Metoprolol, flecainide and prevention?

[Redactrice]

Age 59, lone paroxysmal AF for 12+ years which I have largely ignored because it wasn't that bad. It's been 4yrs since the last major episode but I suspect I am now in low-level AF a lot. I'm guessing at this because I don't have an AF app and due to the pandemic it's been nearly four years since my last cardiology check-up. (I have an appointment but it's not until January. I am trying to get in sooner.)

I have a prescription for flecainide which I've never taken because I haven't had a bad episode since I got the prescription.

I tried metoprolol as a PIP, which was no help when I was in AF with tachycardia, and then bisoprolol as a daily preventive, but that put me into a zombie state -- very low BP/HR, couldn't get out of bed. I stopped taking it. The most recent cardiologist agreed with me.

I'm still adjusting to post-pandemic life (except it isn't really post; Covid is still very much with us) and finding that I get very stressed about things that didn't previously have that effect. I had returned most of the big box of bisoprolol to the pharmacy when I stopped taking it, but I dug out the remainder of one packet and started taking one (2.5mg) in the morning before events that were likely to be high stress. This seemed to help.

I have a high-stress event coming up in 48hrs and just noticed that I've run out of bisoprolol. I don't rate my chances of being able to get any within 48hrs.

I found another box of metoprolol (50mg) and am eyeing it. Previously I took 25mg as PIP. A friend who's a doctor with hypertension told me that that dose was basically a placebo and I could safely triple it, but the instructions say to cut it into quarters (12.5mg) and take with flecainide.

So, I'm going to experiment: cut the metoprolol in half (25mg) and take it as prevention (no flecainide), and see what happens today, when I don't have to go anywhere or do anything stressful.

Q: if I do this for two days, then embark on my high-stress day and go into AF with tachycardia, should I avoid taking flecainide at that point?

[Autumn_Leaves]

You could ring your GP surgery and ask if you can have a prescription urgently. I appreciate that not all surgeries have the same system and accessing a GP is difficult. Mine offers telephone triage and usually a same day call back, though they may need to see in person you to check your BP etc, so that’s going to delay things. Worth a try.

[jeanjeannie50]

Beware with Metoprolol. One night while in hospital I was given 100mg to try to bring my high heart rate down. I got out of bed the next day and collapsed. Later a cardiologist came hurrying frantically to my bed, waving a long stream of paper that had been recording my heart rate. He waved the paper in front of me saying, "Look what your heart is doing." Well it meant nothing to me and I only saw it briefly.

My AF nurse told me afterwards that I must never take more than 25mg which is half of a tablet, she said any more than that could kill me. I know this is dramatic, but it's true.

I'd ring your GP's surgery now and explain the situation and ask if you could speak to someone urgently.

Jean

[Redactrice in reply to jeanjeannie50]

Yikes -- noted! I thought my doctor friend's advice was cavalier (though her remark about a placebo was consistent with the attitude of the cardiologist who had given me the prescription, who was not convinced I had AF because it had evaded the 24hr monitor). I have never tripled the dose or even doubled it.

I tried to get through to GP, directed to e-booking. They won't prescribe over the phone even if it's a refill. Last time I used e-booking, it took them a week to get back to me. Severely understaffed. Also, GPs don't understand AF well, or at least I've never seen one who does. They try to point me in the opposite direction to what I've discussed/agreed with cardios, e.g. 'You should be on blood thinners!' (GP) vs 'Blood thinners are very nasty and you are at low risk so far, so I don't recommend them right now' (cardio).

[jeanjeannie50 in reply to Redactrice]

Once you get to 60 start asking for anticoagulants again. I had an ex work colleague who started with AF in his early 60's and was put on Aspirin. I said to him that I thought he should be on anticoagulants and his reply was that he'd go with his doctors advice. He had a massive bleed in his brain, was operated on, but has lost a lot of his memory. He can still walk and talk, but can't go out unaccompanied.

[Sixtyslidogirl in reply to jeanjeannie50]

My understanding is that the Chads-vasc risk score isn’t high enough for anti- coagulants until 65 for women with no other co-morbidities.

[jeanjeannie50 in reply to Sixtyslidogirl]

Then do as you feel is right.

[Redactrice in reply to Sixtyslidogirl]

Yes, that's what I had read, and the only thing agreed on by all the cardiologists I've seen (six in 12yrs) is that I don't need to be on them yet, or I didn't at my last appt.

[Popepaul]

Re your upcoming stressful day, you seem to be describing a self fulfilling prophesy. That said I do agree that bisoprolol has anti anxiety qualities it dampens the sympatheic part of the ANS.Breathe deeply and slowly and be mindful. This always reduces stress and HR for me.

Regards.

[Singwell]

Honestly I think you're on dodgy ground here. Bodies like regularity and if you keep switching your type of dose, even if it's for PiP how can you tell which is making the difference? And I write as someone who's elected on several occasions to cut pills in half. I'd be asking for an urgent GP appointment to get some guidelines and to keep pushing for your next cardiology one to come earlier.

