What to replace my Beta Blocker with???

I’m a month out from my ablation. So far no bouts of AFib since the ablation. I’ve been on Nebivilol since 2010 to reduce my BP and most importantly I was told to reduce the pressure ( not sure if it’s preload or after load) in my LV as I have mitral valve prolapse with moderate regurgitation. Apparently the BB helps reduce the regurgitation and thus possibly pulmonary hypertension. I take the lowest dose they make, 2.5mg and it does a fine job of reducing my BP and HR. However I think I’ve learned it’s the very thing that makes me tired and feel unwell often. I learned this recently as my EP wanted to do a 24 hr Halter monitor on me to see how slow my HR was going during sleep thinking I might be a candidate for a pacemaker. He had me stop the Nebivilol for the 24 hr monitor. As a result my HR and BP has gone up, thankfully not to a dangerous level but enough I wouldn’t want it to go untreated. I have noticed though since stopping the Nebivilol I’m not as tired as usual and feel better. So pretty sure the BB may be the culprit in causing my fatigue and malaise that I and doctors have been trying to figure out for some time. So I’m wondering what BP med I can take that does what the BB addresses but without making me feel so tired & crappy?? ACE inhibitor, CCB, other???

Pokey

A calcium channel blocker like diltiazem would probably be the first thing to try. I take it for hypertension and it has none of the fatigue issues for me that beta blockers do. Its only negative side effect is swollen ankles, but that's just an annoyance. They don't swell enough to interfere with anything or to even be noticeable if I'm wearing socks. But of course your cardiologist will know more. You might have to try several different things before hitting on the right drug, but there are a bunch of choices.

Why do BBs make a person so bloody tired? I assume because they affect HR so profoundly?? My resting HR during the day on Nebivilol is often in the mid 50s. While sleeping it will go down into the high 40s. As noted I stopped my BB for the halter monitor for which I’m still warn the results but in the meantime my resting HR has come up into the 60s and I’ve noticed a definite lessening of fatigue

Quote
Pokey
Why do BBs make a person so bloody tired? I assume because they affect HR so profoundly??

That's what I think. I wrote a bit more on the subject in this post:

[www.afibbers.org]

And, obviously, RF catheter ablation just adds more scarring to the equation. That's ... kind of the goal :-)

And scarring ... adds stiffness. It's like starching your blue jeans.

I hope you find a better way forward.

My annual echoes and a nuclear stress test ~2 years ago say I still have a pretty healthy heart. My EF is still 65% with no LV dilation or segmental defects and I am 75. I attribute that in part to the fact I was a mountain hunter while living in Alaska where I carried all I needed to survive for 7 days at time on my back at 5-6-7,000ft and I trained year round for such strenuous pursuits. I do however have mitral valve prolapse with regurgitation and thus far have kept it from getting worse with the BB. I do think I need to stay on a BP med, but Im thinking there might be a better choice out there for me than a BB. I clearly note the almost elimination of the fatigue and malaise once I stopped the BB last week. Doctors had been trying to figure out for years why I was so tired all the time. It now seems duhhh, the cause was right in front of our faces. I hope to find out my options after I hear back about my Halter monitor test.

Quote
Pokey
My annual echoes and a nuclear stress test ~2 years ago say I still have a pretty healthy heart. My EF is still 65% with no LV dilation or segmental defects and I am 75. I attribute that in part to the fact I was a mountain hunter while living in Alaska where I carried all I needed to survive for 7 days at time on my back at 5-6-7,000ft and I trained year round for such strenuous pursuits.

I hope you don't take this as snark -- I don't intend it to be -- but you could have all of the above and still have a 'stiff' heart. This is the kind of thing that strain echocardiography is pretty good at teasing out.

Also, spending thousands of hours training as you describe (which, OhByTheWay, sounds awesome to me!) can induce the kind of myocardial fibrosis that's usually associated with stiffening.

Think about a balloon. Now stick six more balloons into that first one, one inside the other. It's very difficult to inflate the seven balloons, but the air comes out under quite a bit of force.

As LVEF (Left Ventricular Ejection Fraction) tends to increase as we age, it's probably reasonable to hypothesize that this is at least partly due to fibrosis that reduces the distensibility of the heart. The net effect of this would be an increase in ejection fraction, just as in my balloon analogy.

Which, again, would limit your ability to augment stroke volume substantially and increase your reliance on heart rate in order to increase your cardiac output.

Again: the Global Longitudinal Strain number determined by Speckle Tracking Echocardiography (STE) yields a pretty good surrogate for degree of fibrosis.

It would explain your response to BB's ... even if it doesn't paint a clear picture of how to treat what needs treating without dramatically worsening your quality of life.

