Hi everyone...I have recently been put on 50mg of flecainide twice daily and 1.25mg of bisoprolol once daily for my afib... two weeks on and it has really improved my symptoms a lot... but my concern is I've always had a relatively low pulse rate around the mid 40,,s to mid 50,s at rest . But have noticed my pulse now seems to be in the early forties a lot more at rest since on the new meds. . I am worried that if I need a higher dose will it not he possible as my pulse might drop to low and if that's the case is there any alternative meds out there that would work instead without dropping the pulse much more ? Or is the flecainide not responsible for the low pulse rate is it the bisoprolol? Any advice or personal experience opinions would be appreciated thanks
Low pulse rate and afib treatments - Atrial Fibrillati...
Low pulse rate and afib treatments
Biso controls rate and tiny bit of rhythm; Flec is antiarrythmic.
I think this is a really difficult one to answer because Bisoprolol is the drug of first choice for medics and for many patients not a drug they can tolerate for various reasons, causing low HR at rest when in NSR just one. How do you feel with such a low HR? I think that will be a factor. I would be on the floor at HR40 but what I’ve started to understand is there is no such thing as ‘normal’ which according to the book is 60-120. Talk to your prescribing doctor about this. You may never need a higher dose and if you have infrequent episodes of AF you could be advised to take a higher dose ONLY when in AF with high HR.
Now I’m the opposite - I can tolerate and did when in AF - HR up to 130 without being that symptomatic and tachycardia up to 150. my AF was triggered by low HR so I now have a pacemaker to stop it dropping under 60 and hey presto - I no longer have much trouble with AF. By the book, most people and many doctors, would be saying that’s unsustainable - yet it’s being doing that sometimes for hours/days for many years and without noticeable damage.
The options if you are concerned are various - to switch to another Beta Blocker to see if that works better for you. Pacemaker to limit the low HR so you can continue to take the Biso. FInd another drug or combination.
It really is trial and error to see what works for each individual but I live in hope that sometime in the future we will have Personalised Medicine which will work out our best treatment options BEFORE we are prescribed.
I think you will get a variety of replies. Good luck.
Hi sorry I didn't answer your question...yes I feel ok with low heart rate as I hav e always had a low rate for a long time due to my fitness activities way before the afib started...
Hi Andy, I have the same issue, my resting HR has always been mid to high 40s but since taking Bisoprolol my resting HR is commonly 42 and at night it always drops below 40 which is picked up by my apple watch. I don't find it an issue, I go to the gym 5 times a week and lead a pretty active lifestyle. Like other have said, its how you feel and more importantly that it controls your AF. My cardiologist is quite happy with the low HR. I was put on a higher dose of Bisoprolol after my ablation and that slowed my HR down below 40 and caused some pretty unpleasant side effects so I was reverted back to my original dose of 2.5mg.
I’m not medically trained Andy but what you have been prescribed regarding Flecainide Andy is a commonly used maintenance dose which is designed to keep you in normal sinus rhythm. From what you have said, it appears to be working for you which is good news. However, if Flecainide is taken as a regular daily dose, it must be accompanied with a beta blocker or a calcium channel blocker otherwise it can cause other arrhythmias to occur. The difficulty you have is that even though you are on the lowest dose available, the Bisoprolol is likely to reduce your heart rate a little because that’s what they are designed to do. The same will apply to any type of beta beta blocker, so unless Bisoprolol is causing unwanted symptoms, there is no point in changing to anything else.
If your medication is part of a treatment plan ie prescribed to help maintain rhythm after a cardioversion, then maybe an ablation should be considered. I don’t think any increase in you Flecainide dose will cause change to your heart rate but any increase to your Bisoprolol dose will likely reduce your heart rate further………
Hi there...no I've never had a cardioversion before...but I am on the list for a cybroablation I think they call it.. thanks andy
Then that’s also good news. It may be decided to continue the maintenance dose for a fixed period after the Cryoablation but if all goes well (which it will!) the dose will be stopped. This is what happened in my case…….
Hi thanks again ...I have read that the cyroabalation doesn't usually work the first time and will likely need a second one.. but will have to wait and see on that I suppose...
I don’t think that’s strictly true Andy. A Cryoablation is often performed first because it is a quicker and marginally less risky way of treating the four pulmonary veins which tend to be source for rogue impulses which cause AF. You may be aware, a balloon is inserted into the entrance of the vein and the tissue around the entrance is frozen to form scars which prevent the impulses from occurring. However, the tissue can be irregular which means the balloon might miss bits and that’s when a second, RF (radio frequency using heat) ablation is carried out to treat the missed bits.
Thanks again for the info...there's so much written on the Internet it's hard to know which is true and which is more myth..
