A little wobble

I had managed to get through my period of slightly elevated drinking without any effects whatsoever.  This week, I was out teaching again so had a pint with my meal, it was a four hour journey to the venue, so I was ready to relax when I arrived.  The training was stressful, fifteen learners socially distanced on a course that normally relies on a lot of group work.  It was a long day; another four hour drive with a Burger King at the services half way back and a glass of wine when I arrived home. 

Later in the evening (22/10) I had a lot of ectopics, to the point where the Kardia gave me an AF diagnosis. 

It wasn’t AF, the beats were relatively regular, but with quite a few missing.  There were no other symptoms, but it was worrying nonetheless.  I took several readings over the next hour or so and had several “Normal” results, but with ectopics and one “Unclassified”. 

In the morning, the first trace I took 8a.m. had lots of missed beats and another diagnosis of “Possible AF”.  Again, there were no other symptoms.  Throughout the day there were several “Normal” and one “Unclassified”, but all showed ectopics.  On the next day everything was back to normal.  Not even a single ectopic.

In the lead up to this episode, my Garmin had recorded a few days of raised stress levels.  It normally averages around 20 on a fairly arbitrary scale, but from the 10th to 17th it was around 30 and, on the 18th and 19th, it jumped to 60 for no apparent reason. It has been normal since then, which is also odd, as I would have expected my stress to be highest on the day of the course and the later arrhythmia (22nd).  Normal is on the left, the high stress reading is on the right.  Note that it suggests I am incredibly stressed during sleep; I am certain that the readings were rogue. 

I am really confused; I don’t know whether it was the stress of work, a low level virus or even THE virus that caused the episode.  There are no after-effects and everything seems completely normal again now.

Alcohol

I have often discussed my love for alcohol and my inability to want to give up completely.  I know its bad for my AF (and my cycling) but I still want to enjoy it.  I try to log every drink I have and try to stay within the government recommended limits, but just over the last six months, I have been a bit lax with my counting and my intake has crept up a little. 

This does not appear to have given me any problems; my GGT is down at the high end of normal, my level of ectopics is lower than ever and I generally feel very well.  On the minus side, my blood pressure is slightly elevated.

I am also currently a little stressed; I am now working less from home and more back in our centres and hotel venues. There is still the threat of redundancy from the sale of the business which would not be a problem, but the organisation is also trying to negotiate down our generous redundancy terms.

I am currently off the bike due to a knee injury sustained removing carpets from the house.  My knees have been fairly fragile since marathon training in the 80s.  I did try a ride at the weekend, which was pain free while on the bike, but increased the pain I felt after I stopped.

I have decided to cut back drinking severely again, just a little wine at the weekend and I will try to edge myself gently back into exercise.

Average speed returning to normal?

I have always been obsessed with data manipulation and since 2008 when I returned to regular cycling after the children were less dependant on me, I have kept details of every ride.  I have logged distance, time, climb, max speed, and average/max HR.  The latter figures were useful in helping my AF diagnosis, but the others were just used as motivation.

After every ride I would log the data and then produce graphs of average speed, climbing, distance etc.  for the month, quarter and full year; this was only for road or trail rides, I logged rollers and velodrome rides separately.

Up until 2015, I was generally averaging 16 mph over a rolling 12 month period.  It then started to dip slightly to about 15.5mph although until I entered persistent AF in February 2016, I thought I was just starting to feel my age.  I continued to ride under the guidance of the cardiologist and my 12 month rolling average dropped to 12.9mph just after my first ablation in April 2017. 

Three months after my second ablation the average started to climb again, hitting 14mph in August 2018 and 14.5mph in July 2019.  I am now (September 2020) finally back to 15mph and can see further improvements daily. 

In the graph below, the blue line is each day’s average speed and the red is the average speed of all rides in the previous year.

Since my return to health, the key difference to my riding is my max HR.  Before I developed AF, my rides were at an average HR of 155, with a maximum in the high 170s (ramp tested maximum was 185).  In order not to place too much strain on my heart I am currently on a self-imposed maximum of 163, although it is usually less than 160, and my average is around 135. 

I am now wondering whether I was as fit as I thought before AF kicked in, and my high HR was not me working to my limits, but my compromised heart struggling to keep up with demand.

Stroke Risk and LAA Occlusion

I still post regularly on AF support forums giving updates on my progress; mainly the AF section of health unlocked https://healthunlocked.com/.  I think this is helpful to new sufferers, as most posts on there are about problems rather than solutions, possibly because “cured” members tend to drift away. I think it is also useful as my treatment is relatively rare in the UK; mini-maze with Left Atrial Appendage Occlusion by the Atriclip device.

