I had a prescription renewal with my doctor (GP) and during our conversation I mentioned that a few weeks back my flutter kicked up for approx. 1/2 an hour then back to sinus rthymn. I said if it does more often in future what would be the next step. He said he could prescribe flecainide as PIP. Currently I'm taking diltiazem for rate and apixaban.
My question is shouldn't a cardiologist or an electrophysiologist prescribe antiarrhythmics and not a GP? Isn't it a medication that some people with afib can easily take every day without problems but in some it could possibly induce especially flutter a worse arrhythmia?
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FraserB
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Hi there, my understanding is that only cardiologists can prescribe anti arrythmics. I was given flecainide at first and it caused a pro arrythmia in me, I was then swapped to Sotalol and have remained on this for the last 4 years. Hoping to get off it now ai have had an ablation. I have afib and flutter
Same here with the Cardiologist. He administered the first dose and I had to be admitted to the hospital for observation once the meds were given. My GP won't mess with any of the meds the Cardio prescribes.
I've just had a consultation with my Cardio Consultant who is going to change my medication. The new ones will be Sotalol ( which I will start immediately ) and Flecinaide BUT before I start that, due to my age (79), he has ordered a CT Scan first.
Thanks for your experience with your cardio consultant, tests need to be done. I know my GP is overworked and wonder if he misspoke regarding prescribing something he has no authority.
I forgot to mention that I also have to have a 7 day Holter monitor fitted ( next Tuesday ) to try and get a better fix on what is going on with my ticker. My other problem is that I am described as asymptomatic and my AF is paroxysmal AF.
While daily flecainide can help prevent atrial flutter, I was told to NEVER take Flecainide as a PIP during a flutter episode. Because in some cases, it can turn a slower flutter into a dangerously fast 1:1 flutter.
And yes, at least in the United States, only cardiologists and mainly electrophysiologists (ep's) prescribe Flecainide. I think your experience with your GP shows why!
In addition, when Flecainide is prescribed daily to help prevent flutter, in most cases it is prescribed with a nodal blocking agent like a beta blocker or Diltiazem for safety reasons.
When my GP mentioned in conversation that if I get worse he can prescribe flecainide as a pip. I knew that wasn't quite right but wasn't one hundred percent certain. I will definitely ask for a referral to the cardiologist.
Flecainide can be a very good drug for some. It originally was given to a wider population but many experienced pro arrhythmia’s. They established that most of those people had issues with structure of heart. Today they will do tests to make sure there are no issues with your heart before prescribing. I am on very low dose of Flecainide along with low dose bblocker to maintain my sinus rhythm
Sorry to hear that, I guess the reactions we have to drugs can be different even if we tick all the boxes. I hope that things have settled and you’ve found another path
It is a hospital initiated therapy but, I was thinking, if you have previously seen a cardiologist, it's possible in your notes he mentioned the future use of flecainide hence your GP's suggestion. Also, your GP might be one who specialises in cardiology as some do have specialisms on top of their GP work.
I had previously seen a cardiologist last year and had all the tests; ,echo, stress, blood panels, X-rays and results were a normal functioning heart except of course a 12 lead EKG in emerg with a flutter diagnosis the year before that. Unfortunately my GP does not specialize in cardiology but you've raised a good point that he was looking at my previous tests.
Yep, that is the same experience for my wife who is scheduled for an electrocardiogram tomorrow to confirm heart structure is okay before they will consider prescribing Flecanide as a PiP for her fast AF, which is happening more frequently of late.
However, I'm now worried about the comment from mjames1 above re. Flutter (and the risks of Flecanide). My wife was also told in the same consultation that she definitely has Flutter too on top of her AF. That said, the consultant also said that Flutter is much harder to control with drugs anyway.
My wife and I have a joke about doctors and consultants being like beekeepers - ask 3 of them a question and you'll get 4 (often contradictory/conflicting) answers.
