Question about what my Cardiologist is saying

I told my Cardiologist I wanted to come off Metroprolol ER (25 MG 1X a day). He says he wants me to stat on Metroprolol ER because it helps keep me out of AFIB because it keeps my heart rate low. My resting heart rate is in the low 50's when I take the wholr extended release pill. Remember, I had Cather Ablation done for persistent AFIB in Feb. 2014 and it has been successful.

I wanted odd Metroprolol because of a low resting heart rate and my blood pressure is not high. Yesterday my blood pressure was 106/68 and I am taking 3/4 of the Metroprolol not the whole pill. It is extended release but as long as it is not crushed it retains its ER properties per the internet and the pill has a score mark on it.

Just wondering what my peers feelings are concerning the statement that Metroprolol will keep me out of AFIB . I want off this Metroprolol ER but if it helps keep me out of AFIB.......

I feel I have very little blood pressure issues.

Thanks in advance.

Is this Dr. Natale telling you to stay on metoprolol, or your local cardiologist? I assume it's the local person.

I would ask Natale (who is the person who did your ablation, right?) about getting off of metoprolol. And I'm guessing Natale will tell you that it's fine to ramp down the betablocker (gradually) to zero. Just my $0.02.

No Smackman, metoprolol will not keep you out of AFIB. Your cardiologist in misinformed. It can help control rate and lessen the intensity and symptomatic nature of the beast, but it will not act as a primary anti-arrhythmic therapeutic at all.

This is another good lesson of why seeking out a very good regional EP is typically miles a head of having regular smaller commmunity cardiologist follow a former persistent afibber. Assuming a really good EP one exists any where near you Smackman in northern Louisiana, which may be hard to find.

As a secondary effect, a beta blocker effect can help you feel better during AFIB for the above mentioned reasons and helps prevent run away high speeds in many cases and can be a valuable adjunct to ongoing AFIB control and management.

But it is your ablation that is keeping you out of AFIB ... not the Toprol-XL (or Toprol-ER if that is the new extended release name).

It's a real shame what some docs will say who are specialist in the same broad field of cardiology.

Its like my early Cardio who told me to take digoxin plus 50mg of Toprol XL a day, then whenever I trigger to AFIB I was to take an extra 25mg of toprol XL every half hour until I converted to NSR!!!

This ill-advised recommendation despite the fact that no BB will ever directly convert you to NSR, by itself! As a result of this crazy Digoxin and Toprol XL NSR conversion protocol concocted by my very well meaning and kind Cardiologist in Hawaii many years ago, I was thrust into the netherworld that first month of DEEP Bradycardia with very long terrible pauses sprinkled within the 32bpm Bradycardia before it would instantly jump to 170bpm AFIB and then back and forth over and over in a truly exhausting, and rather frightening at times, rollercoaster that more than once left me passed out in syncope on the floor during that first month I was on that ridiculous and dangerous protocol gave me a temporary totally drug-induced case of Tachy-Brady or Sick Sinus Syndrome!!

I wound up with a pace-rmaker for that indication, even though I did not need it for that reason, but did .. by chance .. need the pacer for a totally unrelated to AFIB infrahisian left bundle branch block that my new EP found the day before pacer install when he did my first EP study prior to pacer implant ... so it all worked out okay in any event and in spite of my Cardiologist very poor prescription.

When I relayed that story to a restaurant full of EPs and Cardiologist as well as afibbers from Kansas and Missouri region two weeks ago for the GAFA - World AFIB Day 2015 celebration dinner... I watched a lot of docs rolling their eyes and face-palming themselves while shaking their heads bemoaning my fate as well when I recounted that story.

A few Cardio's came up to tell me (after the two talk's and dinner with the first talk by Dr Natale and last was my story) saying of course, they were not all that clueless as a species of Cardio's, which we all had a good laugh with, as it is most certainly true as there are many brilliant general cardiologist too that I know and some would be excellent choices to partner with..

That being said, it is harder to find those general Cardios who will be close to on to caught up with the EP world of nuances. Thus, the best bet for most Afibbers (there are exceptions of course) is hooking up with the best clinical EP you can partner with for long time follow up and if that be your ablationist too that is fine.

Shannon

Thanks Shannon.



Edited 2 time(s). Last edit at 10/02/2015 04:30PM by Hans Larsen.

I agree - it is a rhythm agent. I have been on it for about a year. It has NOTHING to do with stopping an afib episode.
Nancy

Metoprolol can help reduce pac's at times which in turn can trigger afib. So in a round-about-way I am under the impression that it may assist in reducing episodes if they are triggered by certain pac's. ?????
If I were you I would reduce down to 1/2 tablet

Thats what I did a year ago.

