What is the Ideal resting heart rate from Medication with AFIB

What is the general consensus on what a resting heart rate with afib while on medication should be? Is anyone on this forum in the 50s-70s with their resting heart rate on medication?

I mentioned in another post even with 120mg sotalol twice a day and 240mg of Diltiazem once a day my resting heart rate is low 100s to mid 115s or so on average. That is just sitting with no exertion. Sleeping I'm in the 80s and 90s but it just seems high to have a resting heart rate taking both of those medications for 5 months like I have.

When I was on amiodarone the first month my heart rate got just under 50 during sleep but never lower than 47bpm. That medication definitely lowered my heart rate and I had no known symptoms within the first month but it's apparently toxic and It wasn't advised to stay on it long term.

Anyone with low resting heart rates and no ablation just off off medication?

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cornerbax
What is the general consensus on what a resting heart rate with afib while on medication should be? Is anyone on this forum in the 50s-70s with their resting heart rate on medication?

I mentioned in another post even with 120mg sotalol twice a day and 240mg of Diltiazem once a day my resting heart rate is low 100s to mid 115s or so on average. That is just sitting with no exertion. Sleeping I'm in the 80s and 90s but it just seems high to have a resting heart rate taking both of those medications for 5 months like I have.

When I was on amiodarone the first month my heart rate got just under 50 during sleep but never lower than 47bpm. That medication definitely lowered my heart rate and I had no known symptoms within the first month but it's apparently toxic and It wasn't advised to stay on it long term.

Anyone with low resting heart rates and no ablation just off off medication?

I think this is the question you are asking. "If you are in afib all the time, what should your resting heart rate be?" As an aside, not everybody needs meds to achieve this. It all depends on their body.

Source as PDF
Source as web page
10.2.1 p409

This is the 2020 European Society of Cardiology (ESC) guidelines for management of afib.

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10.2.1.1 Target/optimal ventricular rate range

The optimal heart-rate target in AF patients is unclear. In the RACE (Race Control Efficacy in Permanent Atrial Fibrillation) II RCT of permanent AF patients, there was no difference in a composite of clinical events, New York Heart Association (NYHA) class, or hospitalizations between the strict [target heart rate <80 beats per minute (bpm) at rest and <110 bpm during moderate exercise] and lenient (heart-rate target <110 bpm) arm,487,488 similar to an analysis from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) and RACE trials.489 Therefore, lenient rate control is an acceptable initial approach, regardless of HF {heart failure} status (with the exception of tachycardia-induced cardiomyopathy), unless symptoms call for stricter rate control (Figure 13).

Sotalol and Diltiazem are both rate control drugs. Sotalol is a beta blocker and Diltiazem is a calcium channel blocker. Amiodarone is a rhythm control drug and you were likely in normal rhythm on it, which is why your rate was so much lower. Amiodarone can be toxic to the thyroid.

The knowledge on this forum is incredible. You said the same thing the nurse practitioner did prior to my first call with my current EP. She asked about my heart rates and it wasn't such a simple response since I had an extrmely adverse reaction to type 1C antiarrythmics, specifically flecanide and propafenone. I did tell her that as well as my heart rate was never lower since my Afib diagnoses than it was with amiodarone. My fitbit actually alert me many times in my sleep I was under 50bpm. I never got much below 50 but at sleep I was always just over or just under 50 on amiodarone and resting heart rate during the day was in the 70s, 80s tops.

I was taken off the amiodarone within a month because of potential toxicity and put on flecanide and then propafenone which, as mentioned was horrible. I was taken off of those and put on sotalol and diltiazem which is what I have been on for 5 months. It looks like my average resting heart rate is around 107 so that would be below the 110 lenient heart rate listed at least.

I also was always under the impression diltiazem was a rate control drug and sotalol was an antiarrythmic. After your response I researched and it looks like sotalol DOES have antiarrythmic properties and is a class 2 AND class 3 drug but as you said it's still really a rate control drug first and foremost.

What I am confused on is since both are rate control drugs and my current NP and EP knew I was in sinus with amiodarone (my ecg showed sinus rhythm when I was discharged from the hospital on amiodarone) why wouldn't my EP put me on dronedarone/multaq which apparently is a lot less toxic and which may of gotten me back in sinus rhythm like amiodarone did?



