recommendation of a rate control drug that does not cause lung problems

I have never done an edit before and hope that this is right. I made the edit in the first sentence and I’m explaining now: my ablation was not in 2020, it was in 2019.

Hello all,

I had my Natale cardiac ablation in August 2019, & am doing great. Not even on any blood thinners. I do take carvedilol (Coreg) 6.25 mg BID. It has been fine in that overall it seemed the most tolerable & a great plus was that it not only controls my rate, but controls my moderate benign essential tremor of hands. But many times I have been at odds as to what to do because it is definitely affecting my breathing. I have a chronic dry cough that happens mainly on deeper inspiration (I mean just slightly deeper), so I cough & am a bit short of breath easily. It has gotten noticeably worse the last couple of months.

Hx: Mild paraseptal emphysema which I found out because after my ablation & being started on heavy beta blockers (sotalol), my breathing changed immediately. Mostly the doctors would ignore me about it. Cardiologist eventually sent me to pulmonologist & LFTs showed "mild paraseptal emphysema." No meds were prescribed at that time though. Frankly, I don't do well on many meds, so I was kind of relieved not to start more.

What I have tried:
Metoprolol (cardioselective): For some reason I have tried it a few times & I have many more reactions to it than carvedilol, but maybe I could tolerate it now in light of carvedilol affecting my lungs so & I have been on carvedilol a few years off & on, maybe 4 or 5 yr. My metoprolol reactions were headache, dizziness, very cold hands & feet, feeling of reflux (wh I never had). Never could stay on it long enough to see if it helped tremor (or I don't remember). I took doses like 25 mg BID.

Carvedilol 6.25 mg BID: Great until lung problems got worse. I loved how it gave me back almost total agility with my hands & fingers. But not being able to breathe is something to consider more now.

I read bad stuff about the ACE inhibitors (CA). Am thinking possibly the ARBs okay, like losartan (Cozaar). Or maybe I should try metoprolol one more time & see if the lowest possible dose might work.

Does anyone know about what might be good for me? I want to:
1. Control heart rate. My BP is pretty normal most of the time even w/o beta blockers, but I can easily get over 120/80. My pulse is on the higher side, maybe ave 70-high 80s.
2. Control moderate benign essential tremor of hands.
3. The least adverse affect on lung function.

Over the yrs, I have tried to get help with this fr my PCP, cardiologist, pulmonologist, endocrinologist (who put me on carvedilol even before afib started), and ENT specialist. It often seems unless a doctor has experienced adverse symptoms, they don't give much credence to what you say you are experiencing & don't think you should stop the med. It is hard to get help. I will say at the start of the pandemic my PCP was going to switch me to losartan, but then there was some scary stuff going around about it in relation to the virus, so I stayed with carvedilol.

Thank you in advance for possibly reading my plea for help.



Edited 1 time(s). Last edit at 01/28/2022 06:09PM by Madeline.

This would probably be an easy choice without the essential tremor. Diltiazem will control your heart rate and it has no effects on the lungs, but it probably won't do anything for the tremor. Diltiazem is a calcium channel blocker, and there's another CCB that does control tremor (nifedipine), but one of its side effects is tachycardia so that's a no go. The other drugs that are used to treat essential tremor are anti-seizure meds and tranquilizers, so adding one of those to diltiazem might work. There's probably a good combination of drugs that will do what you want, but what that combination would be is a bit out of my wheelhouse. What you probably need to do is find a practice like Mayo that can provide an entire team to figure out your problem.

Not sure what you read about ACE inhibitors but it sounds like some of the early worries that it could worsen COVID because they both affect the ACE receptors, but those concerns have since been allayed. It turns out that ACE inhibitors and ARBs both significantly reduce the risk of severe COVID disease. So ACE inhibitors are just fine but I doubt they're going to do what you want. They don't control heart rate.

Thanks Carey.

I knew the other stories re the virus and the ARBs had been allayed.

I did see this tonight - 2021 · Cited by 5 — A recent study reported that use of ACE (angiotensin-converting enzyme) inhibitors (ACEIs) was associated with lung cancer.

