Beta blockers

[Thomas29]

I see many people here take beta blockers with Flecainide. Can I ask why? I have been on 200 mg of Flecainide now for two years but was never offered beta blockers. Probably a silly question but what is the connection between the two? I assumed it was one or the other. I think I have a lot to learn!

[mjames1]

It's a safety precaution. Flecainide can in some cases cause a fast aflutter. So a beta blocker or calcium channel blocker is often prescribed along with it to act as an AV Nodal Blocker.

Most here, but not all, therefore take either a beta blocker or a calcium channel blocker like Diltiazem, with their daily Flecainide. They also take a nodal blocker with a PIP dose of Flecainide.

I started with 50 flecainide twice a day and 120mg slow release Diltiazem. Now that I'm down to 25mg twice a day, my ep said I could stop the Diltiazem.

From what I've read here and advice elsewhere, there seems to be quite a divide with doctor's and how they prescribe Flecainide.

Some treat it very carefully and screen patients for any type of structural heart disease with treadmill stress tests before even prescribing and/or administer the first dose in a medically supervised setting with follow up ecg's at dose changes and only prescribe it with an AV Nodal Blocker. Others, seem to give it out a lot more freely.

Jim

[Thomas29 in reply to mjames1]

Thank you for that. Was very informative. I was prescribed Flecainide over the phone by cardio after I’d spent a few days in AFi b. Now on 200mg. Hopefully might be able to reduce at the end of my banking period… 9 weeks.

[tunybgur in reply to Thomas29]

I assume he checked your ECG first, I understand Flecainide is not suitable if you have a long QT interval.

[Sacstate in reply to mjames1]

Hi friends,

I’m a 75 year old man, and I was diagnosed with Paroxysmal AF several months ago. I have been on 50 mg Flecainide twice per day and 25 mg timed release metoprolol once per day for several months. Here in California, my cardiologist required a echocardiogram and a treadmill stress test before prescribing the Flecainide. So far, I have been doing well with no AF episodes since on both meds. I walk and bicycle and lap swim vigorously with no problems and consider these meds wonderful for the improvement they have brought to my life. However, I wonder if any of you taking these meds find nighttime miserable? Overnight, I wake up frequently feeling simply awful, as if I have a strong case of the flu, and I often have vivid nightmares, which I read are side effects of the metoprolol. Very shortly after I get up for the day I feel fine again, but always know my nights will be a challenge. Any similar experiences, comments or suggestions?

[mjames1 in reply to Sacstate]

Definitely could be the Metoprolol. When I was taking 50mg Flecainide twice a day, my ep put me on 120 Diltiazem ER (extended release). You might ask your doctor if you can switch. The Diltiazem serves the same safety function as the Metoprolol -- they are both AV Nodal Blockers -- but Dilitazem is a different class of drug (calcium channel blocker) compared to the Metoprolol which is a beta blocker. Your doctor may want you to wean you off the Metoprolol rather than just stopping/switching all at once.

FWIW I finally reduced my Flec to 25mg twice a day and because of the low dose was allowed to go off the diltiazem completely. Not suggesting this for you now since you're overall doing so well but just something to think about for the future if you keep having nighttime side effects.

Curious, how long have you been in normal rhythm with Flecainide and were you given instructions on how much extra Flecainide to take should you go into afib?

Jim

[Sacstate in reply to mjames1]

Hi Jim,

Thanks very much for your remarks. I’ll definitely investigate Diltiazem; it sounds like a possible solution.

While I have had palpations all my life, I began having a few new and more frightening episodes of sustained wildly erratic, racing heart rates beginning last year in October that lasted 5 to 8 hours per episode before they resolved each time on their own. I started taking metoprolol on Dec 14, did a 14-day Holter monitor in Jan, which revealed the AF, and began taking 50 mg Flecainide twice daily in late February, after cleared for it by the diagnostic tests. I had one breakthrough, sort of “mild” AF episode while taking both metoprolol and Flecainide in early March that resolved by itself in 50 minutes. I’ve been in normal rhythm since and have been doing well, except for the nighttime difficulties.

As for what to do if and when I again go into AFib, my cardiologist advises that I should probably take a metoprolol right away and then I could take Flecainide if the wild arrhythmia continues. Rather than suggest any certain dosage of Flecainide at any given stage of an AF episode, he will only say that I can take “extra” Flecainide to a maximum dose of 300 mg per day if my atrial fibrillation does not resolve within 24 hours. So it’s pretty much my choice when and how many “extra” pills to take up to the 300 mg/day. If I had to make the choice right now in the throes of an AFib episode, I think I’d start by taking 100 mg of Flecainide and then wait a couple hours to see what happens to my symptoms. Also, at his advice, I am not taking a blood thinner, and so cardiologist suggests that I go to ER for Cardioversion if the atrial fibrillation hasn’t resolved within 48 hours, Despite that advice, I would likely err on the side of caution and go to the ER far sooner than waiting 48 hours simply because I do not take a blood thinner.

John

[mjames1 in reply to Sacstate]

I only went into afib the first couple of weeks on 50 flec twice a day. My instructions were to take an extra 50mg pill in pocket dose (PIP) and another 50 if still in afib in an hour. Then repeat next day if needed. In reality I only took the combined extra 100 PIP once and probably didn't even need the extra 50 since I converted right after I took it. Many here take more of a PIP dose, up to 300 total in a 24 hour period counting the loading dose which in your case would be 100. Your plan sounds like a good one taking an extra dose of metoprolol and another 100mg.

