Slow heart rate on Beta Blockers

Went into afib for the first time beginning of January, admitted for 3 days. Was put on 150mg of Metoprolol and Apixaban. Was in afib solid for 4 weeks, had cardioversion on 5th Februrary and was in Sinus until Feb 13th Feb, went into afib but then self corrected after 13hrs, just before I was getting uber to go to emerge again.

Heart rate has been low though since cardioversion, in conjunction with Nurse, adjusted to 50mg a day, but heart rate resting during waking hours can be as low as 42 bpm in sinus and rarely above 50 unless moving a lot with the 50mg of metaprolol per day. I've been told I need to be on the metaprolol to stop going back into afib, I don't feel great however at this heart rate, but haven't fainted or anything.

Is this normal, and is it safe to have a heart that slow? I.E. Standard treatment afib or should I be advocating more to get off the beta blocker?

I'd ask the EP, but it;'s Canada, when I asked why I hadn't received the EP appt yet, nurse laughed at me and she's be retired before I got that appt, and that it would be at least a year or likely more till I got my first appt.

Yikes! Sorry that you have to wait so long to see an EP. Did they explain to you that Metoprolol is not an antiarrythmic so won’t prevent Afib only lower the heart rate when you do go into Afib? You could ask about trying an antiarrythmic like Flecainide. EPs usually start people on 50 mg twice a day. It isn’t dangerous to have a heart rate of 42 but as you have discovered, it may not feel great. You could ask for them to lower the dose a bit. While a beta blocker is usually prescribed along with a certain class of antiarrythmics like Flecainide, there is no need to prescribe a dose that lowers your heart rate that much. It is pretty standard treatment to prescribe a low dose of an antiarrythmic like Flecainide and a beta blocker to a new Afib patient. Glad that they gave you Apixaban!

In British Columbia the wait to see an EP is about 3-4 months, but that's if all the ducks are in order, and he/she doesn't want or need any further diagnostics like and angiogram or MIBI stress test. From the first consult, it's another 4 months. Emergency cases can be done in just over a week. We have long emergencies here in Canada.

Metoprolol is more a rate control drug, and it reduces the force of contractions. This means it's good for incipient hypertension. In high enough doses it can place a person into very low bradycardia which is generally accepted to be any rate below 50 BPM. However, you can live with a rate as low as about 30, which is the 'failsafe' rate that your Atrio-Ventricular node, the lower of the two electrical impulse generators in the heart, will generate if that's all you have left. I wouldn't worry too much about a rate above 40, especially at rest. But you should have someone on call whom you can consult if your rate starts slipping below the 40 mark routinely.

I don't know anyone who was placed on 150 mg of metoprolol as a first dose. That's exceedingly high. The maximum recommended does, according to the gentleman who administered my angiogram, is 200 mg, and up to 400 if in heart failure. I started on 12.5 BID, so one tablet broken in half, but ended up at 150 before I had my second ablation. I never understood that it was to keep me out of AF, but it was meant to control the rate so that it didn't run at 148, as it had been doing lately.

I agree with the other responses.
What was your normal HR while in NSR before you took the Metropolol?

Sounds like you need to go down to 25mg for a trial, and then raise the dose back as needed if your are actually in AFIB.

The Anti-Fib: Thanks for the advice. Normal HR in NSR before afib was 57-60 bpm.

gloaming: Alberta

Glad to hear it's not life threatening.

JC
I am in Calgary and my wait time for the first appointment to see an EP was 13 months. That was November 30th 2023 and at that appointment I was given an estimate of 6 to 9 months for the ablation.

I am on Sotolol and Apixiban. Last year I started passing out when I would convert from Afib and later found out they called these blackouts "pauses" my pauses ended up at an average of 9 seconds long. They would not do anything for me unless it was proven or caught on a EKG, ( its like they did not believe me). Finally last July 2023 I was in ER and they caught the pauses one as long as 18 seconds!!! One day later I had a pace maker.
The pace maker is set not to allow my heart rate to go under 50.
No pauses since and I still exercise 6 to 7 days a week.

Alberta wait times are insane! I phoned an EP in Guadalajara Mexico and he said he could do the ablation in the next 10 days but the price was $45,000USD so way out of my price range.

I hope you get things worked out.

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calvin
Alberta wait times are insane! I phoned an EP in Guadalajara Mexico and he said he could do the ablation in the next 10 days but the price was $45,000USD so way out of my price range.