There is biological evidence to support this finding, as use of ACEIs could promote lung cancer development through accumulation of bradykinin and substance P in lung tissue, both of which may play a role in carcinogenesis.Jan 13, 2021

I did not know ARBs & ACEIs would not control heart rate - is that primarily pulse or BP or both?

I will check out diltiazem

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Carey
This would probably be an easy choice without the essential tremor. Diltiazem will control your heart rate and it has no effects on the lungs, but it probably won't do anything for the tremor. Diltiazem is a calcium channel blocker, and there's another CCB that does control tremor (nifedipine), but one of its side effects is tachycardia so that's a no go. The other drugs that are used to treat essential tremor are anti-seizure meds and tranquilizers, so adding one of those to diltiazem might work. There's probably a good combination of drugs that will do what you want, but what that combination would be is a bit out of my wheelhouse. What you probably need to do is find a practice like Mayo that can provide an entire team to figure out your problem.

Not sure what you read about ACE inhibitors but it sounds like some of the early worries that it could worsen COVID because they both affect the ACE receptors, but those concerns have since been allayed. It turns out that ACE inhibitors and ARBs both significantly reduce the risk of severe COVID disease. So ACE inhibitors are just fine but I doubt they're going to do what you want. They don't control heart rate.

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Madeline
I did not know ARBs & ACEIs would not control heart rate - is that primarily pulse or BP or both?

Heart rate means pulse; the two are synonymous. BP is an entirely different thing that has nothing to do with heart rate.

Both ARBs and ACEIs are commonly used to control BP. I currently take an ARB for BP, but I've taken ACEIs in the past for the same reason. But neither one will lower your heart rate. They'll only affect BP.

As for that one study linking high dose ACEI usage over long periods of time to a slightly increased incidence of lung cancer, that's an outstanding example of why Dr. Google is sometimes not your friend. There are probably a dozen things you could change in your life that would reduce your risk of lung cancer hundreds of times more than avoiding ACE inhibitors.

Thank you so much Carey. You are very helpful. I know I have gotten the pulse/BP thing mixed up before too, but I am going to write it down in my afib file for future reference in case I forget again. Of course, I have to remember where I wrote it down!! My afib file is broken into many categories. Over the years (before afib even) I have asked many ppl in the med field what exactly was the difference in BP, P, heart rate, etc., & mostly every single person had no explanation & basically said they were the same.

I believe if I remember from this site one wants to keep their pulse rate below 100 for sure. Is it okay to run in the high 80s? I basically stay very busy either with physical or mental activity from sunup to sundown. I do meditate as well. But I tend to easily run a higher pulse, but not over 100.

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Carey

I did not know ARBs & ACEIs would not control heart rate - is that primarily pulse or BP or both?

Heart rate means pulse; the two are synonymous. BP is an entirely different thing that has nothing to do with heart rate.

Both ARBs and ACEIs are commonly used to control BP. I currently take an ARB for BP, but I've taken ACEIs in the past for the same reason. But neither one will lower your heart rate. They'll only affect BP.

As for that one study linking high dose ACEI usage over long periods of time to a slightly increased incidence of lung cancer, that's an outstanding example of why Dr. Google is sometimes not your friend. There are probably a dozen things you could change in your life that would reduce your risk of lung cancer hundreds of times more than avoiding ACE inhibitors.

Quote
Madeline
I believe if I remember from this site one wants to keep their pulse rate below 100 for sure. Is it okay to run in the high 80s? I basically stay very busy either with physical or mental activity from sunup to sundown. I do meditate as well. But I tend to easily run a higher pulse, but not over 100.

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I had my Natale cardiac ablation in August 2020 & am doing great. Not even on any blood thinners.