You never know, but chances are you will convert very quickly with the flecainide and will not have to go to the ER for cardioversion. The reason your doc wants you to get to the ER within 48 hours is because they won't do a cardioversion after that time unless you are on thinners for a couple of weeks before. There is an exception, however, if you have a TEE performed just before the cardioversion. I had that done 2-3 times back in the day before I had any rate control drugs on hand. It was no big deal and done at the same time under the same sedation.

After I learned about rate control drugs and before I started Flecainide -- instead of going to the ER for cardioversion, I'd take a combo of diltiazem and metoprolol to bring down my rate and then I'd usually cardiovert within 12-36 hours at home. At the time I wasn't taking thinners so I'd start a daily thinner at the onset of the episode and continue for a few weeks. This is called on-demand anti-coagulation and is a bit controversial but my ep was ok with it at the time.

Good luck if you switch out the metoprolol for diltiazem.

Jim

[Sacstate in reply to mjames1]

Hi Jim,

I can’t thank you enough for sharing all your knowledge and experiences with this matter. I have learned more from your comments than from my questions to my cardiologist. (As time goes on, and especially if I have any negative changes, I plan on insisting on consultation with an EP.) Thanks especially for saying that you went into AFib only in the first couple of weeks of your taking Flecainide. My last episode that lasted 50 minutes occurred 4 days after I began taking Flecainide. That has haunted me since, since I was and am taking both meds. However, your suggestion that AFib in the early days of taking Flecainide might be more likely significantly eases the underlying worry for me. Again, thanks for that! Just curious, how were you able to reduce to 25 mg Flecainide twice a day? Ablation or something?

John

[mjames1 in reply to Sacstate]

No ablation yet. Long story short, I just wanted to test the waters at lower doses and was lucky to find an ep who believed in shared medical decision making.

So, with the ep's blessing, I gradually reduced to 25mg twice a day which was my target dose, because at that low dose my ep said I could stop the diltiazem.

At some point I may go off daily flec completely and just use it as a PIP, but not in any rush to test those waters.

Jim

[Bagrat]

I am oldish have been on flecainide 100mg twice daily since 2011. Didn't tolerate beta bocker so swapped to flecainide on its own. Understand bisoprolol or similar is a safety feature. I'm still here.

[Thomas29 in reply to Bagrat]

Good to hear that! Long may it continue.

[Paulbounce]

Flec on it's own can cause flutter - this why a small amount of beta blockers are recommeded. I wish I known this before. It's worth talking to your doctor about say 1.25 of Bisoprolol (low dose) would most likely tick your boxes.

Paul

[Thomas29]

So did Flecainide cause your flutter? How can you tell the difference between a short period of AFib or a flutter? Would I be able to tell?

[wilsond in reply to Thomas29]

Yes flutter goes very very fast and regular. Affects ke far more than AFib. If you have a Kardia( mini ecg device very good cost about 100.) you can see the saw tooth pattern of flutter.

[Frances123]

Not a silly question at all. I’ve been on Flecainide 50mg twice daily for 17 years. Never taken or offered a beta blocker at any time. First dose of Flecainide was given by IV in hospital under watchful eye of medics. Unless it’s changed it use to be only a cardiologist/EP who could initially prescribe Flecainide and first dose to be given or taken in hospital or clinic setting. x

[KMRobbo]

I developed Atrial flutter 9 days after my Cryoablation for afib. According to my EP , the flecainide promoted this . I had never shown flutter previously nor during the PVI ablation . I know this is correct as I was asymptomatic in AFib except for high ventricular rate, whereas walling to the kitchen to make a cuppa made be very breathless. I would have noticed.AFib is an irregular irregular heart beat. AFlutter is a Regular Irregular heart beat. I.e. the beat us regular but very fast and the rate is dependent on the conduction ratio. I was a constant 140 bpm with the rate being controlled by the diltiazem I was taking. Without the diltiazem it could have been up at 300 bpm.

ATRIAL flutter is normally ( not always) right atria. It was for me.

My flutter was stopped by a second ablation one month after the first. I spent a month mostly lying down as I could do little else owing to the breathlessness on the slightest exertion

Not medically trained just describing what happened to me with 2 x 50mg flecainide daily.

By the way I think flecainide is a great drug - it kept my afib under control until I stopped it 3 months post ablation, but obviously if I ever need to take it again it would have to be with a rate control drug.

[wilsond]

I am a prime example of why! I had a chemical conversion of very fast AF by flecanide and given I think 50 x2 a day at the time.This was by cardiologist at local hospital.A week later blue lighted into cardiac unit at large teaching hospital, with flecanide induced atrial flutter. Told I should have had a safety dose of bisoprolol to avoid that very thing and put under the care of an Electrophysiologist ( not condemning cardio chap but obviously he was not as au fait as the EP).

So now have both.

But there may very well be a reason.

It's strange to me that some people are given flecanide without supervision as it's a well known recommendation.

Xx

[SuziElley]

Flecainide is used for an arrhythmia so may be used as well as beta blocker, or with calcium channel blocker. Or it might be used on its own…..