Re. the original question, my wife was prescribed beta blockers as an antiarrythmic many years ago by her local doctor after they did a 24h ECG. No suggestion of seeing a cardiologist at that time. This was UK.
My wife scheduled electrocardiogram tomorrow to confirm heart structure is okay before they will consider prescribing Flecanide as a PiP for her fast AF However, I'm now worried about the comment from mjames1 above re. Flutter (and the risks of Flecanide). My wife was also told in the same consultation that she definitely has Flutter too on top of her AF.
Just so we're on the same page, PIP Flecainide is when you take it only once an afib episode starts. Daily Flecainide on the other hand is taken daily to try and prevent afib episodes from starting in the first place. In both cases, they are usually taken in conjunction with a nodal blocking agent such as a beta blocker or Diltiazem to help prevent a very fast flutter from developing.
The decision whether to take Flecainide PIP or daily is mostly based on frequency of episodes. If they are very occasional, then PIP makes a lot of sense. But if you're starting to have them weekly, then daily might make more sense. Of course, we all have our own individual thresholds on this.
So, assuming your wife qualifies for Flecainide with a structurally sound heart, she should do just find on either PIP or Daily Flecainide, especially if taken in conjunction with a nodal blocking agent.
The thing again to remember is that while daily Flecainide can help prevent both afib and aflutter, PIP Flecainide should only be used for afib, and never for flutter, based on what my ep's have told me.
For this reason it's important that your wife knows whether she is in afib or aflutter before she takes Flecainide to terminate an episode. I've always found it easy to tell the difference using either my Kardia or Apple Watch, but if she is not sure, then this should be discussed with her doctor.
Thanks, Jim, useful info. I probably wasn't too clear actually... We are hoping her AF has only increased in frequency due to current thyrotoxicosis. The cardiologist suggested Flecainide (presumably as a daily dose) to try and keep it at bay a little until the thyroid issue is resolved. Prior to this becoming an acute thing her AF was less frequent (maybe once every month of so) and Flecainide was suggested as a PiP. The extra flutter diagnosis was only very recent too. She's also been on regular Diltiazem for a while but that doesn't seem to reduce the rate by much (either in AF or NSR).
Out of interest, our Kardia only ever says "Possible AF" and never mentions flutter. I gather it doesn't identify flutter automatically? I understand there's a sawtooth pattern for flutter but I'm still not 100% clear on what I'm looking for, and I've studied a lot of online ECGs. Most of her traces might be AF+Flutter since they're usually always 140bpm+, sometimes up to 220bpm, and we can see the clear irregular gaps. Anyway, if you're comfortable, would you be willing to share an example Kardia ECG in AF with and without flutter to help me see the difference? I realise not all traces are the same - using my wife's Kardia I eventually understood why my own ECG trace is so very different to everyone else in the family (turns out I have an extreme left-axis deviation, but my GP claims it is "normal"). DM me if you prefer. Thanks
Thanks for clarifying. Should your wife go on daily Flecainide, hopefully it will prevent both afib and aflutter. It was very successful preventing both with me.
Keep in mind that flutter doesn't always present the same and there is not always a "saw tooth" pattern. The main difference is that flutter is "regular and fast" while afib is always irregular. So maybe better if you upload one or two of the ekg's where you cannot see the "irregular" gaps, but that Kardia says is "possible afib".
But you are right, Kardia is not currently programmed to say "atrial flutter" and will usually just call it "tachycardia".
As to Diltiazem alone, that never helped prevent either afib or aflutter with me and it's not surprising because it has very weak anti-arrythmic properties and is mainly a rate control drug. However, Diltiazem is often given alongside daily Flecainde for safety reasons.
I have asthma so can't do beta blockers (I took Verapamil for 10 days which nearly finished me off) .. now take Edoxaban with Flecainide PIP (100mg) for Afib and I have noticed that for a few days after taking the Flecainide PIP I can have bouts of tachycardia/palpitations (per Kardia) at night. It somehow felt like a side effect of Flecainide and I did wonder if it was flutter.
