Are beta blockers prescribed in paroxysmal AF without proper consideration?

NICE guidelines recommend beta blockers other than sotalol for rate control, as regular ongoing treatment.

I see the logic of giving them for frequent episodes of symptomatic adrenergic type AF (precipitated by anxiety, stress and exercise) with high heart rates. Also in combination with Flecainide to reduce proarrhythmic effect.

I'm not sure vagal AF (slow, asymptomatic, nocturnal after exercise or a meal) is considered often enough, and here beta blockers may be unhelpful.

For those of us with infrequent AF, or short-lived episodes or only mildly symptomatic, taking a beta blocker regularly often compromises our quality of life, possibly with no benefit.

Does anybody in this situation agree/disagree with my feeling that some GPs may simply follow NICE guidelines without thinking it through? Or perhaps the guidelines could be more comprehensive on this particular recommendation.

A rapid acting oral beta blocker as pip might be useful. Presumably they don't exist.

atrialfibrillationblog.com/...

edit: I used to have vagal episodes of AF, now permanent AF/AFL

[wilsond]

Yes I agree. I was given bisoprolol on my diagnosis of pAf in 2013.Never got on with it really,tried different dosage,time of day etc.

Put up with it. Then I had a TiA out of the blue,result...onto 200mg flecanide daily,off bisoprolol as had very low heart rate. Week later,went into Flutter,back on bisoprolol as well,daily 5mg.

Long story short......as my Flutter is a very rare visitor and as AF with me is not often fast type (now believe it maybe vagal) With my EPs knowledge and with my GP,have come off betablocker as dai!y dose and use 5 to 10 mg as a PIP.As an aside,I have also come off flecanide as a daily dose as well. I am having LESS AF and AFl episodes than before,my BP is perfect,and cholesterol is normal.

I am rigorously fol!owing nutritional diet,losing weight steadliy,exercising more.I was unable to do so on betablockers,out of breath and frightened.Viscious cycle then,more weight on,less good circulation,etc.

For me the use of a betablocker as a PIP works well at the moment.

Will be interested to see other replies!

[Hidden]

I disagree. I was put on Bisoprolol in the beginning 9 years ago. It holds my heart rate at 65. I follow a nutrition plan re food as my AF is vagal in origin. The amalgam of all this has kept my AF at bay since April 2015, except for one incident almost a year ago when I went into AF sleeping on my left side. My medication has never been prescribed as a PIP. I have no loss of QOL.

[jeanjeannie50 in reply to Hidden]

Carneuny, are you able to advise the person, a few posts back, who's querying about his HGV license?

[Hidden in reply to jeanjeannie50]

Hi Jean,

Yes, I saw that. Will post tonight, been a bit busy last day or so but fully intend to make a comment. 🙂

John

[wilsond in reply to Hidden]

Mine was at 35 to 40 so took me too low for everyday livig really. Think Oyster was wondering if the docs just chuck them at us and assume one size fits all!!

[BobD Volunteer]

I agree that beta blockers and bisoprolol do seem to be the fall back position for most GPs. Bear in mind that thet are not allowed to prescribe anti arhythmic drugs and few have ever heard that beta blockers should NOT be prescribed to people with asthma.

[Bagrat]

I have read before that beta blockers in vagal af may be counter productive. Beta blockers were stopped for me because they dropped my heart rate. I am inclined to think I have " mixed" af. Definitely appears vagal ( woken from sleep, bloating and post prandial) but did have one episode when heart rate fast. I get the feeling many doctors lump all AF together rather than differentiate.

[MyCloud in reply to Bagrat]

My experience too. I have PAF and my gp recommended beta blockers. When I saw specialist he said it is vagally initiated and beta blockers are contra indicated . Am on pip flecainide.

[ILowe]

For quick action betablockers. I have not done the research. Need to check the pharmokinetics??? to look at speed of absorption and time of first effect and peak action.

I was talking to an American doctor recently. She said that the way my AF starts just when stress stops is interesting, and perhaps I should research the use of betablockers as PIP for stage fright. Check the doses -- they are not the minimum.

Another approach, little discussed, is the day to day use of the minimum, then PIP booster when needed.

Sigh, what we really need is drugs which block the high rates while still allowing the resting rates to stay unchanged. A compromise would be a short duration of action blocker, that you only take for daytime use.

[Droopy60 in reply to ILowe]

I was taken to A&E 9 years ago with a HR of over 200 and diagnosed AF. I was given Bisoprolol which reduced the rate but brought on bradycardia with my HR dropping to below 40. The solution was the insertion of a pacemaker. I have reduced the Bisoprolol dose from 10 to 5 mg as I was getting extreme breathlessness. I now think that the Bisoprolol is lowering the HR but the pacemaker is stopping it going too low. This I think causes a conflict which results in everyday activities being a chore. I raised this with my GP who said the heart needs protecting so in effect agreed with my assessment. Oh how I wish I could use the Bisoprolol as a PIP!

[ILowe in reply to Droopy60]

I think you can use betablockers as a PIP. Two weeks ago I was talking with an American doctor. When I get a minute this is on my list to google. Perhaps you could google for instance: betablockers and stage fright. The one that keeps being mentioned is Propranolol. A quick look suggests that a small dose of 40mg lasts about four hours but I am not sure on this. Perfect. Take as needed. It has an effect in 1 to 1.5 hours. The half life is four hours drugs.com/monograph/propran...

My cardiologist, in the days when I was taking a PIP of bisoprolol + flecainide, said I could also use propanolol instead of bisoprolol. Now I know why.

When you dig a bit, you find that some betablockers act faster than others, and have a shorter life. Soon, I will go through the BNF list of those prescribed in UK, and do a table, and see for myself.

[Hidden]

Yes, I agree. I think they are used as a ‘one size fits all’ treatment on initial diagnosis of paroxysmal AF, without regard for the patient’s regular HR & BP when not in AF. More checks should be done first.

I think it needs a new approach/protocol as so many on here seem to have suffered low BP and unacceptably low HR after taking beta blockers, making it difficult to function as a normal human!

I also agree with BobD who mentioned GP’s not knowing those with asthma shouldn’t be prescribed beta blockers. In my case the hospital doc who prescribed them for me (& indeed brought me the first dose with a glass of water saying ‘swallow this’), didn’t take much of a history & certainly didn’t ask if I was asthmatic.

Pat x

[ILowe in reply to Hidden]

You say the doctor did not ask if you were an asthmatic before prescribing a betablocker. This is the old story - you must have looked well, so the doctor did not check . One more reason why the patient needs to be very alert and proactive and tell/question the doctor. That way a doctor can choose a 'cardioselective' betablocker such as nebivolol which supposedly is safe, or safer, for asthmatics.