Edited 1 time(s). Last edit at 06/29/2023 05:58PM by cornerbax.

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cornerbax
What I am confused on is since both are rate control drugs and my current NP and EP knew I was in sinus with amiodarone (my ecg showed sinus rhythm when I was discharged from the hospital on amiodarone) why wouldn't my EP put me on dronedarone/multaq which apparently is a lot less toxic and which may of gotten me back in sinus rhythm like amiodarone did?

While they hoped that Multaq would be as effective as Amiodarone, it did not prove to be so. It is considered to be a mild antiarrythmic and rarely will convert someone to sinus. It is better at maintaining you in sinus though and this why some EPs like Natale, often give it for a couple of months after an ablation. It did prove to be a safe drug though. I took it after a spectacular failure with Flecainide and it was pretty good for the first few months but then I started getting more and more breakthroughs in the months before my ablation. I did take it with good results after the ablation though.

You need to revisit your meds with your EP. 100-115 is too high, and it's high enough to be damaging over the long run.

Resting heart rate should be somewhere between 50 and 80 depending on your level of fitness, with athletes falling near the bottom of the range (very highly trained athletes can go down in the 40s).

more great info thank you once again. In my case I need to find meds that will get my heart rate down as amiodarone did without the toxic harm. I've done research on medication and I can't take anything in the 1C class and amiodarone can't be taken long term. Both sotalol and diltiazem don't get my heart rate Low enough so not sure what else would be left as far as medication goes.

Maybe Dofetilide/Tikosyn? I know I'd need to be monitored in the hospital for 3 days on this just as I was on sotalol.

I did read that 540mg can be taken daily in some cases for diltiazem and they did up me from 120-240mg per day which did drop my heart rate another 10 or so bpm on average. I wonder if taking 360, 440 or even 520 would help. I haven't noticed any side effects or issues from either the sotalol or the diltiazem. It can't hurt to ask my EP. Anyone on this forum take high doses of Diltiazem?



Edited 1 time(s). Last edit at 06/29/2023 07:05PM by cornerbax.

The dosages of both drugs can be increased.

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Carey
Resting heart rate should be somewhere between 50 and 80 depending on your level of fitness, with athletes falling near the bottom of the range (very highly trained athletes can go down in the 40s).

However the low end of this range is not something to strive for while in afib 100% of the time and on rate control meds. You could discuss whether a different rhythm med might work for you, other than the ones you've tried. If you are in rhythm, then the rate control meds become moot.

Initially I was in afib on all of the ecgs
After some medication It turned into flutter.
I have no idea if I was between afib and a flutter
Off and on. I have not converted to normal sinus rhythm
Since the entire fiasco with flecanide and propafenone.

I did convert with amiodarone early on. From my fitbit and kardia it appears at any given time I am in a flutter or Afib. I can see the kardia say tachycardia when it's flutter and afib says afib directly. I've definitely been persistent in afib or aflutter with no normal sinus rhythm since being on sotalol and diltiazem for 5 months. And as mentioned, I am almost always over 105bpm at rest with those medications.

I don't know if this matters but I can say I've had no noticeable SYMPTOMS on either medication. I don't even feel any palpitations unless I'm over 135-140 which doesn't happen unless there's exertion. I have no shortness of breath, dizziness or anything else.

Is it a good or bad thing I'm alternating between afib and aflutter? We know it isn't a good thing my resting heart rate is over 100bpm at rest regularly.

Also, any ideas of a good rhythm control medicine that I can mention to my EP?

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cornerbax
Is it a good or bad thing I'm alternating between afib and aflutter? We know it isn't a good thing my resting heart rate is over 100bpm at rest regularly.

Also, any ideas of a good rhythm control medicine that I can mention to my EP?

It's never good that you've got either and alternating isn't an improvement, but it's also not unusual. Neither one is desirable and they often go hand in hand, as you've discovered. I spent several years dealing with both.

Your EP knows about all the antiarrhythmic drugs available without you mentioning them. I doubt you need to change drugs but rather just dosages. I would definitely adjust dosages of drugs you know work for you before I switched to another drug, especially since the only three left to choose from are Tikosyn, Multaq, and amiodarone. Tikosyn is a heavy hitter, requires a hospital stay, and is expensive. Multaq is weak and unlikely to work for you, and you already know the reasons you don't want to take amio.