I thought that beta blockers could help prevent the initiation of afib in afibbers with adrenergic triggers - they reduce the sympathetic response of the ANS. This obviously would not be of any help to a vagal afibber. I'm also not suggesting to Smack that he should not get off the BB. I completely agree with Shannon, but wanted to put this out. I have an adrenergic afibber friend who was able to keep it relatively at bay using BB's. Analogous to putting a governor on an engine.

"beta-Blockers also reduce the incidence of AF, particularly in HF or after cardiac surgery, when adrenergic tone is high. Furthermore, the chronic treatment of patients with beta-blockers remodels the atria, with a potentially antiarrhythmic increase in the refractory period." <[www.ncbi.nlm.nih.gov]

My EP told me that my Sotalol was the anti afib pill and the metoprolol was the rhythm agent. Of course he might have just been simplifying it for me. I'm adrenergic, not vagal, and I do know that the metoprolol did nothing for stopping my afib episodes.
Nancy

Hi George,

A beta blocker can have a secondary impact on initiation as you noted but it is very minor impact in degree. By itself it will not have a anti arrhythmic action to an ongoing arrhythmia nor will it ever convert a person to NSR from an active arrhythmia.

It was an old wives tale many years ago with few AAR drugs were around and beta blockers were all docs had pretty much to combat the impact of AFIB and it certainly heps make you feel better and can help very much in preventing heart failure etc in the face of AFIB.

But the suggestion Smacks doc made that it was his toprol dose that was keeping him out of AFIB when he was in persistent AFIB on Toprol and the moment he had his ablation was his last real AFIB not to return at this point in a year and a half has nothing really to do with it.

One other area in which a low dose beta blocker or calcium channel blocker can help after an ablation is to help in keeping an otherwise higher resting HR lower and less noticeable, if it bothers one at all, for 6 months to a year or more in more rare cases in which the high HR keeps going.

The bottomline is that for the vast majority of people depending on a BB alone to keep AFIB away is a losing game long term, it does have its role and another secondary effect if from hypertension controls which, in turn, can help slow down HT mediated fibrotic changes and thus slow the progression of the disease long term for those with hypertension.

The main thing is how you feel off of it Smack. Do you know for sure you dont have moderate HT?? you have been on the BB a long time if I remember correctly, perhaps that is keeping your underlying HT at bay as intended and when you go off it might increase some. You can always add back a low dose 12.5mg toprol or 2.5 bystolic after you go off if you find your HT getting up there that is not well managed by natural means first.

Shannon



Edited 1 time(s). Last edit at 10/04/2015 01:15AM by Shannon.

Doesn't dr. Natalie instruct his patients regarding meds after an ablation?

Lynn, Dr Natale and his staff typically control meds for the month leading up to an ablation and typically 6 months after the ablation. When all is good and in NSR the patient is turned back over to their local cardiologist or EP for ongoing local follow up and medication following.

With his huge ablation numbers there is no way to keep them all on with him as their prime prescribing EP indefinitely.

Dr Natale has done well over 7,500 AFIB/Flutter ablations since the advent of the PVI at beginning of 1999 ( the seminal paper from Bordeaux came out in late 1998 defining the PVs as the prime source of paroxysmal triggering, which launched the entire ablation field as we know it now. Prior to that time Dr Natale was working on focal AFIB ablation, as were the Bordeaux group and other up and coming players at the time and he has well over 8,000 total ablations under his belt including SVT, stand alone CTI flutter, VT ablations and early focal AFIB ablation experiments.

A good deal more than anyone else in the world .. especially since 1999 when his career really kicked into high gear. So its easy to see how they simply don't have the time they to cover all of his ablation patients cardiac needs for good. However, he is always open to answering questions from such former patients whenever he can.

Shannon



Edited 1 time(s). Last edit at 10/04/2015 02:34PM by Shannon.

Lynn - My experience with Natale ablations spans 12 years, with the first, in 2003. He did (then) direct my pre- andpost-ablation meds... which were staying on flecainide and warfarin for about 2 months and then off. The protocol then if one had a breakthrough was to use the PIP method... Pill in Pocket... and my version of that was at the onset of AF, take 25 mg of metoprolol (or 50 mg) to slow the heart rate and after about 30 minutes, follow with 100 mg flecainide. Wait an hour, and if not converted, take another 100 mg flecainide. That worked well for until 2013 when I began having breakthrough AF....and then much of it was actually flutter. Then, for me, it was rare to have it convert w/o electrocardioversion.and thus the second ablation.

