What to do when Metoprolol fails to lower your heart rate?

I am in my 70's and have probably had AFIB for at least 20 years. I have been following the Strategy (Magnesium, Potassium, Taurine) for at least 1 year. Also taking Eliquis and Diltiazem . Was in paroxysmal and persistent AFIB until March 2017 when it turned into permanent AFIB.

Had intestinal issues most of the time and decided to stop the Strategy (still on Eliquis but stopped Diltiazem on my own) to see if the intestinal issues went away. The issues seem to persist and then in the fall of 2017 my liver AST and ALT numbers went up and Blood Platelets went down. My PHCP sent me to a liver doctor who said my liver was fine but the heart was having problems. He suggested that my cardiologist do an echo test. After the echo the cardiologist found out that my heart rate was around 150. Note, when I go to all doctors and the nurse takes my HR with the finger sensor it usually is in the 50-90 BPM range, so 150 was a surprise.

Then to lower my HR my cardiologist put me on 1 pill per day of Metoprolol Succ 50 Mg.
Then after 2 weeks taking 1 pill/day the HR was still high (140). Then he had me take 2 pills per day.
Then after 3 more weeks taking 2 pills/day the HR was still high (140). Then he had me take 3 pills per day.
Then after 4 more weeks taking 3 pills/day the HR was still high (135) and he had me take 4 pills per day.
Now after being on 4 pills per day for 1 week I measure my rate with a Heal Force Prince 180B single lead ECG (I don't have a smart phone, but no P wave detected) and I see an average HR of around 135.

So, I see the doctor in one more week (still at 4 pills/day until then and after 11 weeks experimenting) and my HR will likely not be below his HR goal of 100. He said at that point he is going to put me on Digoxin, which I know has a poor reputation.

So, my question is what have others done when Metoprolol fails? Is there another beta blocker brand that worked better? Did you use a calcium channel blocker; I have had some luck with Diltiazem? Use some other type of drug? What about a cardioversion or ablation? Digoxin? Then what?

Thanks,

Yes Diltiazem works for me and others to lower HR during AFIB, and you can take it with a Beta-Blocker. I would try another Beta-Blocker and start out with a low dose and titrate up like you did with the Metroprolol, and then take Diltiazem simultaneously. Coreg worked for me, and it's supposed to help keep the Heart Muscle strong. What dosage of Diltiazem are you currently taking?

Have you had Cardioversions before?

You need to do whats necessary to get your AFIB HR down, as too high of a heart rate can lead to a weakened Heart Muscle.

As for checking your AFIB Pulse by those sensors or even by using your finger, its common to get a lower reading than is actually occurring. This is because the smaller beats are not detected or felt. A 12-lead EKG will give an accurate rate.

Finding a Cardiologist EP Specialist may helpful, if you don't already have one.

I suggest the following pending approval from your Doctor.

1) Try other Rate-Control Drugs. (New Beta-Blocker + Diltiazem)
2) Cardioversion?
3) Plan towards an Ablation from an Expert Ablation Dr.?



Edited 3 time(s). Last edit at 05/03/2018 09:16AM by The Anti-Fib.

A rate of 150-ish that doesn't respond to beta blockers is most likely atrial flutter. Flutter is notorious for not responding to rate control drugs (nothing could slow mine). I absolutely wouldn't take digoxin. It comes with a toxicity problem and in people without heart failure it increases mortality. Is your cardiologist an EP? My guess is he's not since an EP would have told you what that rhythm is and wouldn't be likely to try to bury you with beta blockers or give you digoxin.

My first step would be find a new EP and get that rhythm diagnosed. If it is flutter, an antiarrhythmic like flecainide plus a cardioversion might be the solution, and of course there's always the ablation option.

Anti-Fib and Carey, thanks for your feedback. I am not taking Diltiazem at this time. The doctor thought Metroprolol might be enough. I am also taking Furosemide (Lasix) with the Metroprolol. I did have a Cardioversion some years back, but it only lasted a few days.

My cardiologist is not an EP. Sounds like I should get a second opinion. Or, should I try the Strategy again?

Can you tell from the single lead strip below from last night if it is atrial flutter?

There might be some flutter mixed in there at first, but the rest is afib. I'd agree with Anti-Fib's suggestion in view of this.

Yes, that is definitely AFIB, notice the irregularity of the Heart Beat. Flutter would be evenly spaced.
Have you tried any Anti-Arrythmic Drugs, like Tykosyn or Flecainide?

JakeL - Since you are taking Lasix, you will need to keep up with replacing the core electrolytes that Lasix flushes out electrolytes. Use small doses of magnesium, potassium and you do need some sodium...and do it consistently.

Jackie

Check out Dr. Stephen Sinatra's protocol. He recommends d-ribose and it helped me quite a bit. Metoprolol caused me more problems than it was supposed to. BTW, how is something that has a side effect of arrhythmia supposed to control the heart rate?

Anti-Fib, I have tried Flec and it worked until it stopped working. I am fairly permanent now, but will check again with the doctor next week.

Thanks, Jackie, I will restart the Strategy next week.

Alxndr01, I have not tried d-ribose. I will look into it.

JakeL:

You asked about getting a Cardioversion?
I would get a new Anti-Arrythmic Drug started before doing an Cardioversion, that way you might stay in NSR longer.

The solution to your rate control would be acheived if you could maintain NSR. If you decide to get an Ablation, Dr. Natale has the best reputation, and has helped many others with tough AFIB cases.

JakeL,

How does it feel to be in permanent atrial fibrillation? Do you feel it? Does it bother you? I know that some people are asymptomatic, which means that they hardly feel the irregular heart rhythm. Unfortunately, I am very symptomatic and suffer a lot when it happens to me.

Leah, I am usually asymptomatic (don't notice) my afib when I am in a quiet state. So, sitting at the PC, watching TV, or walking slowly, I don't notice any abnormal heartbeats and don't feel weak. However, if I am walking up stairs, carrying something heavy, or walking quickly I can get out of breath and feel week. Sometimes I will stop to rest or catch my breath.

However, it seems to have gotten worse recently. But I am not sure if that is entirely the afib or if it's the 4 pills per day of Metoprolol. I think the Metoprolol is now playing a larger part of my weakness. I am now taking Diltiazem (can cause dizziness) along with the 4 pills per day of Metoprolol to lower my heart rate, so I suspect the weakness will get worse.

So has the Diltiazem helped to lower your HR Jake?

So, after being on Metoprolol for 10 weeks (4 pills/day at the end), I went to the doctor. I was given an ECG and the heart rate was around 150. They talked about Digoxin and I showed them a March 2018 article from the Journal of the American College of Cardiology titled: "Digoxin and Mortality in Patients with Atrial Fibrillation". A summary is below:

"In patients with AF taking digoxin, the risk of death was independently related to serum digoxin concentration and was highest in patients with concentrations ≥1.2 ng/ml. Initiating digoxin was independently associated with higher mortality in patients with AF, regardless of heart failure."

JCCC Article

Since I would be "Initiating Digoxin", we decided to try Diltiazem first and stay on the 4 pills/day of Metoprolol. After starting on the Diltiazem (1 pill/day) my heart rate measurements with the Heal Force Prince 180B single lead ECG are down a little in the 120 range (one day I had a measurement of 103, but was 127 the next day).

I see the doctor in 2+ more weeks, will let you know more then.

Try adding d-ribose. The Metropolol made the Afib I was having even worse. I went to Dr. Stephen Sinatra's protocol and it helped quite a bit. With the d-ribose, a natural supplement that athletes use to control heart rate the A-fib calmed down dramatically.