I wasn't aware of the need to balance Flecainide with beta blockers (in relation to flutter) so this is something I should maybe clarify with the cardiologist.
Last June I started with AFib and moved to AFlutter (due to Flecainide PIP). I had this switching between Fib and Flutter back and forth for a few days until cardioversion. I have a Kardia single lead and what I noticed during the Flutter episodes was it would say Unclassified and sometimes Normal Sinus Rhythm. I knew the NSR wasn't real because I didn't feel right and my rate was around 80 bpm. Normally I would have dropped to 60 if true NSR. The Kardia scans during Flutter looked normal but the P wave was very flat, which isn't normal for me. Turns out I was 3:1 Flutter due to heavy beta blocker I was on, hence the consistent 80ish BPM.
I believe there's a way to use the Kardia single lead to get a second lead, which may show the sawtooth, but the exact process escapes me at the moment. It's something about using your knee on one pad and your fingers on another.
I liked your comment about contradicory/conflicting answers. My "journey" through the flutter (afib) world since I was diagnosed in 2022 has also had slightly different variations on the same question I've asked from technicians to specialists.
I recently had an episode of AF, took flecainide as a PIP and later that day my heart rate jumped to 126. After a spell in a&e I ended up in the cardiology ward and was told my heart had actually gone into atrial flutter, not fibrillation. As with Jim I was told in future not to take flecainide as a pip because it's not effective against flutter and I'm guessing it's what pushed my HR up. She even put this in my discharge notes in capitals to reinforce it...Dave
Really depends upon his training and competence. A GP I had back in the day when I started with AF, prescribed Flecainide for me - but then he always worked as a Cardio Registrar and knew me really well as I had a lot to do with the Patient Liaison Team at the time and he had results of echo and bloods
My understanding is that generally needs to be prescribed by secondary care for precisely the reasons Jim gave.
Here in UK primary care doctors (GPs) may not prescribe antiarrhyjmic drugs without instruction from a cardiologist. Once so instructed they may continue to renew such prescriptions.
My Gp prescribed Flecainide as Pip he was telling me that he can prescribe that and bisiprodol. He was telling me that he had folks waiting for cardio appointments that he knows would be better on sotalol but he’s unable to prescribe that or other medications
I had to go hospital for a few days, when they started me on Sotalol, to monitor me, as it can cause problems with the heart. It made me feel dizzy, when they gave it to me and they reduced the dose and I was ok then. I’ve had no problems with it since then. I’m now coming off it very slowly, as I had an ablation last September. I’m a bit worried about stopping it, as I’ve been on it for quite a long time. .
Will do it’s a year on Saturday but will probably do it later today as I’m a polling Clark today for the police and crime commissioner election, I’ll need something to fill the time. 😂
Definitely a Cardiologist or EP. For one thing,Flecanide is a Rythym control drug not a rate control drug. Flutter is characterised by high regular rate not crazy Rythym. Query this!. In some cases Flecanide is dangerous.
When I had my first episode of flutter it was in hospital emerg in 2022. The doctor on that day wrote down on my discharge note AFIB, which I know my GP eventually received a copy and this could be his assumption too. And possibly emerg docs since they are not specialists understand that if you have one you have the other??? But months later with many heart tests completed appt with cardiologist said it was flutter when he looked at the ekg from that emerg visit. I'm currently paroxysmal but when my heart has episodes it will be super fast high regular rate, not erratic. So I will cede to the cardiologist for any future meds. Better yet a referral to an EP.
My Flecainide was originally prescribed by an EP I saw privately, to take as a PiP but as episodes increased it was changed to 50mg twice daily and now 100mg twice daily but I am not sure who actually made the decision. As I no longer have episodes of AF I have stopped taking anticoagulants which all disagreed with me and I had already been advised to stop the Bisoprolol as the lowest dose brought my heart rate down too low! We are all so different and I hope you have doctors who appreciate that and find what works for you.
