Treatment for a-fib

I had my follow up office visit (3 month), and since I had an appointment scheduled to check my pacemaker next week, they went ahead & did that as well. I was very happy to tell my docotor that I was feeling good--no dizziness at all, and even symptoms of a-fib seem milder & less frequent. I was recently prescribed a low dose of metoprolol, which seemed to help me turn a corner.

A few hours later, his office called to tell me that my a-fib is actually poorly controlled at this time & they intend to double my metoprolol dosage. They followed this news with cautions about worsening side effects, like extreme fatigue & drops in blood pressure causing dizziness. I tried to decipher the print-out from the pacemaker lab, and from what I can tell it registered arrhythmia 13% of the time, the last event being 4 days previous. This is pretty much the same as it has always been. I guess the reason I feel better overall is that the pacemaker has eliminated pauses around the incidents. 

I am just wondering: If I am feeling better, how necessary is it to control a-fib, especially if the medication comes with side effects that sound as bad or worse than the condition itself. I find it funny that I can sit in my doctor's office & read pamphlets on living with a-fib, yet he seems determined to "cure" mine! Also, I'm interested in hearing of other experiences with metoprolol--I was told that side effects may be temporary as my body adjusts. Have you found this to be true? I am taking 25mg 2x & will be doubling that to 50mg 2x. . 


6 Comments

Control is the key.

by Gemita - 2021-05-15 12:24:13

I like your attitude TLee.  My own feeling is that Atrial Fibrillation (AF) cannot be cured.  Yes there are treatment options which are more effective like an ablation and this can provide in some instances many years of respite, however, I believe sooner or later AF will return.  I think it is all about keeping a balance.  The most important treatment for AF is stroke prevention if needed and rate control to prevent high heart rates leading to heart failure symptoms.  I believe control of AF is possible whereas total elimination is not.

A lot of us are able to live with AF and live well.   I also believe that going in with a sledgehammer is wrong.  My doctors, thankfully, go by how I feel, what symptoms I have, whether my heart rate is controlled, how frequent my episodes of AF are, whether my risk of an AF stroke is adequately managed, for which I have been given anticoagulation, whether I have dizziness, breathlessness, chest pain.  In other words whether I am symptomatic when in AF.  Yes ideally I would like to stop it completely but as we age, electrical disturbances become increasingly common, particularly AF.  What price are we prepared to pay to be rid of the arrhythmia?  A beta blocker cannot cure AF, only calm it and reduce the heart rate.  I would ask:

1. Are my heart rates well controlled?  If yes, why would you need ever increasing dosages Metoprolol?  Control is what we require, nothing more.

2. I would ask whether my anticoagulation is adequate to protect me from an AF related stroke.

A balance has to be sought between treatment, control of AF and quality of life.  If your quality of life is poor with ever increasing doses of meds which are unlikely to cure your AF, is this really a sensible way forward.  I do not think so.

I understand all about AF begets AF and quickly causes remodelling of heart tissue leading to worsening periods of the arrhythmia from paroxysmal to persistent to permanent, but I also understand that medication has a very poor efficacy rate compared with say an AF ablation, (my EP quoted 1st ablation up to 75% success rate - higher with a second ablation - with only 35-40% success rate with anti arrhythmic/rate control meds).  Rate control meds would appear somewhat safer than anti arrhythmic meds but medication alone is not the treatment of choice for AF, even though some do very well on medication.   High doses of medication though can cause many unwanted symptoms, symptoms that might be too difficult to tolerate and live with.  However no treatment for AF is pleasant or without an element of risk, particularly an ablation.

I have never tried Metoprolol but I know many who have and do extremely well on it TLee.  I am on Bisoprolol low dose instead, but beta blockers all cause similar side effects.  It is trial and error to find one that suits.  Like you TLee I am presently living well with my AF and pacemaker.  My pacemaker has done more for me than my medication has ever been able to do.  Why would I change anything.  I would go by how you feel, not those numbers.  If you start feeling dizzy, breathless or have other symptoms, this could be an indication that your AF is worsening.  If you notice your heart rate exceeding 100 bpm, this would also be an indication that your arrhythmia needs better control.  