Cryoablation is also not always suitable for everyone as not all have 4 equally sized veins. I have 2 which are co-joined so 2 normal veins and 1 huge vein. The balloon couldn’t ablate the co-joined vein.
My first time cryoablation has lasted 4 years 3 months so far!
I am sure a lot of other peoples will have too. It may just be they have not stopped on the forum so you don't get so much feedback. If you don't have 4 pulmonary veins, or if they are not round or if they vary greatly in wall thickness then you may not have a total success but you may just need an RF ablation to touch up any missed pathways.
Not medically trained.
You need to make a list if the points you need clarification with your EP.
Be warned you will be read a list of possible issues and success rates by your EP. They appear to me to be standards. If you have read the leaflets for flecainide and bisoprol on possible side effects you will get the gist.
What you want from the EP is for them to tell you that you are a good candidate for a ablation.
Best wishes
I was on 2.5 bisoprolol and 100 mg flec 2x day. I had a cryoablation March 2021. After six months I came off all meds but unfortunately AF came back so I am now on a waiting list for a 2nd ablation which I am told will be RF. Good luck on your journey as they say we are all different.
Thanks , all the best
Hey guys I'm in much the same position. I also have a low heart rate and on 1.25 of bisoprolol. I was due to have an ablation 2 months ago but was put on hold due to a high pth blood test reading. It appears I have secondary hypothyroidism due to a stomach bypass procedure 4 years ago. Anyway It was also queried if I had sick sinus Syndrome which was could be causing the slow heart rate. Anyway I agree with all the replies. If the meds keep you stable then go with it and query your specialist if you have concerns. We are all different and different drugs and procedures will affect us all in a different way. We will have to adjust our treatments as our body reacts. So ask questions and listen to your body. If you get worried then ask more questions. But try not to worry as stress will not help either.
I'm sorry if my answer has raised more questions than answers. I am having to do the same myself but the guys here do help you realise that you are not alone.
Thanks for that malcolm you are right
There are a few of us on here who take flecainide with no beta blocker cover but that is definitely a decision for your EP. Bisoprolol even a tiny dose dropped my pulse to 40s and I was far from fit and felt like a limp rag.
Based on my personal experience at 60yo on diagnosis, active sporty lifestyle with Lone Paroxysmal AF:
Firstly ease off on the training, suggest half the intensity you normally do as this area can be the principal AF trigger. Build this back slowly when AF free and stabilised.
Secondly, Flecainide may reduce your HR a couple of points but not significantly. So you should be able to increase Flec to a medium dose of 200mgs if deemed neccesary as it was with me to stop the AF. As for Biso, I know very little except it affects HR more. My cardiologist didn't prescribe it as with mid 50s HR he said anything extra would make me feel unwell, no more explanation given. So far he has been right as over 8 years my energy has built back 100% but I don't push my luck and have made many lifestyle changes in the interim.
Stay on this Forum as essential for homework when talking options to medics and builds confidence, keeping you in control.
Hi can I ask have you had an abalation or just stayed with the meds for the last 8 years ? And do you get any breakthrough afib episodes at all ? Cheers andy
Just stayed with the one med Flecainide. Only 2 episodes lasting 20 mins each over the 8 years, one triggered with gulping a cold fizzy soft drink Ginger Beer (but watch out for quinine in Tonic water too) and the other visiting a past bad AF episode site - both these experiences indicate my AF is vagally mediated i.e. the Vagus Nerve is a key actor.
Hiya … do you take Biso and Flex together? Just curious as the EP put me on Flex twice a day and said I could take Bisoprosolol as a pill in pocket if experienced breakthroughs (high HR) or he was happy for me to take both Flec and Biso … it was trial and error! Eek? He explained the Flec should reduce bouts of afib. I get ectopics too. Have low BP / pulse unless experiencing paroxysmal afib where my HR shoots up to 200. He put me on Flec (was just taking Biso as needed) after I experienced a month of intermittent episodes that culminated in chest 45 mins of pain.
i take the biso and flec together as told by ep if flec taken everyday without a small dose beta blocker it could cause the lower ventricles to beat to fast or more irregular and cause other arrhythmias so its a precaution really. ..u thinking flec is taken just as a pill in the pocket approach you don't need the blocker....all the best
No, taking Flec twice a day but up to me to add Biso once a day or as needed. Interesting I wasn’t told same as you about Flec. No wonder we all get confused! Even local chemist said you don’t take Flec/Biso together. It got so confusing when I was first dx a year ago that I stopped all meds … that landed me back in emergency! The confusion continues but I’m too frightened to stop the Flec as feel better on it. Bisoprosolol zombies me out even 50mg at night. It’s the fatigue that’s so horrible 
I take lowest dose bisoprolol at 1.25mg and 50mg flec ....I've just gone with what my EP has instructed...it can get confusing though and scary you ate right....