After ablation #2 (Aug. '14) which isolated the left atrial appendage, I was not prescribed any meds other than the anticoagulant, Eliquis. I remained in contact with the nursing support staff in Austin and by weekly heart-trak monitoring. As it turned out, I began to have some 'activity' seven months after the LAA isolation so was immediately scheduled to return to Austin for ablation #3 to clean up the few last stragglers. Again, no meds were prescribed. In fact, Dr. Natale emphasized he did not want me using a beta blocker since my HR was 59 and he didn't want it that low.

I never found that a rate controller/beta blocker had much positive effect in reversing my afib although since my HR often was very high... 120 bpm if my counting was even close to accurate... it was welcome relief to have that slowed down.... Even 100 bpm was some relief, but for functionality, forget it. Unless, of course, it turned into flutter and then I was much more functional and mobile.

Just a comment about Sotalol or Betapace... while we all respond differently, that drug was the first one prescribed for me by my first cardiologist who really didn't know much about afib and neither did the next two I consulted. That was 20 years ago. Sotalol never did anything to help with afib in the two years I used it and the afib progressed significantly. But when I changed to a cardiologist associated with EPs at the Cleveland Clinic, I was switched to the anti-arrhythmic, flecainide which worked well (until it didn't )...as is so typical.

Some years later, I (thankfully) found this forum. When Hans published his first book in 2002, he wrote about various drugs used for arrhythmia. About Sotalol (Betapace, Sotacor) he said on p. 85:

" Thirty-eight (22 vagal, 3 adrenergic, 11 mixed and 2 permanent) afibbers had tried sotalol. Not one (0%) had found it beneficial although one vagal afibber thought it might have reduced severity, but not frequency of episodes. Twenty-nine (76%) of all users reported side effects with 11 actually reporting heart palpitations or fibrillation as the main side effect. Another 7 reported increased fatigue. The most common dosage was 80 mg twice a day. With a success rate of 0% and side effects occurring in 76% of users, sotalol is easily classified as the most useless drug for lone afib. Unfortunately, it is the most frequently prescribed one."

Jackie

I agree with Tsco and GeorgeN's responses.

PAC's are one of the things that has to occur to initiate an AFIB episode. Beta-Blockers can greatly reduce PAC burden. The question is does Smackman have PAC's? and how many?

It's my understanding that PAC's originate from the Pulmonary Viens in the Heart. So if the patient has had a successfull Natale Ablation, the Pulmonanry veins should be pretty much isolated, and thus few PAC's.

The scenario of Beta -Blockers really having an substantial impact on AFIB would be a non-ablated patient, or one with an unsuccessfull PVI Ablation, or as GeorgeN stated, one with Adrenergic Triggering.

I don't agree with your Dr's inference that you need to keep your HR that low to keep from having an episode.
As Shannon pointed out there are also other Beta-Blockers, such as Bystolic. I have taken Bystolic, and it works better for me for PAC reduction than Metropolol, and because it is a "cardio-selective Beta-Blocker" it does not produce as much of a sedative effect.

Are you that scared of an episode? If the Ablation worked at all, then it should be one of short duration. So if it was me, I would be more ready than your Dr. to experiment with lowering your Metropolol dosage.

That makes sense I guess. I was under the assumption that once I met with Dr. Natalie he would be my Primary EP and that would have one closer to home for emergency situations.

Shannon Wrote:
-------------------------------------------------------
> Hi George,
>
> A beta blocker can have a secondary impact on
> initiation as you noted but it is very minor
> impact in degree. By itself it will not have a
> anti arrhythmic action to an ongoing arrhythmia
> nor will it ever convert a person to NSR from an
> active arrhythmia.
>
> It was an old wives tale many years ago with few
> AAR drugs were around and beta blockers were all
> docs had pretty much to combat the impact of AFIB
> and it certainly heps make you feel better and can
> help very much in preventing heart failure etc in
> the face of AFIB.
>
> But the suggestion Smacks doc made that it was his
> toprol dose that was keeping him out of AFIB when
> he was in persistent AFIB on Toprol and the moment
> he had his ablation was his last real AFIB not to
> return at this point in a year and a half has
> nothing really to do with it.
>
> One other area in which a low dose beta blocker or
> calcium channel blocker can help after an ablation
> is to help in keeping an otherwise higher resting
> HR lower and less noticeable, if it bothers one at
> all, for 6 months to a year or more in more rare
> cases in which the high HR keeps going.
>
> The bottomline is that for the vast majority of
> people depending on a BB alone to keep AFIB away
> is a losing game long term, it does have its role
> and another secondary effect if from hypertension
> controls which, in turn, can help slow down HT
> mediated fibrotic changes and thus slow the
> progression of the disease long term for those
> with hypertension.
>
> The main thing is how you feel off of it Smack. Do
> you know for sure you dont have moderate HT?? you
> have been on the BB a long time if I remember
> correctly, perhaps that is keeping your underlying
> HT at bay as intended and when you go off it might
> increase some. You can always add back a low dose
> 12.5mg toprol or 2.5 bystolic after you go off if
> you find your HT getting up there that is not well
> managed by natural means first.
>
> Shannon