But you tell me you are feeling better now, so I would perhaps ask your doctors if you could wait to give your body a chance to settle down to pacing.  It is still early days and you might find your AF episodes will reduce over the next few months.  This was my experience.  I asked my EP to delay further treatment during the "settling" in period.  He agreed reluctantly at the time, but now agrees it was the right decision for me.  Alternatively try the extra dose of Metoprolol and see what happens. 

Ideally I would like to stop my AF.  I would like a cure.  But does a cure exist?  Why are we being told that AF is not a serious arrhythmia?  Perhaps because it is not likely to cause sudden cardiac death as say would Ventricular Fibrillation, unless AF were to cause a fatal stroke.  Why are so many patients living with it, suffering from it?  Could it be because AF has so many different causes, some of which can not be totally eliminated, like the ageing process itself.  The only thing that concerns me is the potential for Atrial Fibrillation to ultimately lead to heart failure or to dementia if it is not firmly controlled.  So control is the key using a balance of meds, ablation, lifestyle changes and treatment for any health conditions present.  For me my pacemaker is a very valuable tool as well for helping to control my several arrhythmias as evidenced by my reduced time in AF today compared with pre implant data

Metoprolol and Afib

by Marybird - 2021-05-15 14:55:34

Gemita, great advice and info, as always.

Just my own experience with this stuff. I've taken metoprolol in varying doses for close to 20 years, and I have no issues with low blood pressure ( on the contrary, I'm blessed with high blood pressure that can be hard to control), so at this point, any symptoms I may have with this drug are pretty much nonexistent at this point. Other than an occasional tiredness, which may just come with the territory ( old lady), I don't have what I'd identify as side effects.

I took 50 mg/day of metoprolol and 180 mg/diltiazem to control my tachycardias ( atrial tachycardia, not afib, at least till recently) for a number of years, till I developed significant amounts of bradycardia, so the cardiologist stopped the diltiazem. We had to increase the metoprolol to control the tachys after that, from 50 to 150 mg/day, but that ramped up the bradycardia ( at least I blamed the metoprolol for that) though it did a fairly good job with the tachycardia, albeit there was some breakthrough tachys. I felt crappy but the symptoms were due to the bradycardia- and we discovered through medication decreases and changes that the bradycardia was most likely an underlying condition I had that the metoprolol had enhanced or brought to light. So they labled it sick sinus syndrome and I won the pacemaker.

Following the pacemaker, I took low doses of both metoprolol and diltiazem to control the tachy ( 50mg and 180mg, respectively). The EP later increased my diltiazem to 360mg/day, to better control the blood pressure.

Then, about 8 months after that EP visit, I got a call from the cardiologist's nurse ( not the EP, who left the practice, but the cardiologist I had been seeing before the pacemaker), with instructions to increase the metoprolol from 50 to 100 mg/day. She said they had gotten alerts from my remote pacer reports of "excess mode switching", which I learned was associated with tachycardias. I got another call from them about 4 months after that with instructions to increase the metoprolol to 150 mg/day. The cardiologist's PA, whom I saw at an office visit after that, informed me that they had been seeing "short runs of afib" on the pacer reports, and their plans were to watch it, and keep it from increasing with metoprolol as needed. This PA said the incidence of afib was less than 1%, so I didn't need an anticoagulant at this point, but it needed monitoring and "hit" with metoprolol to keep it down. He mentioned the possibility of increasing the metoprolol to 200 mg/day ( or more, I guess) and he didn't want me to decrease the diltiazem at that point, as we think maybe diltiazem does enhance the effectiveness of the metoprolol. But that's just me. I know I had tachy breakthroughs when I took 150 mg/day metoprolol without the diltiazem, and still feel some breakthroughs at times with both, but I'm hoping these don't occur as often now with both drugs.

