Commentary: Atrial fibrillation strikes an electrophysiologist
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Riding a bike requires heavy breathing and pulling on the handlebars, which are both difficult when the ribs are cracked. After two hours in the oppressive heat and constant pain that day, we rode by the tiniest of country stores, miles away from anywhere. Sitting down inside the store, I felt hot, sweaty and dizzy and chalked it up to the associated pain combined with dehydration. An electrophysiologist knows it is a vagal response. A bit of blurriness of the eyes and black and white vision came over me and I tilted my head down for a few minutes and they passed.
Moments later, back on the bike, the heart monitor revealed irregular heart rates in the 120-140 range. Uh-oh! My breathing was labored and my legs had no power. A funny feeling in my throat appeared, like a tickling, thumping sensation that induced a faster breath. No, it couldn't be atrial fibrillation! Every time the pavement rose, my heart rate spiked and my usual power was absent. A teammate offered the observation, "You don't look so good."
Finally, nearly two hours later, I arrived home and my chest still felt funny. What was this irregular floppy sensation in my chest? After years of hearing patients describe AF in many ways, I sat on the porch with the same symptoms as they have imparted to me.
To Staci, my wife and a doctor, I proclaimed, "It's AF." She felt my wrist and palpated the irregular pulse and nodded her head with acknowledgement.
Becoming a patient
I walked into the heart station at my hospital and was greeted in the usual friendly manner. The face of the ECG technician gave me the answer: Yes, it is AF. Within minutes, another technician was there with the echo probe. The ER was calling and there was a bed for me. Word traveled fast in the hospital. Still, the rib pain was far worse. The echo was normal and the heart rate was only 80 and so home was better than the ER.
My partner, another electrophysiologist, answered the phone immediately and it was nice to hear confirmatory words. “This AF episode is probably vaguely mediated. Try some flecanide tonight and the AF will likely convert," he advised.
Even though I prescribe medicine frequently, it was a different matter altogether when the time came for me to ingest a drug that affects the action potential. But, my heart was still fibrillating and there were many cases to do the next day. Surely, one cannot operate after a cardioversion, so I swallowed the little white flecanide tablets before bed. Awakening a few hours later, I immediately reached for my pulse as my chest felt normal and, indeed, my rhythm was regular.
For weeks later, I had annoyingly frequent palpitations. How many times have I heard from patients with a stressed look on their faces, "Doctor, the skip is every fifth beat"? Now, it is me holding the carotid pulse, feeling the premature beat that is known to be benign, but yet is persistent and representative of a chink in the armor of a middle-aged bike racer. An ECG suggested a right atrial origin to the offending beat, while the 24-hour monitor revealed 5,000 of them in a day.
Fortunately, the annoying beats have dissipated and a sense of normalcy has returned. After months, it is now increasingly less daring to have that extra cup of coffee.
Why did the atrium have this hiccup? The arrhythmia passed as mysteriously as it arose and now an arrhythmia doctor stands educated and certainly more empathetic.
Sometimes life can make one a better doctor.
Dr. Mandrola is a cardiac electrophysiologist in private practice with Louisville Cardiology in Louisville, Ky. He also is a masters bike racer, competing at the national level. You can read more at his blog.