From personal experience Flec made my condition worst, after 3 months of taking it had really bad AFL, heart went haywire, had to have a cardioversion, Good thing is went to the top of the ablation waiting list. If you read my posts from around December 2019 to June 2020 you will get the details. Flec is a miracle drug for many but can make things very worst for some.
My question is that whether or not a GP can rx an anti arrythmic who would want them to? Many have black box warnings and Flecainide can cause flutter or other arrythmias. When a drug effects the rhythm of your heart why would you not want it managed by an expert. This whole GP thing is very disturbing to me. They cannot possibly be experts in every specialty. We would have no need for specialists if that were the case. This is your heart not a cold.
I concur with what Jim stated above. I myself have taken Flec as PIP for AFIB with success. I've always taken it with a beta blocker. About a year ago I had an event that started as AFib and Flec PIP didn't work and actually turned my condition into 3:1 Aflutter. I needed a cardioversion 5 days later.
I won't take the max PIP dose (for me 300mg) again as I believe the large amount of Flec is what triggered the conversion to AFlutter. It could be my AFib has gotten worse and the PIP no longer worked and AFlutter popped up or something else.
Anytime Flec is used there should be an exam (Echo, MRI, CT, etc.) for a structurally sound heart and most definitely be prescribed with a nodal blocker (beta blocker, CCB, etc.) to prevent the very dangerous 1:1 flutter event.
sometimes even cardiologists don’t know Flecainide. I had a cardiologist prescribe me flecanaide saying that’s what an EP would do. When I came up with another arrhythmia every time I took a pill the cardiologist told me to give it time and keep taking. Well, I stopped it and started seeing an EP. He switched me to taking it as a PIP and it worked wonders. That cardiologist had no clue how to deal with Flecainide. Needless to say I never saw her again.
What happened to you makes me realize that if a cardiologist makes a wrong call on the medication then a GP if they are do not have a specialty in cardiology may even be worse.
Yes according to my cardiologist Flecainide can only be prescribed after an echocardiogram to look at the structure of the heart. If there are structural issues in the heart then Flecainide is not appropriate.
Hopefully you have had an echocardiogram?
I was prescribed daily Flecainide but I opted out of that and have it as a PIP. I'm underweight and take just 50mg for Afib, if it doesn't work in 1/2 hour I take another 50mg which (touch wood) always works. It's a very powerful drug, I tend to get bouts of tachycardia/palpitations in the nights after I use it as a PIP.
That’s exactly how I took Flec and it worked every time. I no longer take it as I had a mini maze and don’t need it. But it was my best friend for over a year.
In my post the bottom paragraph is relevant to your question but I thought I'd add some context on how I got there.
I just want to add a bit of information to the thread. I've had P AF for over 15 years and have been taking Flecainide and Digoxin for most of that time. However, last year I had 2 Cardioversions and my heart specialist booked me in for an Ablation. After the Ablation I was slowly taken off these 2 meds and I'm only on Eliquis now.
Nine months after the Ablation I get ectopic beats every now and then, These episodes slow me down and I get some pain on the left side of my heart making me feel unwell for a while. To stop this I would take half a tab of Flecainide twice a day and half a tab of Digoxin once a day for a couple of days. This put my heart back into a normal sinus mode and I'd stop taking the Flecainide and Digoxin.
Last week I was at my 6 monthly checkup with my Cardiologist and I mentioned that I took the Flecainide and Digoxin to get my heart back to normal beating, He said that this was not the best idea and if I did do it that I must take the medication for at least 7 days, The reason was that these 2 drugs can also cause AF. He has also recommended that if I do go into AF to take a high dose of Flecainide and Digoxin for 2 days and if that fails go to hospital. I do have the dose amounts written down that he recommended for this.
Interesting and informative to read your experience and the cardiologist's comments on the timing of both meds, if not can result in AF. And gives me a lot more knowledge on how a specialist's experience can make a difference on what works and what doesn't.
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