Hi Madeline,

If you are doing well after your Natale ablation, are you in NSR (normal rhythm)? If so, no need to worry about the 100 BPM heart rate. It is common and normal for heart rates to go above 100 when you are in NSR and active. The issue is for those who are in persistent afib. Their resting afib heart rate should not be above 100 for extended (weeks, months) periods of time. If a person in afib has heart rates > 100 for extended periods of time, the heart can enlarge leading to cardiomyopathy and heart failure. For someone in NSR, their resting heart rates are almost always < 100, so not an issue.

George

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GeorgeN

I believe if I remember from this site one wants to keep their pulse rate below 100 for sure. Is it okay to run in the high 80s? I basically stay very busy either with physical or mental activity from sunup to sundown. I do meditate as well. But I tend to easily run a higher pulse, but not over 100.


I had my Natale cardiac ablation in August 2020 & am doing great. Not even on any blood thinners.

Hi Madeline,

If you are doing well after your Natale ablation, are you in NSR (normal rhythm)? If so, no need to worry about the 100 BPM heart rate. It is common and normal for heart rates to go above 100 when you are in NSR and active. The issue is for those who are in persistent afib. Their resting afib heart rate should not be above 100 for extended (weeks, months) periods of time. If a person in afib has heart rates > 100 for extended periods of time, the heart can enlarge leading to cardiomyopathy and heart failure. For someone in NSR, their resting heart rates are almost always < 100, so not an issue.

George

Hi George,

Thank you for chiming in. Let me correct one thing: I mistakenly said my ablation was in 2020, but it was in 2019.

My current ave BP/P is 121/77, 79. That is with taking BP fairly randomly & even in the mornings sometimes not too long after thyroid meds (wh Include natural dessicated). Here & there my pulse will be 90 or more though & not after exercise, perhaps more exhaustion & stress.

So, last fall at my annual EKG by cardiologist, all was okay with him at my not wanting to take a blood thinner anymore as long as my BP stayed under control. I had been off of it by then since Sep of 2020 & doing well. I brought my machine to his office & it was corroborated against theirs. I go back for a recheck end of March.

I am female (we are not counting that point for the CV score), 72, no hypertension (that part was confusing to me bec I did not know if one was on meds, even if slight, if they considered you to have hypertension, but I guess not since he did not count it against me).
So my score is 1.

I have been off the blood thinner of Xarelto since Sept 2020. I do take a turmeric pill & a ginkgo biloba pill daily - just for a bit of insurance. I know, some people may think this is nonsense.

Thank you. I am trying to gather good info for a visit with my PCPs NP this Wednesday. I hate to randomly be started on any old medicine from a quick visit with the NP. We have actually discussed this before. I can't seem to get anyone to help me find something to replace the carvedilol since it affects my lungs.

I ruined my nsr by taking ginkgo biloba. Yes, I’m unusually special :-) so I asked my cardiologist if she knows if ginkgo biloba is arrhythmic? She said definitely yes…so it isn’t just me. Kudos you can take it. Your “afib monkey cage” (ablation) was really successful! You are very lucky.

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Madeline
Does anyone know about what might be good for me? I want to:
1. Control heart rate. My BP is pretty normal most of the time even w/o beta blockers, but I can easily get over 120/80. My pulse is on the higher side, maybe ave 70-high 80s.
2. Control moderate benign essential tremor of hands.
3. The least adverse affect on lung function.

From what you've described, In my non-medical opinion, I don't think you need to worry about #1. Only something that will do #2 and #3. Completely out of my wheelhouse to suggest anything.

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GeorgeN

Does anyone know about what might be good for me? I want to:
1. Control heart rate. My BP is pretty normal most of the time even w/o beta blockers, but I can easily get over 120/80. My pulse is on the higher side, maybe ave 70-high 80s.
2. Control moderate benign essential tremor of hands.
3. The least adverse affect on lung function.


From what you've described, In my non-medical opinion, I don't think you need to worry about #1. Only something that will do #2 and #3. Completely out of my wheelhouse to suggest anything.

George,
Would you still say that knowing my pulse easily gets into 90s (i was quoting average fr my BP machine) or at least 88 fairly frequently & sometimes the BP something like 137/90. My BP is always high at dr's office. I am not afraid of the dr (white coat hypertension), but I am so stressed I guess with all I want to impart & plead for & get it in, in the few minutes allowed. I come with lots of notes & work I have prepared.
I am a bit OCD for sure & most people seem so relaxed about things compared to me.