Sorry meant same eg: 1.25mg Bisoprosolol nightly (as needed / pill in pocket) and 50mg Flecainide twice daily (100mg total) but a week ago I dropped Flec to 25mg twice a day and added 1.25mg Bisoprosolol at night. The 50mg Flec daily gave me too much energy. I was like that Duracell Bunny just couldn’t stop, or sleep! I even dropped half a kilo in a week because of it! I see my EP in July (three months from starting on Flec) as he thinks I’m a good candidate for an ablation. PS: I’ve always had low pulse/HR at 50 or under and in 40s resting. It suddenly went up a year ago and EP says my loop monitor clocked 200bpm. I never felt unwell with a low HR and can tolerate it between 40-50 but at 200 I become extremely unwell. Hope my new regime hits the mark. Good luck to you. Keep us all posted on the ablation! Not sure I am game for that so I’ll keep researching it
Will do take care
Hello Andy. I am 64 years old and am on 40mg Sotalol for my A Fib as 1.25mg Bisoprolol wasn't keeping my episodes under control and had to have a Cardioversion last April. My pulse rate fluctuates between 43 and 45 bmp [resting] and only gets up into low 50's when walking which I hate as it restricts my ability to go for long walks. I'd love to get back cycling but realistically not at the moment as I get tired very quickly and my heart doesn't like it if I overexert myself and starts lurching/fluttering. It's catch 22 - the medication mostly keeps my heart regular but limits my abilities. Hope you can find a 'happy medium' with your medication. Take care.
Hi there...does your pulse race up to very high beats when your in afib or just stay around the normal rate but beats irregular....mine beats lore irregular and doesn't really climb much up at all ...my pulse will go up when I'm walking or excercisng though.. have you thought about a possible abalation that might help....thanks for the reply,, take care....
I decided Andy to only take my BP/Pulse when I really felt unwell. Several weeks ago I was sitting watching tv in the evening after spending the afternoon shopping with my Grandaughter and I thought my heart was going to 'burst' out of my chest. However it was only 48 bpm but felt a lot faster. My blood pressure shot up to 171/69 and I felt really unwell but didn't know what to do so sat up till 2.00a.m waiting for it to settle down again. I went to bed but around 6.00a.m my bp shot up again to 163/75 with pulse of 54. I really don't know what to do when this happens as my main worry is BP and coupled with the lurches/flutters am worried I'll have a stroke???? Maybe overreacting but nowadays you know how much pressure the NHS is under to don't really like bothering anyone about it.
Cardiologist said no ablation as this carries it's own risks.
I wouldn't worry about putting pressure on the NHS...I know they are kept busy and are doing a fantastic job with the resources they've got , but at the end of the day it's your health and your entitled to try and get it sorted just as much as the next person is...also abalation carries a very minimal risk apparently and the results can be really life changing , but of course that's your decision...but I would definatley get back in touch in with your gp or cardiologist , your entitled to any treatment they will give you.. all the best andy.
Cardiologist told me how much it costs per ablation [in Australia] for some reason then proceeded to tell me it might take 2 not one plus I need to reduce my BMI which I am aware of, so reading between the lines as they say I assumed it's a no. Just recently diagnosed with diabetes after many years of hypos and dieting and finally being listened to so I guess it's in my hands now and remaining positive and seeing diabetic nurse and hopefully losing the pounds. Been referred back to Cardiologist and on waiting list for 'event monitor.'
Not medically trained but probably the bisoprolol. That is the rate control drug. I had 1.25mg dropped from 70 to mid 40s resting I coukd not tolerate it. Flecainide is the rhythm control drug. It keeps your heart in rhythm or can put it back into rhythm if in AFib
The bisoprolol makes my HR drop 4-5 beats at 1.25 mg. My EP thinks a dose that small doesn't do much and since my Afib comes on at night (when pulse) is lowest he said not to take it. General cardiologists often like to prescribe it when I'm admitted for a urgent cardioversion and my EP always overrules them once he knows. It also makes me faint and extremely breathless. Hope this helps x
Hi Andy,
My experience is similar to yours in that before I had AF my resting heart rate was in the upper forties to low fifties.
My first experience of AF (persistent) was last December, I was put on 2.5mg of Bisoprolol to bring my resting pulse rate below 90 which it did and after a week it settled in the mid seventies.
I subsequently had a cardioversion that put me back into normal sinus rhythm and was told to continue with 1.25mg of Bisoprolol.
