Having a quick delve into the arcane world of rate control drugs recently I found a pretty interesting article from the European Heart Rhythm Association:
Beta-blockers in atrial fibrillation—trying to make sense of unsettling results
Some snippets:
"Heart failure with a reduced ejection fraction is the only condition in which" beta blockers "provide unequivocal benefits that result in higher ejection fractions and a longer life."
"Sinus rate lowering in patients with a normal ejection fraction increases the risk for atrial fibrillation"
"we contend that beta-blockers are overused in atrial fibrillation. The available data suggest that the adverse effect of beta-blockers is most pronounced in patients with a normal ejection fraction and low heart rates, typified by patients with paroxysmal atrial fibrillation on high maintenance doses of beta-blockers that markedly suppress the sinus rate"
"it is generally overlooked that calcium-channel blockers, have a pharmacological advantage over beta-blockers. They preferentially bind to activated calcium channels making their effect on heart rate use dependent. In other words, they have little effect at lower heart rates, while exerting a robust dromotropic effect at rates encountered with fast conducting atrial fibrillation and thus provide protection from tachycardia-induced cardiomyopathy when it is most needed. By extension, calcium-channel blockers have little effect on sinus rate, filling pressures, and wall stress to explain why the progression towards permanent atrial fibrillation may be slower and why they are better tolerated than beta-blockers"
Conclusion
"Considering the uncertain evidence basis, the known unfavourable side-effect profile, and the availability of alternative medications we avoid beta-blockers in patients with atrial fibrillation in the absence of a clear and specific indication. When considering the high prevalence of atrial fibrillation, there is an urgent need for larger randomized outcomes trials that compare rate-control strategies."
Thanks for posting. My cardiologist was against beta blockers from the beginning as an early intervention. He had me stick to Diltiazem, a Calcium Channel Blocker. From what I read here and elsewhere, whatever "cure" they offer, often seems worse than the Afib they are suppose to help.
Personally, the only time I took rate drugs was when I was in afib to get my rate down to a safe level. Why make myself sick with side effects when I'm not in afib, with a drug that doesn't even pretend to keep you out of afib?
If you're on daily beta blockers and are suffering from them, ask your doctor for a medication review. You might even want to bring in a print out of the article referenced here. Medication, like all medical treatments should be a shared decision.
You'd be surprised at how many doctors will go along with ideas you bring up, as long as they are reasonable and of course based on medical science.
Just to clarify my own situation a bit, my own regime of PIP flecainade stopped working some months ago and I'm currently on daily beta blockers which do seem to be preventing afib from kicking off at the moment! How this is possible is beyond me and my arrhythmia nurse as she says that I have vegally mediated AF and slowing the HR down even more should backfire....
I'll definitely be talking to her about swapping the BBs for CCBs at our next review though.
Why not just drop the BBs and see if it makes any difference? In other words, no BBs. No CCBs.
Both BBs and CCBs are very weak anti-arrythmic's, so arguably neither is necessary if you're not in afib. Once you're in afib, a different story. Both BBs and CCBs, or a combination, can be very useful to bring your heart rate down to safe levels.
In over 40 years, the only time I used BBs and CCBs was when I was in fast afib and maybe for a week after. The exception was the one year I was on Flecainide, when I took the CCB, Diltiazem, as a nodal blocking agent, for safety reasons.
But what about those of us on flecainide (even PIP like me) who are given BB (metropolol, in my case, 75 mg daily, divided doses) to prevent other arrhythmias? What is considered "high dose BB's"? It does suppress my sinus rhythm to 60ish when I was previously in the 70's. I don't feel I'm "suffering" from BB side effects except some balance issues; in fact, in the beginning they stopped all of the awful PAC's/PVC's I was having--now PAC's are back & metoprolol doesn't seem to be helping them anymore.
Maybe I'll revisit this w/ my drs. but as long as I'm taking flec, even PIP, they may want me on some amount of BB. Thanks for your thoughts. Diane
"But what about those of us on flecainide (even PIP like me) who are given BB (metropolol, in my case, 75 mg daily, divided doses) to prevent other arrhythmias?"
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Hi Diane, Yes, of course.
Thanks for the heads up. I should have qualified my statement and will make an edit shortly. Many ep's, including mine, feel it's important for safety reasons to take a nodal blocking agent like the beta blocker Metoprolol or the calcium channel blocker, Diltiazem along with the Flecainide. In my case, we chose Diltiazem.
Thanks, Jim. I wish Diltiazem had worked for me. When it was prescribed in the beginning of my AF journey about 13-14 yrs ago, it did nothing to stop my vagal AF episodes. I wonder if "things change" and it might be worth giving it another try. Metoprolol, though, does block epinephrine & has a bit of a calming effect. I don't think that's the case with Diltiazem.