I have few if any side effects from either of these drugs at this point, and I think ( hope) they're doing a good job at keeping the afib at bay. Whatever those palpitations/floppies I feel sometimes are, they are very mild and only last a few seconds, and many times I think are asymptomatic, so it's hard to tell, though I'm hoping those drugs are doing their job. I haven't heard from the cardiologists' office a third time, so fingers crossed that no news is good news, and I feel good most of the time. Guess I will find out when I see the cardiologist and have an in office device check later this year.

I can't think the medical establishment is out there to "cure" afib to the point where it's not detectable, not with rate controlling drugs, anyway, because it's not going to happen as I understand it. From what I've read, seems as though ( as Gemita said) the goal is to make it as asymptomatic as possible for the patient, and to decrease the risk of stroke associated with afib. Hence the reason for the anticoagulation ( and at an approximately 14% afib burden, TLee, I'm sure you are on an anticoagulant), and apparently keeping the heart rate (with a beta blocker or calcium channel blocker) down below 100 even with afib improves the symptoms, and hopefully minimizes the risk of tachycardia/afib-associated cardiomyopathy. Perhaps this is what your cardiologist is referring to, TLee, perhaps not decreasing the % burden of your afib with the metoprolol, but keeping the heart rate under 100? It's certainly something you can discuss with your cardiologist/care providers, especially if you find the side effects of metoprolol or other beta blockers unacceptable over a long haul.

I'm thinking that perhaps my cardiologist, in prescribing increasing amounts of metoprolol, may be doing so not just to keep the heart rate low, but also to keep my percentage of afib as low as it is now, ie, below 1%, to try and avoid the need for anticoagulation. That's a whole 'nuther topic, though, as I'm finding a number of references for "subclinical afib"- ie, that's detectable only on pacemaker/other cardiac devices or long term monitor reports, and is asymptomatic to patients. I think that applies to me at this point.

 

 

 

Metoprolol

by Dixie Chick 65 - 2021-05-15 15:06:05

I have taken Metoprolol ( 50mg )since 2012. Starting in 2007, I took 25mg of Atenolol. I was started on Atenolol because during an exercise stress test in 2012I went into Afib. Had a heart cath ( but no stent ) and then my beta blocker was upped and changed to Metoprolol. Yes, I think the fatigue and " draggy " feeling is a common side effect. But in my case, I eventually got through that OK. I have never had Afib again, as far as I know. Of course, every " body" is different and I don't remember how long before I felt normal again. Maybe about 4-6 weeks. I got my PM last May due to intermittent heart block and bradycardia. 
Gemita has some wise words on AF and I agree completely ! All the best to you.

Metoprolol and other drugs

by Theknotguy - 2021-05-15 16:43:46

Some people get along fine with metoprolol, others have a hard time with it.  If you're getting along fine with it then keep using it.  I've been on it for seven years and get along fine.  If you do have problems with it, there are a lot of other heart drugs that can help so you have plenty of options.  

As for "curing" afib, you don't cure it.  Ablation stops it, either chemical or mechanical. Mechanical is using heat  or cold and killing the part of the heart tissue that's causing afib. Even after the ablation, afib can still come back.  

People with afib should take some kind of blood thinner to prevent clots from forming in the heart then being pumped out and causing a stroke.  Risk is risk so you should immediately take the blood thinner.  

You can live with afib.  Even with metoprolol and programs running on my pacemaker I can go into afib for up to three days at a time. With the pacemaker I don't usually notice it.  I think I go as high as 30-40% of the time I'm in afib so you can live with it.  Both my now retired EP and my new EP don't see a reason to do anything  more than what they are doing.  If it ain't broke, don't fix it - is their attitude.  They could cause more problems by doing a mechanical ablation than by leaving it alone.  And as long as I'm getting along fine - no major shortness of breath, dizziness, etc. they don't see a reason to change things.  

I really hate it when a doctor's office goes into a panic mode.  People don't think clearly that way and can make mistakes.  Since it's your heart, you'll really want to make sure the course of action taken is the best action for you.  
 