Occasionally, I will be admonished by other members of the forum for not remaining on anticoagulants; the feeling is that the risk of stroke continues after NSR is returned and that there are possibly times when I could be in AF without realising it.

Today I found a reassuring video of a PPT presentation by Michael Hoskins of Emory University Hospital. https://wondrmedical.net/videos/Atrial-Fibrillation-Therapies-38BC74612

The presentation discussed a couple of medical trials: ProtectAF and Prevail.  Protect was to look at how the outcomes of LAAO compared with Warfarin.  Initially ProtectAF showed that post procedure stroke prevention was as good as warfarin, but there were issues with complications.  Prevail was designed to examine the safety aspects of LAAO after the original issues with ProtectAF came to light.  This research and the later entrants to protectAF showed that these had been resolved as surgical experience improved. 

The data after five years showed that LAAO was not inferior to warfarin for ischemic stroke, although there was a slight inferiority visible on the graph.  Importantly, it did show a great advantage with regard to haemorrhagic stroke and a large reduction in all case mortality.  A secondary finding was that ablations with LAAO were more effective and less likely to revert. LAAO has always been controversial, some cardiologists believing that it may have an as yet unknown function, this report concludes that the existence of the LAA contributes to the chances of developing AF.

Overall, this study gives me confidence that I made the correct choice and am happy to continue my drug free life.

LFT results

A few weeks ago I had my LFT test; unfortunately they forgot to do the GGT, which was the only one result that was out of normal range.  I was called back for a GGT test only and while looking for the result, I found some other results from back in 2006; these had been added to my patient record due to a change in the records policy at my GP. 

At the time of the tests, I was experiencing severe back pain that was eventually diagnosed as a gall bladder infection.  At my consultation with the Doctor, I specifically asked for liver tests as I was regularly drinking above guidance limits and the symptoms I was experiencing appeared similar to those of pancreatitis. 

The practice notes at the time gave GGT as 166 (the normal maximum is 61) which was accompanied by the note “Abnormal, speak to Doctor”.  I did speak and a raft of other tests were ordered, but the high GGT was not mentioned; I was told the liver was fine.   I had further tests over the next few months; the GGT was lowered, but this could have been due to stopping drinking over this time.

In October 2012 I was invited in for a health check.  Again, I specifically mentioned that I habitually exceeded guidance levels on alcohol, but no further tests were done.  The questionnaire decided that I was quite a fit individual and the advice given by the nurse was that “everything is OK, just carry on doing what you are doing”.

At the time of my AF diagnosis, I was subjected to many tests including liver function.  This was the first time I had been able to see the results and was very pleased to see that the majority were exceptionally good; as a cyclist I was particularly happy with the haemoglobin and haematocrit being practically at maximum.  The one outlier was GGT at 217.

The doctor was unconcerned, but I researched this and realised that high GGT with no other issues was generally related to alcohol.  I severely restricted my drinking, following government guidelines on units.  After a year of minimal drinking the level had dropped to 112.  At this point, I had the first ablation and stopped drinking completely. 

After another year, the reading was still at 71.  I resumed drinking, within government guidelines (with a few more lapses than intended) and am now still hovering between 60 and 70, the replacement for the forgotten test being 69.  

I am not convinced that this is 100% OK, but all the medical profession seem quite happy with it. I may be able to reduce it by another 10 by complete abstinence, but there is no guarantee of this. I enjoy my glass of alcohol, so I will continue in moderation.

Cadence and heart rate

An interesting mini article at the bottom of an interview with Dan Martin in the July 2020 issue of Procycling.  I have heard it said many times before; high cadence riding is most efficient but requires higher levels of oxygen. 

Historically, I was always a “masher” using very big gears, I rode a 88 inch fixed gear around the peak district and my 12 speed had a lowest gear combination of 42 on the front and 19 on the back.  I was regularly out of the saddle using brute strength to power the pedals round.  Years later I was still riding the 52/42 but had moved away from the time trial block to a 12/21T

In 2008 when I got back to cycling after a break, I managed to bend my frame and the costs of repair were massive compared to the option of buying new.  So I bought a cheap Bianchi; this was my first ever aluminium bike and also my first with brake lever shifters.  The main difference, apart from the weight, was the gearing. It had a 38T chainring and a 23T sprocket; this seemed a ridiculously small gear to me at first, but I got used to it. 