Both Metoprolol and Diltiazem are primarily rate control drugs with very weak anti-arrhythmic properties. So, not surprising the Diltiazem didn't stop your episodes back then and I doubt if you would have had better luck with Metoprolol.
But nodal blocking is different. Here, the drugs are used to slow the heart's electrical signal, not to stop episodes. So either Diltiazem or Metoprolol should be equally effective.
That said, if you tolerate Metoprolol well, perhaps no reason to change.
Hi again, Jim. Yes, I knew Metop. was not really anti-arrhythmic--we were really just using it to knock down my heart rate at the beginning of an AF episode--but for some reason, two GP's and a cardio have suggested that it would keep AF episodes at bay & it did seem to do that for awhile. I work with patients as a research dr/therapist (mainly in Psych, where many patients are on anxiety meds) so I figured they were basing this on experiences they'd had with patients... you know, kind of "horse sense" gained from yrs of seeing what works in off-label ways, etc. But now I am wondering where they got this idea. My problem these days is increased PAC's/PVC's which, after a week or so, tend to kick off AF. At least my episodes are mild & with 150 mg of flec will end in 2-3 hrs... but still... ugh. Just whining at this point .
Not sure if "horse sense" or just following the herd I believe the less meds the better, so only take what is needed. That said, if ectopics are triggering your episodes, a beta blocker or calcium channel blocker may (or may not) help with the ectopics.
Ectopics were also a trigger with me, so I would up my Flecainide a bit when they got bad. The effect in many cases was less ectopics and therefore no afib. So if you're on PIP, speak to your doctor about using the Flec prophalactively like that. 25 or 50mg extra was the most I would take in those situations.
It can all be so crazy-making. About taking flec to stop ectopics... My first dose of 300 mg of flec brought on such horrible waves of ectopics, I called the cardio RN in a panic. She actually said "Take another 300 mg tomorrow." I did--and 5 days of the most dreadful 24/7 ectopics ramped up until I thought I was having a heart attack. When I spoke to the cardio, he said "Oh no. She should never have said to take flec for ectopics! Don't ever do that again. I will speak to her." Yet, you upped your flec & apparently got less ectopics & AF. About a month ago I started to get random ectopics, but I noticed after 3-5 days, I'd go into AF... then no ectopics for a few days, then it started all over. I am going to start walking (I work full-time) when possible and see if it has any effect. Sorry for the long story... just, grrrrrr!! hard to know what to do w/ this rhythm stuff. Diane
Yes, Fleacinide got rid of my ectopics. FWIW I never took the big 300mg doses many here have. 50mg twice a day held me in normal rhythm most of the time. The handful of times during the year I did go into afib, another 50mg was all I needed to convert. I think once I took another 100mg. So that, plus the 50mg already in me, was only 150mg. That was my limit.
Do you think Diltiazem lowers the heart rate? I was taking Diltiazem as a PIP but noticed it wasn't effective at stopping afib but I did notice my HR was dropping to the low 40s with dips once in a while in high 30s so ER Dr. suggested I stop taking it, which I did for over a year now, HR still drops to low 40s but have never noticed it in the 30s.
Yes,Diltiazem lowers rate just like beta blockers. However it lowers rate more selectively than beta blockers like bisoprolol or metoprolol.
So if you go into fast afib -- say a rate anywhere from 130-200 -- Diltiazem can be very effective to get your rate down to a normal and safe level. However, let's say you're not in afib and/or your resting heart rate is 80. Diltiazem will more or less leave your heart rate alone. Beta blockers on the other hand have a tendency to lower your heart rate whether it's fast or slow.
So when in fast afib, both do a pretty good job, however when out of afib, Diltiazem allows you to go about your business with a more normal heart rate. While I don't think either Diltiazem or Bisoprolol is needed in most cases when you're out of afib, if you do use it, Diltiazem will have the least overall effect on both rate and blood pressure, which for most of us is a good thing.
healingharpist May I ask did the doctor recommend dividing the dose of Metoprolol to prevent side effects. I have been recommended 75mg also but taking dose at once seems to cause insomnia.
Thanks, mav (I have a side career as a professional and medical harpist ) Yes, right from the beginning, my GP said to take one 25 mg pill w/ breakfast & one with supper. (Later we upped it slightly to one and 1/2.) But he never mentioned side effects, except "might get cold hands & feet". It was mainly for reducing my heart rate at the beginning of AF episodes; then I thought for awhile it was actually reducing the no. of AF episodes, but I'm having ectopic issues now, so not sure WHAT metop. is doing! It dropped my HR to 60 but that doesn't cause me any issues except mild balance at times. Maybe the divided dose is why I don't have any other side effects. I wish you all the best w/ it... Diane
I was taking 25 mg metoprolol 2x day, one at bedtime one in morning, ( along with flecainide) and found it very fatiguing. My PCP talked with cardiologist and they both agreed to drop to only one 25 mg metoprolol at night and it’s been much more tolerable and still keeping me out of afib. This article is interesting though I’m gonna stay with what works for now. I’m on a pretty low dose of metoprolol but since my heart rate is naturally pretty low i think I can’t tolerate much. I’m wondering if a lot of the problems people have (in general with these meds) might be ameliorated with more reduction of the dosages? Obviously we are all different and it stands to reason the standard protocol might not work well with everyone.