And your GP can absolutely turn around a prescription for Bisoprolol in 24 hours. I've had them do it for my anticoagulants when I ran out. Call the surgery and go in a few hours later to collect the prescription and take it into the pharmacy by hand.

[Redactrice in reply to Singwell]

This is the thing -- I have never taken anything regularly because for a long time I was rarely in AF. It took three years to diagnose because it was elusive + dismissive attitude of first cardiologist, who refused to accept that anyone but a cardiologist could diagnose it (I was undergoing minor surgery when it was finally caught on tape, and the interventional radiologist knew exactly what it was).

This has changed over the past year, especially since I finally caught Covid in May (after successfully dodging it for three years). I am now thinking I might need daily medication, which I'd agreed with several cardiologists was not necessary over the past 10yrs. I am just beginning to learn to deal with this because now it seems to be progressing.

My GP surgery is desperately understaffed. I've been trying and so far I don't have the prescription. 12.5mg of metoprolol seemed OK when I took it yesterday. I'm not keen to exceed that.

[Singwell in reply to Redactrice]

So you'll need a strategy going forward. I think metropol is aneta blocker so offers rate control. Bisoprolol does the same. Flecainide is different- it's an anti arrhythmic and kicks your heart back into rhythm. Doesn't suit everyone. I was on it for 3 years till my 2nd ablation did the trick (for now). Not sure I'd go back on it if AF became a more regular visitor. Hope you get sorted.

[davephx]

Different meds affect different folks differently. I have been on Metoprolol for years. I only have occasional A-Fib but my heart rate is only in the 60s, normally, and when in A-Fib per Kardia monitor.

[Ossie7]

Morning , I agree with others advising trying to get a new script of bisoprolol as that’s what your body is used too . I have no experience of metropolol so can’t comment on that but have been on bisoprolol for a long time . However I would love to come off it due to issues with exercise tolerance , weight loss etc .

Could you maybe book a one off private cardiology assessment to get you back in the cardiology system sooner ? I’ve had to do that twice . Both times money well spend .

[JOY2THEWORLD49]

Hi

I read a book where the lady took BB before a date! She uses it and the Dr prescribed it for anxiety. I am learning.

But Metoprolol is a no no for me because it causes breathlessness, no energy, and 24hr-heart monitor showed it was causes pauses during the night.

I was changed to Bisoprolol but even 10mg did not bring down my H/R Day at rest.

Even 2.5 controls my BP.

A private H/Sp referred to by my locum Dr who has had AF, introduction to CCB Diltiazem finally controlled my H/R but the dose 120mg lasts 12 hours only. But that is what I needed with a H/R Night avg 47.

Balance is necessary and Bisoprolol was reduced to 2.5mg and separated by taking it at Night CCB AM.

cheri JOY. 74. (NZ)

[Vonnegut]

After I was eventually diagnosed with paroxysmal atrial fibrillation and the lowest dose (1.25mg) proved too much for me to take daily, I saw an EP privately, who having introduced me to a Kardia (and smartphone) prescribed 100 mg Flecainide for me to be taken as a PIP after I had sent him my first Kardia reading of some of an AF episode. At first I just took it that way ( with the low dose Bisoprolol added on the very rare occasions when heart rate exceeded 140) but now I take 100mg twice daily and only had a breakthrough episode once around the time I must have been infected with covid (despite all the jabs)! Heart back to normal after an extra 100mg of Flecainide ( 300 a day being the maximum) and tested negative on my day 15 though felt no different from usual throughout.

[Redactrice in reply to Vonnegut]

Food for thought here, thank you. I forgot to ask for a referral to an EP (never seen one). I should probably get Kardia, too, because otherwise I'm flying blind. How old are you and do you have any side effects from the flecainide? How low is your low dose of bisoprolol as a PIP?

[Vonnegut in reply to Redactrice]

I’m 79, never been overweight with a healthy diet etc. It seems my troubles started when I had a bout of shingles when the excruciating pain came before the rash and couldn’t get an appointment at my surgery for almost two weeks by which time the rash had appeared and the pain had gone (but too late for an antiviral)! The chronic fatigue I have also started around then though the doctor doesn’t believe I have it! Perhaps because I don’t seem to have “brain fog”! Sadly fatigue is also a side effect of the flecainide as well as some constipation which I’d never had before, though for “1 in 100 people”! My husband has had to become my carer but I’m still able to enjoy family and other occasional events etc.

[Budken]

I would be very wary of taking Metoprolol. I have been taking Flecainide for twelve years without any problems, except when it was taken along with Metoprolol. I had constant PVC's along with occasional episodes of Afib. A new cardiologist told me to stop taking the Metoprolol saying that he thought it was causing my problems. Although weaning off the stuff was terrifying ( episodes of Tachycardia ) once I stopped taking it, all the problems stopped. I would never take that stuff again!

[Redactrice]

How horrid, not helped by a disbelieving doctor. One would hope that general awareness of post-viral effects will improve due to Covid. I hope I'd escape fatigue as a side effect of flecainide as I'm still some way from retirement; I am likely to find out before much longer. Thank you for the reply.