That's nuts. You can get an ablation with Natale for that much or maybe even less.

And any EP who can do an ablation for you in less than a few weeks isn't the EP you want.

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Carey

Alberta wait times are insane! I phoned an EP in Guadalajara Mexico and he said he could do the ablation in the next 10 days but the price was $45,000USD so way out of my price range.

That's nuts. You can get an ablation with Natale for that much or maybe even less.

And any EP who can do an ablation for you in less than a few weeks isn't the EP you want.

Well in Mexico I am sure things are different. The EP I spoke to came recommended by a Doctor friend from Tamaulipas. He said he had been doing ablations for 16 years. Any way its moot now as I could not afford even half that and I am now in the Alberta system.

Calgary too, today was told 12 months for EP appt and 2 years for ablation if they deem you worthy. They are managing new and existing AFIB patients with nurses atm as they don't have enough EP's. It's being blamed on too many baby boomers.

Also have got conflicting information from the nurse about rate control stopping afib.

As I'm not in afib, I take it I shouldn't need the beta blocker unless I am in afib?



Edited 1 time(s). Last edit at 02/21/2024 06:37PM by jc.

The beta blocker does two things: it slows the heart RATE...not its inclination to enter into or to leave an arrhythmia of any kind...only the RATE, and it also weakens the contractions so that one's blood pressure doesn't become so much of a problem if it's creeping up a bit.

If you enter into AF, and your rate soars to 135, and stays there, at what point would you decide that it's time to take a PIP beta blocker? It takes about 45 minutes after ingestion for the concentration of BB to begin to control that high heart rate. If taken soon after a meal, it might be even longer due to the contents of the stomach diluting it and keeping it in the stomach and not moving into the small intestine where much of the absorption takes place. It's a rhetorical question because the BB is meant to be taken prophylactically. It clips your heart rate when, and if, you go into AF. Most of us are paroxysmal, meaning in and out of it on our own sweet time...or rather the heart's. Beta blockers are like insurance. It has to be in place at the time of need, not afterwards. It's not the same for anti-arrhythmic drugs. If you can keep the rate down, you probably won't even need an anti-arrhythmic because you'll convert back on your own, even if it's hours later. But you'd want to keep a lid on the rate if it does go.


So, PIP for anti-arrhythmic, but take the metoprolol or whatever, diltiazem, prophylactically.

"As I'm not in afib, I take it I shouldn't need the beta blocker unless I am in afib?"

What is your typical HR while in AFIB?

It depends on how uncomfortable your AFIB episodes are, and your individual situation, but your right, you probably don't "need to" just for the sake of AFIB. Personally I just take the rate control drugs when I am in AFIB. I carry them with me at all times. If someone is using Diltazem only when actually in AFIB for rate control, then the immediate release tablets are the way to go in the event of an sudden AFIB episode.

Taking Metropolol chronically would make more sense, if you had high BP, or a high HR while normally in NSR, or if you had a history of Heart Failure.

I'm sure Carey's right if you talk to them and pay without insurance. I know my first ablation with Natale 5 months ago amounted to $250,000. With my insurance, I only paid $7,500.

I was first alerted to my slow heart rate in the military at the age of 20 where I had a 32 heart rate. While taking about 1/4 of a 5mg Nevivolol as needed, I've seen my heart rate get down to 29 watching TV.

I will say this, however, I've noticed that taking Main Coast Sea Vegetables Triple Blend Flakes (for Iodine), my nightly resting heart rate rose from ~33 to ~39. Double edge sword I supposed if you consider that too much iodine might tip you into a slight hyperthyroid state which could cause more ectopy. I just don't know.

JohnG



Edited 1 time(s). Last edit at 03/03/2024 03:12PM by JohnG.

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With my insurance, I only paid $7,500.

And with Medicare and a Medicare supplement plan my out-of-pocket was zero.

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Daisy
And with Medicare and a Medicare supplement plan my out-of-pocket was zero.

It's odd, but I hear so often how superior private insurance is to Medicare, but as someone who recently went off an employer-provided plan and onto Medicare, I couldn't disagree more. With my former employer's insurance I paid $750/month premium, had a $3000/year deductible, and had to have prior approval on most expensive procedures. With Medicare, I pay $675/month premium, I have no deductible, no copays, and nothing needs prior approval.

That's great. Thanks y'all. I can look forward to that in 4 years. Thanks Carey

JohnG