What you say makes complete logical sense but in the medical field logic doesn't always apply as in one word being moderate than severe in the same breath so to speak lol.

Yes, amio I wouldn't touch long term and if Multaq wouldn't work or isn't likely... Tikosyn would be the only thing left. I don't want to be back in the hospital again for 3 days to try a different medication.

Both Tikosyn and Sotalol can potentially cause Torsades De Pointes which can be fatal. I'm sure that's why you're monitored for 3 days. Do you think increasing the dosage of sotalol can also increase the chance for Torsades de Pointes or any other adverse effect?



Edited 1 time(s). Last edit at 06/30/2023 12:11AM by cornerbax.

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cornerbax
Both Tikosyn and Sotalol can potentially cause Torsades De Pointes which can be fatal. I'm sure that's why you're monitored for 3 days. Do you think increasing the dosage of sotalol can also increase the chance for Torsades de Pointes or any other adverse effect?

Well, yes, but are you blowing that risk out of proportion? How much did the sotalol increase your QT interval? You're asking questions that are way above my pay grade and probably can't even be answered by your doctor without hospitalizing you. I've been put on sotalol, had my dosages adjusted, and been taken off it without spending a day in a hospital. I'm male and have no issues with wide QT intervals, so that's probably why. Women have naturally wider QTs, so that's also part of the equation.

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cornerbax
The knowledge on this forum is incredible.

George is wicked smart like Good Will Hunting.

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I was just asking if increasing the dose also would increase the possibility of potential torsades De pointes. I didn't think I was blowing it out of proportion it was a very quick question.

The reality is I'm on Sotalol 240mg now, 120mg twice a day and even with 240mg Extended release diltiazem my resting heart rate is over 100bpm most day. I guess what I was thinking is since I haven't read as much adverse affects of Diltiazem and up to 540mg daily can be taken in some cases than maybe it would be best to increase the diltiazem one or two fold? I'll ask my EP as you said.

I will say the sotalol didn't seem to do much to my QTC intervals while In the hospital and they started with 80mg twice a day. The hospital EP two days later upped it to 120mg twice a day and my heart rate barely dropped with either dose. That is why they added the diltiazem which helped but didn't drop the rate a lot either. I was wearing a heart rate monitor the entire time and sotalol literally did little or nothing and seems the same way months later. I'm questioning if I should even be on it as it didn't do anything In the hospital rate wise and hasn't months later.

I'll ask my EP his thoughts.



Edited 1 time(s). Last edit at 06/30/2023 11:19AM by cornerbax.

I was on put on 400 mg of Multaq x2 after I needed to be cardioverted after my second ablation. This worked for a few months until flutter/tachycardia reappeared.

Stopped Multaq and put on sotalol 40mg x2. Worked for a few months before flutter reappeared and needed to be cardioverted again. Dosage was upped to 80mg x2. My HR dropped to the mid to high 40s. Only worked for a short period before flutter/tachycardia reappeared.

Started 500 mg of dofetilide { required 3 day hospital stay}. Converted to sinus on the second dosage while in the hospital. Continue to be in sinus after 3 months without any issues. My resting HR on the dofetilide is around 55-60.

I do not want to be on an antiarrythmic long term so I am planning on getting a second opinion before deciding my next move.

it sounds like you had a great resting heart rate but it didn't last long, unfortunately. I'm not convinced Dofetilide at 500mg would work for me but I will mention it to my EP. As Carey stated, I don't have many options for medicine left and Amiodarone worked exceptionally as far as heart rate and no known side effects, but long term that likely isn't the case.

You also ahd lower resting heart rates on other medicaitons prior to Dofetilide and prior to the issues you had. On Sotalol and Diltiazem if I just stand or sit my heart rate almost never is under 100. Only laying down and primarily sleeping will I get to mid 70's to mid 80s. Upping Diltiazem seems the most logical choice to start and than maybe Sotalol if necessary. I'll talk to my EP and see what they think but constantly over 100bpm just standing still or sitting still isn't ideal long term.