of coffee.  He suggested that if this happens again, I should get someone to punch me very hard in the chest and phone an ambulance.  He had previously said that coffee is not a problem, but his opinion now is that I should avoid it.

Apart from that, everything is fine and I should come back to see him in twelve months.