In 2012, I bought a new bike which came with a compact (50/36) and a 12/28.  I was going to swap it out to an 11/23, but left it for a few weeks to give it a try.  It did seem a little odd again, but I could pedal uphill while seated, very comfortably and only needed the bottom two gears for serious hills like Winnats Pass. 

Over time, I started to use the lower gears and spin a little more, but I still used to power uphill, generally out of the saddle. 

Then AF hit me.  At first I didn’t know what it was, and the effects were relatively mild; I assumed I was ageing and getting less fit.  Eventually, I found myself with a 30T sprocket and using it more often, although it didn’t really feel comfortable.  Then finally, persistent AF made itself known and my fitness dropped off a cliff.

Three years later and I am back to normal.  I still have the 30T and I am using it regularly on the steeper slopes, I rarely climb standing and I spin rather than mash.  I don’t think this style is inherently any slower than my previous style. 

One interesting point is that spinning is supposed to require a higher level of fitness and more oxygen demand, but I am not sure it is that simple.  When I spin up hill, I can keep my HR low, but when I stand, it rises above 160 almost instantly.  It seems to me that standing and mashing requires more oxygen than sitting and spinning, possibly due to the fact that I am also supporting my bodyweight.

Overall, I think my current style is more efficient and I am working to refine it.

Cycling Weekly

Another mention of AF in Cycling Weekly this week 11th June 2020.  This time as a possible outcome of overindulging in alcohol.  I have long believed my own AF was caused mainly by over-exercising and a genetic predisposition; my mother also had AF and was a committed athlete in her youth.  I had also considered that alcohol may have been a factor for me (not for my mother, she was a lifelong abstainer)

I was always fond of a drink and there are several ways it may have impacted on my heart.  Firstly, I drank too much as a youngster which may have had a toxic effect long term.  Later in life, I drank much less, but still more than government guidelines and with some occasional nights of bingeing.  Finally, I would often go out for a group ride after several drinks the night before.  Although I would not be hung over, I would be slightly dehydrated and my heart trying to push too little volume may have contributed to my ill-health.

After diagnosis, I pretty much cut out alcohol, and my abstinence continued for a long period afterwards because I did not want to further compromise my liver considering that I had large quantities of amiodarone left in my system. 

Now, three years post ablation, I have very few drinks.  I log every drink that I have and largely remain under the 14 units per week limit, admittedly with a few lapses on special occasions.  I also log the number of ectopics or other ECG anomalies I pick up on the Kardia.  Luckily everything remains fine. 

Further improvements

Last May I published a post bemoaning the fact that I had not returned to full fitness; I wasn’t sure whether it was my relative lack of exercise or slight excess weight that was the cause or just that I was not completely back to normal.  Although I was incredibly happy with my condition compared to what I expected on diagnosis, there was the niggling worry that my recovery had hit a plateau. 

My resting HR, which had been falling steadily since the ablation, had still not returned to “normal”; it was 70 instead of 57.  My bike rides were 2mph slower than they used to be and my hill climbing was quite poor; although a small part of this may have been related to restricting my HR to 165 rather than 185.  I was also experiencing regular runs of ectopics.  As it was then nearly three years post ablation, I was not expecting to see any further recovery.

Over the last year, I have continued to improve my cycling capability.  I am still self-limited to a HR of 165 but my average speeds are a little higher, perhaps only 0.75mph down on a few years ago.  My recovery from exercise seems good and my Garmin watch says my VO2 max is “excellent” at 47, although I did not have this facility until recently so I can’t compare this with previous data.

My monthly level of ectopics is also down at a post-ablation low: 0.6 per minute this year as opposed to 1.7 in 2019 and 1.4 in 2018.  I believe I was completely free from ectopics prior to AF, but can’t be sure of this; my pre-AF pulse seemed rock solid, but in hindsight, I may have subconsciously disregarded any pauses.

Recently, due to the coronavirus lockdown, I have stopped my rides on flat trails as they are too crowded.  I have resumed cycling on roads, which is normally slightly faster in spite of the hills.  My lower max HR does not seem to really be a limiting factor and I am now wondering whether the ease at which my HR elevated in my youth was possibly a sign of lack of health.  In the eighties, I was very proud of my RHR of 42 and max HR of 190, which were both much more extreme than others in the gym I went to.  In retrospect, this was very unhealthy and I think the primary cause of my HF.  Below is my May training log from Strava.

Strava milestone

I was just looking at my Strava account and noticed a milestone: 20000 miles since joining in mid-2008.  It’s not a big average and doesn’t compare with the stupid miles I did in the eighties, but they’re not on Strava and apparently therefore didn’t happen