But if nothing else ... you'd have my sympathies :-)

I’ve had strain “bullseyes” done with echoes in the past and they were ok. I’m sure I have some atrial fibrosis given my AFib. It is what it is and as far as I can tell my ticker is doing better than many others at my age. I am surprised that after being off the BB a week my BP & HR seem to be in acceptable ranges thus far.

Quote
Pokey
I’ve had strain “bullseyes” done with echoes in the past and they were ok.

Which raises two questions for me:
* How far in the past, and
* What does 'ok' mean?

If we're talking years ago, then things could certainly have changed.

Also, this isn't the time or the place to dive deeply into it, but ... I finally got my answers after two separate years-long medical odysseys (first, eyes, then, heart) by trusting the tests more than I trusted the people whose job it was to interpret those tests.

Locally, Cardiology deemed my wife's strain echo to be 'ok.' It wasn't.

Particularly when a technology is rather new, the expertise in using it doesn't come on day one. That's another reason why I ask how long ago yours was done.

Again: none of this really gives you the answer you need -- how to control HR (and BP) without stapling you to the sofa -- but I'm a big believer in understanding exactly what's going on before taking steps to try to address it. Minimizes potential risk, maximizes potential reward.

I don’t remember exactly when the strain echo was done, it’s been a while. I had a heart MRI after that and I’ve had numerous std echoes , TEEs, a nuclear stress study and ZIO patches. For what it’s worth lots of studies. I just learned today the result of my halter monitor. No arrhythmias noted and thus no pacemaker required. Now I have to talk
to my regular cardiologist to determine if I am to go back on the Nebivilol, something different or nothing at all. My BP seems to be doing fine w/o the BB. I feel better without it but I have mitral prolapse with regurgitation and I was initially put on the BB I was told to reduce pressure ( preload??) in my LV & thus not worsen the MVR if I understood my cardiologist correctly????

Yes, BB reduce both the frequency of contractions in all four chambers, but also the strength of the contractions...which is why BB can also be used for incipient hypertension.

Gloaming. Please define “incipient hypertension”. That’s a term I am not familiar with.
Pokey

In the medical field, incipient means 'beginning, early stages, early in evolution...' Hypertension means 'high blood pressure', with anything over the current high mark signifying a need for at least monitoring if not some form of medication. I think the current high mark is 130, but there's lots o internal argument in the field about whether that is too high or too low. I think that at one ages, it's naturally going to get higher, and that might not be a bad thing if one gets into the 'hypertensive' range at, say, 75/80. Again, some physicians would strenuously object to that rationale.

Mine tends to run 110-115/60s-70s much if the time except, it seems, when I go to the doctor. Then it bumps up 130+/80+. So I don’t think I have a significant HBP issue. I only take 2.5mg of Nebivilol, which is the lowest dose when some folks take 40mg. But it does often make me tired. So I’m asking my cardiologist if I can switch to a CCB or Ace inhibitor.

What are your BP numbers when not taking the nebivilol? 115/70 isn't even close to hypertension and 130/80 is barely borderline on the systolic only.

Hi Carey: when not taking the BB my BP will run in the 120-130+/70-80+ depending on circumstances, sometimes lower. If I’m anxious it will hit 140/80-85. There are times when I’m on the BB it runs to low, 100/60. I’ve seen it hit 95/60. When my HR at night is in the 50s and I’m assuming my BP is running on the low side I think 🤔 it causes my SpO2 to drop lower than 95% according to the Oximeter I have that monitors my O2 continuously through the night. I get dips below 95%. I’m going to ask my cardiologist that either I try no BP med for a while and see how it goes or ask for a CCB or Ace Inhibitor. In the past I was on lisinopril and later on verapamil. I don’t recall any issues with either. They tried me on diltiazem after my A flutter ablation but I didn’t tolerate it well as I recall.

I'm not sure I understand why you're being treated for hypertension. If I were in your shoes I would ask to stop the meds entirely, monitor your BP regularly, and see how it goes.

I think I agree with you when it’s all said and done…… My understanding when I was put on nebivilol back about 2010 it was to keep the pressure low in my LV in order to help reduce my mitral regurgitation due to my mitral valve prolapse. My BP may have been up then, I don’t recall. Maybe that was a misguided approach ??? I do think the BB is what is making me complain of being tired much of the time and I think, though I don’t know for sure, it’s possibly why I’m having events of mild sleep apnea. Low pulse, low BP I would think can contribute to lower SPO2?? This is why I’m discussing this all with my cardiologist tomorrow.

After meeting with my cardiologist he thinks it’s fine if I stop the BB nebivilol and see how it goes. If my BP should start to creep up he will put me on lisinopril. I’m coming up on 7 weeks post ablation and thus far no arrhythmias 🤞