Your pulse getting into the 80s and 90s due to daily events is absolutely nothing to be concerned about. It's perfectly normal and we all do that.

And don't think that things like whitecoat hypertension are due to you being afraid of doctors. My wife has a perfectly normal BP that's typically 110/70-ish no matter when she measures it. But at the doctor's office she's often 140/80-ish. She's not in the least bit afraid of the doctor, his office, or the staff. It's just a weird thing that happens to many people.

Your heart rate is perfectly normal.

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Carey
And don't think that things like whitecoat hypertension are due to you being afraid of doctors. My wife has a perfectly normal BP that's typically 110/70-ish no matter when she measures it. But at the doctor's office she's often 140/80-ish. She's not in the least bit afraid of the doctor, his office, or the staff.

I've known I've had white coat hypertension since 1982. My BP this morning was 102/50. I'm fine going to a doctor's office, unless I know they will measure my BP. If so, I can feel my pulse accelerate from its normal 50's into the 80's or 90's and my BP can go to 150 or so. It is a mental thing with me, and it is self reinforcing. My dentist office decided it was a good idea to measure BP at a teeth cleaning. I told them no way. It is now in my files they don't measure.

Going to the Dr. is "exam" time. Who doesn't get a bit nervous when you know you will be tested and want to look/be 100% normal.

I did not read all the responses. I take cardizem for a rate control med. works well for me.

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GeorgeN

And don't think that things like whitecoat hypertension are due to you being afraid of doctors. My wife has a perfectly normal BP that's typically 110/70-ish no matter when she measures it. But at the doctor's office she's often 140/80-ish. She's not in the least bit afraid of the doctor, his office, or the staff.

I've known I've had white coat hypertension since 1982. My BP this morning was 102/50. I'm fine going to a doctor's office, unless I know they will measure my BP. If so, I can feel my pulse accelerate from its normal 50's into the 80's or 90's and my BP can go to 150 or so. It is a mental thing with me, and it is self reinforcing. My dentist office decided it was a good idea to measure BP at a teeth cleaning. I told them no way. It is now in my files they don't measure.

Well, George, I certainly don't have low pulse rates & BPs like you do. I frequently can have high pulse rate. It was 92 late last night, but my BP was fine. I just don't understand it.

I wonder why the Chads scoring considers hypertension (BP problems) but says nothing about rate control. Also my cardiologist will be checking my BP hx to make sure it is okay to let me continue without a blood thinner. My machine shows pulse at the same time; but I think he mentioned the BP as important. Yet, here I am also hearing it is more about rate control, not BP.

Good decision to tell your dentist office to cool it w/the BP stats!!!

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Madeline
Well, George, I certainly don't have low pulse rates & BPs like you do. I frequently can have high pulse rate. It was 92 late last night, but my BP was fine. I just don't understand it.

It could be a latent after effect of your ablation. I don't know what your NSR resting heart rate was prior to your ablation, but commonly post ablation resting heart rates will rise, for a time. In fact, it can be the hallmark of a successful ablation. These higher heart rates will usually return to pre ablation levels after a time. I'm guessing that time is variable by individual.

"A normal resting heart rate for adults ranges from 60 to 100 beats per minute." Source.

Also women tend to have higher heart rates than men.

There can also be a fitness component. Endurance exercise can lower resting heart rates, though I wouldn't go wild about this.

Since your resting heart rate is < 100 BPM, I would not worry about it and certainly not take a med for it.

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GeorgeN

Well, George, I certainly don't have low pulse rates & BPs like you do. I frequently can have high pulse rate. It was 92 late last night, but my BP was fine. I just don't understand it.


There can also be a fitness component. Endurance exercise can lower resting heart rates, though I wouldn't go wild about this.

Since your resting heart rate is < 100 BPM, I would not worry about it and certainly not take a med for it.