I guess finding that balance is the main thing

by TLee - 2021-05-15 20:30:49

I am so grateful that I can come here & get advice and reassurance when I need it. 

This is still a fairly new journey for me as far as being officially diagnosed and beginning treatment. I have had tests, procedures (including an unsuccessful cryo ablation) & some pretty scary medications--more than I ever dreamed of! I will admit that I have my moments of wanting to stop it all & go back to the good old days. Of course it wasn't all that good, struggling to breathe & not able to walk to the end of my own driveway! But there is a part of me that gets very discouraged when I am told that I am not "fixed" (or even fix-able), and that more treatment is necessary. However, if I am completely honest, I do feel that there is room for improvement. especially with the issue of fatigue that is common with afib.

You have made it clearer to me that what I need to do is to find what works for me, so that I can live with the symptoms AND with the medications. Finding which medicine helps me feel my best with the fewest negative effects is the goal. I did have positive results with even the lower doseage of metoprolol, so maybe the slight increase will be just the thing. If not, I am wiling to keep trying!

Afib and Metoprolol

by AgentX86 - 2021-05-15 20:34:38

As others have indicated, Afib by itself isn't dangerous but its side effects are.  The two problematic issues are tachycardia induced cardiomyopathy and blood clots froming in the heart, caused by the turbulent flow/pooling of blood.  Keeping the heart rate below 100bpm (i.e. out of tachycardia) and anticoagulation reduce the risks of AF to close to that of the general population.

But even short runs of AF can raise the risk of clotting.  Anticoagulation is something that should be seriously considered but the downside of anticoagulation is the possibility of hemoraghic stroke.  These two risks have to be balanced.  The CHA₂DS₂-VASc score is used to compare one risk against the other.

<https://www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk>

Beta blockers are the tool of choice to reduce heart rate but do have their side effects.  These can usually be mitigated by dosage or a different beta blocker.  Calcium Channel Blockers can also used.  I've been on metoprolol since 2007, in various doses from 25mg/day to 400mg/day, to 200mg + 200mg ameoderone (a beta blocker as well as a serious antiarrhythmic)

No, there is no "curing" Afib but it can be managed.  If you don't care about its side effects (or aren't symptomatic at all) there is no reason to do anything but the above.  Let it ride.  However, if you are symptomatic, it's far better to do something sooner than later.  It's also better to go for the gold, right away.  Hopping from one drug to another before considering an ablation reduces the chances that the ablation will successful greatly.  As noted above, Afib begets Afib.  Let it go and there may be no coming back.

Previously, the standard procedure was to do an ablation only after nothing else worked.  Increasingly this has been seen to be short-sighted.  By the time it's found that the drugs don't work, or you've climbed the drug ladder when each failed (they will), an ablation won't likely work anymore either. 

All antiarrhythmics are toxic to one degree or another, with the more effective also being the more toxic (ameoderone at the top of of both lists), another reason not to put off an ablation if you think it might be in your future.  There is a very real risk taking antiarrythmics, too.  Ameoderone damaged my thyroid (recovered, fortunately) and Sotalol damaged my SI node so that I needed the PM.

The risks of an ablation are quite small now, less than that of a pacemaker implant, so should be considered if it's a matter of quality of life.  It's imperitive that you only go to the best ablatonist.  Ideally one who has done thousands of ablations and hundreds per year.  It's all some EPs do.  Try to find one.  It makes a difference.

I've had three failed (climbed the drug ladder too long) ablations.  Two of them were done with only local anesthesia and the other with only light sedation.  I could feel the burning during one (not fun) but the worst part, by far, was laying on my back for several hours while the leg wound "healed" enough to stand.  Both my back and bladder were in serious pain by then.  ;-)

Your choice but if I could do it again, I'd have gone for the ablation before all of the drugs.  My problem by then was flutter but the process is the same.

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I, too, am feeling tons better since my implant.