After 10 days my resting heart rate was down to 40 during the day and 37 at night and continuing to be pulled down by the Bisoprolol, so my cardiologist told my to stop taking the Bisoprolol.
All fine for about 4 weeks then slipped back into AF, and now back to taking 2.5mg Bisoprolol which keeps my heart rate in the mid seventies again.
I did query why I was not prescribed Flecainde or similar and the cardiologist said no point as that would have lowered my heart rate even further.
I have now booked to see a private EP this week and will certainly be asking about pacemakers as a naturally slow heart rate just complicates what is already a difficult balance when it comes to medication.
Hi there...it all gets confusing as my EP told me the flec would only effect the rhythm of my heart and not the rate as its a rhythm control drug not rate like a beta blocker cheers andy...
Told same
Andy - I had 15 years of AF which 2 ablations and all the drugs failed to control but was worse - made me very ill.
There were triggers that I identified and avoided or changed my lifestyle, to no avail as AF always returned. I was very symptomatic and eventually we identified that although my HR was normal to high during the day, at night it would drop to the low 40s or high 30’s. I captured this mainly through my smart watch. My EP then advised a re-synchronisation therapy Pacemaker (not all Pacemakers are equal). This was implanted in 2018 and since then I have had 3 episodes of AF - all when I had a chest infections and none of which were symptomatic.
It’s not an easy procedure to implant a RST Pacemaker and not all cardiologists/EPs are trained or competent as placing the left ventricle wire can be very tricky and can sometimes detach, but for me, when done well it was nothing less than miraculous.
Medtronic have now also recently launched a new pacemaker with an algorithm to specifically target AF - it’s called a Reactive ATP Pacemaker - research it.
Thanks again
Sorry for the short reply but my boss walked up behind me as I'm at work lol...sorry to hear you have really suffered with your afib over the years but glad you are sorted now...I have only really had palpatations wen in afib and no other symptoms, my pulse rate never really moved up much during episodes it is always just irregular...I've always had a low pulse rate though wen resting so that's why it probably doesn't bother me that much....did your pulse go up a lot during afib or was it something else that made you feel terrible ?
hi, I was given bisoprolol daily but the gp stopped it as my pulse rate dropped too low. I was put on Flecainide daily last year but wasn’t happy with that as when I took it daily a few years ago, after a while it didn’t,t work. I now just take bisoprolol and flecainide as a pill in the pocket approach, this seems to work for me, so far.
I do the reverse. Flec daily and Biso as pocket pill. But that’s because rhythm is my main issue over intermittent high HR.
Again, no medical training, but my view would be - if the 1.25mg of bisoprolol is the right dose for you, why would it need to be increased? Everyone is different, and responds differently to the drugs. If bisoprolol is not suiting you, there are other beta blockers that could be tried, and also calcium channel blockers to be tried instead, rather than increasing the dose which currently works.
One thing is for sure, in the UK you really need to take a positive pro-active stance regarding your medication. Ask the doctors "why?" and tell them when you are not satisfied. If you don't, they will assume everything is fine with you, when it's not.
HiI take CCB Diltiazem 120mg am and Bisoprolol 2.5mg at night.
Since December I am controlled.
I have a very low night heart rate and the 2.5mg has kept it the same.
The daily avg dropped 50-60 with Diltiazem. I take that in morning.
I guess you need to pracise at getting the right balance. 180mg Diltiazem was too much as51 during day too low and I was light hearted.
cheri JOY
Yes it's trial and error I think for sure....all the best andy
Hi I also have low pulse 40s to low 50s & was put on 1.25mg Bisoprolol for my ectopics. The consultant said forget the numbers it’s how you feel. It slightly improved my ectopics for a few months & I felt ok but then they started to get more regular again & he agreed for me to take an extra tablet (as a pill in the pocket) I ended up in aA&E and was told not to take the extra one. A few weeks later I felt rubbish & went to the doctor , he took my pulse which again was low 40s & told me to stop the meds altogether . I am still getting the extra beats but nothing like before & waiting for holter monitor.Everyone is different so give it a go & it may suit you. Good luck
Thanks mate ...all the best
Same for me so maybe rhythm is your issue and Flecainide would sort that out. I’d ask as it has helped me immensely!
Hi Yes I wondered if Flecainide may help & I will ask the consultant. Thank you
I also have a low resting heart rate and after an Afib episode that lasted nearly 3 days I was given 1.25mg Bisoprolol but after reading the information in the packet I decided not to take it. I told the arrhythmia nurses and the advice back was that this low dose would be safe. However I decided to avoid the medication and told them that.
I have now had my ablation and everything seems to be fine.
Glad your doing well after the abalation...
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