The thing is I do lots of exercise - almost daily min 30-40 min walks. Today I took a 1-hr bike ride. I do yoga/Pilates (a vigorous class 2x/week) & a mild yoga 1 day, & a Pilates class another day. I am pretty active all the time, pretty strong, very flexible. I can clean my house like no other cleaner can who is 30 yr younger than me bec of all the extra steps I go to get high & low places. I am agile, strong & able - even though I now have a tumor on the Schwann cells affecting my balance, all my prior yrs of excellent balance keep me going. I can easily look quickly left & right again on my bike (couldn't after my vertigo episode 2 yr ago, but I've kept at getting better.

But, good to know that it is okay even if I do run pulses in the 90s sometimes. I just don't want to risk afib again & I don't want to have to go on a blood thinner again. Even the primary care dr wanted my BP to be below 130/80 all the time & unless on the carvedilol, it could go over that sometimes. I had read in older people it was okay for the BP to be a bit higher. It seems every dr wants a little more from me than I can give them unless I get on one of their meds. I think Carey once told me if I wasn't doing a blood thinner, I should at least be safe & cover my bases with a rate control bec of my h/o afib. The carvedilol calmed me a little (maybe mostly bec the hand tremor almost gone completely) & it did not slow me down like I hear many (Carey esp!!) say about beta blockers. But I don't think my dose is considered much at all.

Thank you.

I believe I remember Carey telling me he was surprised my resting ht rate was not low like most exercisers. But you know, I have never liked running - gave me a headache. I like strength, balance, agility type stuff more than aerobic exercise. But I do realize my walks & biking are a bit aerobic too..........I am just never going to be a real low ht rate kind of person.

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Madeline
but controls my moderate benign essential tremor of hands.

For what it was worth, this thread showed up on essential tremor. [www.reddit.com]

This guy said two things have helped his tremors: Wim Hof breathing and a keto diet. I know nothing about tremors, but have done Hof breathing (for probably 8 years) and keto (I've been keto adapted since 2009). So found it interesting.

Thank you everyone for your responses. I appreciate the help.

George, I will check into Wim Hof breathing, but I tend to feel like that person who says the tremor is neurological & muscular.

The tremor can also be called
Postural tremor -as it occurs when my hand may be outstretched & palm down in yoga, but not when my hand is turned up
Intention tremor - when the intention to flip a pancake begins the aim of the hand already can start to be responding incorrectly

I do have a neurologist bec I have the tumor in one ear on Schwann cells (intracochlear schwannoma) & it is monitored with brain scans.

Like ppl say, mostly the drugs are much worse than carvedilol such as primidone (wh I really don't know much about) & tranquilizers - certainly don't want to get hooked on daily tranqs. My cardiologist once wrote me a script for propranolol ER 60 mg once a day (Inderal) s few yrs back. He thought it would be simpler than multi dosing & that sounded good,but it was way too strong for me, was awful - I hated how it made me feel. I always reserved the thought that perhaps if I went back & got a very small dose & tried it slowly, maybe it would have worked.

I think I am having a more exaggerated adverse lung effect now bec I could have had Covid recently as I have had a very slight sore throat & unusually dry cough on a deeper breath. I am prone to respiratory infections now & then, so I have been treating it like that is what it was except the cough should be productive. I had sinus drainage, but the cough was not productive, just dry & hacking & still not allowing me to breathe deeply. I would imagine maybe that is what asthma feels like. Maybe I need a bronchodilator like Susan D. suggested of ipratropium .... (Atrovent) that her pulmo prescribed for afib pts. I took a Covid home test yesterday & it was negative, but I had had these symptoms about 14 days to that point.

I don't think I am going to be able to completely stop the carvedilol, just lowering nighttime dose as the effect is too much. I have had smooth sailing for a good while now with writing & drinking & activities & it is so nice. I have to figure out what to do.

If the exaggerated breathing problem is from catching Covid, I wonder how long it will last. Regardless, it can't be good to be on a medicine that also impairs the lungs.