I feel stupid but what is HT? Are you talking about anxiety? If so, Yes I have anxiety from the issues I have "down below" in my "private parts" possibly CPPS.
I have not stopped my beta blocker. I have cut it from 25 MG ER 1X a day to approx 18 mg 1X a day to hopefully increase my resting Heart rate.
My internet has been down all weekend; Just got it back 30 minutes ago. Also my blood pressure is good 115/75
ALSO and I think I am right here, I am cutting out my Fentanyl Patch with a slow taper I started Sept.. 9,2015, This Wednesday, I will be halfway thru the taper. I feel when I get off this Opiod, My resting Heart Rate will increase from what I understand.

This morning, my resting Heart rate was 55. Now, I walk 2.5 miles at least 5 days a week and also have been doing fairly intense pelvic floor exercises to hopefully give me some relief from my chronic issue I have below which I feel is CPPS or Chronic Pelvic Pain Syndrome.

5 mg Valium a day as needed.
20 mg Prozac daily
15 mg Prevacid a day
60 cc shot of Testosterone Cypionate every 10 days. Testosterone is low due to schedule two narcotics.
.5 mg Arimidex 2x a week to keep Estrogen levels in check. T shots can cause rise in Estrogen.

100 mg Metoprolol ER 1x a day
25 mg HydroDiuril fluid pill 1x a day every 2 days.
Neurontin 900mg a day (for Neuropathic pain IC/CPPS)
800 mg of Magnesium daily . Different types
81 mg aspirin 1X a day. Heart Doctor order due to stent installed in Jan. 2012.
2.5 mg Eliquis 2X a day

Miralax 1x a day for constipation issues. I have tried so many different methods for Constipation since 2008. Fiber is in my diet but to much Fiber really Constipates me.




25 mg/hcr Fentanyl.patch changed every 2 days

1st ablation done Feb. 27, 2014 for Long term persistent AFIB Dr. Natale
2nd Ablation done June 16,2016 Dr. Natale LAA isolated



Edited 1 time(s). Last edit at 10/05/2015 11:48AM by smackman.

Hi Anti AFIB,

Another poster sent me your post above with a question about if PACs that trigger AFIB all originate from the PVs. Just to clarify, while PACs do indeed also come from the PVs they are not at all only from PVs. The main extended portion of of the most successful advanced ablation methods by Natales group, Bordeaux and others is to do first a PVI or PVAI and then seek out at zap Non-PV triggers most often in the form of PACs in many other areas of both the left and right atrium , along the posterior wall, SVC, CS, LAA and across different regions like the septal wall and roof of the LA as well.


Your idea that AFIB triggers often have PAC like triggering=, they are not at all exclusive to the pulmonary veins, For example, during my LAA isolation 4 years after my index ablation there was zero reconnections in all 4 of my PVs... they had been rendered perfectly silent in that first ablation and have remained so, and the only remaining trigger sources where in my LAA and hence the need to get a full LAA isolation then.

Hope that clears the PAC issue up. And keep in mind too that the kind of runs of PACs many get during the day in short spurts are rarely associated directly with triggering AFIB. Even though when AFIB is triggered it often involves AFIB associated PACs ... one is not the same as the other exactly and its more a putting the cart before the horse thing.

Cheers,
Shannon

Shannon, what is HT? You ask if I possibly have this and maybe the beta blocker was suppressing it.

You said,

The main thing is how you feel off of it Smack. Do
> you know for sure you dont have moderate HT?? you
> have been on the BB a long time if I remember
> correctly, perhaps that is keeping your underlying
> HT at bay as intended and when you go off it might
> increase some. You can always add back a low dose
> 12.5mg toprol or 2.5 bystolic after you go off if
> you find your HT getting up there that is not well
> managed by natural means first.

Thanks

In my experience (I have vagal AFI Metoprolol actually made AFIB worse, and I have also read the same. It is only good for androgenic AFIB. Now I'm taking it with Flecainide (fortunately Flecainide reduces the arrythmogenic affect of beta blockers, and you're supposed to take a beta blocker with it anyways to avoid the possibility of long QT syndrome).

I believe if I hadn't been put on a beta blocker, I could have eliminated my AFIB through natural means.

Smackman,

Sorry for the delay in reply, haven't had a lot of time to read all the posts recently. HT means 'hypertension' as in high blood pressure.

Shannon