Per bios, the authors of the subject article. Dr Meyer has little experience in dealing with afib, at least per this bio. Dr Lustgarten is very experienced. The study was funded on a grant from the NIH.
The conclusion of the article is very strong "There are no long-term safety and efficacy data for beta-blockers ".
Would be nice to read a peer review from others. The subject article has valuable information and the facts expressed certainly should be considered, but like all articles and opinions/personal experiences expressed on this forum each individual must make their choice in consult with their doctor who is aware of their exact condition including other medical conditions.
Thanks to Barny12 for bringing this important article to our attention.
Thank you. I find this very interesting. Bisoprolol is so often used as the default drug for AF . This has caused alot of problems for me , not least because it has been prescribed alongside my Disopyramide when NICE clearly warn of major interaction.
Interesting that. I have AV re-entrant tachycardia because of an accessory pathway in my heart. I was put on Bisoprolol 10mg and Disopyramide slow release (Rythmodan Retard) 250mg twice daily nearly 40 years ago and I'm still alive! Yes I did read that a while ago but my current cardiologist has not said don't take them together as I suppose having been on this same regime for so long my body is used to it. Saying that when the Retard version became difficult to get hold of about 3 years ago I went onto the 100mg versions and now only take 300mg/day instead of 500mg with no adverse effects. I also reduced my Bisoprolol down to 7.5mg/day about a year ago after asking my cardio if this was OK and so far all of this works.
I was diagnosed with PAF three years ago and luckily I'm asymptomatic at present. Apart from adding Apixaban my medication has not altered as it seems to keep the PAF at bay and he thinks things will probably stay that way (fingers crossed) because of this mix. We will see.
Thank you for your comments hausjac. You are obviously doing well with the combination. I've been on Disopyramide for about 28 years with a gap when it was no longer available in the UK...about 2008/9? The unwanted effects of Bisoprolol have only become apparent in very recent years and particularly so recently.
I'm also on 300mg daily since 250mg became unavailable. 100mg is also unavailable at present but hospital pharmacy were able to let me hsve 2 months supply from their stock!
Bisoprolol seems to have got itself a bad name. I was started on 5mg and I do remember complaining about the effects but I was told to give it time which I did and eventually it was upped to 10mg which again took time but not so long. I decided to reduce it off my own bat as didn't think I needed such a strong dose and so far it's worked. Its a good drug but it does take time to adapt to it.
Yes Disopyramide being an old drug is sometimes unavailable so what I did a while ago was to leave my scrip at 500mg and only use 300mg so I created a stockpile over a few months which has proved useful when recently they couldn't supply it but as I had my extra I was fine. As I've been away for a month I must check the pharmacy to see if they managed to get it. None of the others like Amiodorone, Verapamil worked for me and Flecainide gave me arrythmias and tunnel vision so I'm stuck with this one!
I did similar to get my stoc kpile. I've just spoken to the UK distributors. NEON...and was told that 100mg is still unavailable and not expected until Dec/Jan but no guarantees then.
Yes. I've just messaged my friend in the South of France to ask her pharmacy if they can obtain them for me as that's what I did before. Totally crazy!
I do wonder whether they will stop manufacturing Disopyramide as not financially viable. It is not prescribed much these days. I believe it is now unobtainable in Canada
Interesting but only in my first six months after diagnosis of AF did I ever take a beta blocker and that was atenalol alongside flecainide PIP (300mg if AF started) . As soon as I met my EP he switched me to propafanone which is a rhythm control drug which also has some beta blocking ablility, No AF since third ablation in 2008 but now taking nebivolol for something else.
Thanks for the link , very interesting .It could well explain why I never did well on beta blockers no matter which condition I was given them for.
I may have Tachycardia along with AF and Arrhythmias but I also have low blood pressure and a normal EF. Beta blockers always seemed to create a spiralling vicious circle to my symptoms.
You describe my same situation exactly. I'm in SR after a recent cardioversion without any drugs but Eliquis. Diltiazem and metropolol have never done anything for me for rate control or rhythm, not even when given via IV. Neither drug touched my tachycardia, AF or AFL. I've never had high blood pressure, but sometimes low blood pressure. I have normal EF. Both drugs have very unwelcome side effects. I'm glad to be rid of them (with my cardiologist's approval), and she's going to have to talk very convincingly to ever get me to try them again.
Glad to know someone else has had a similar experience in a similar situation.
That is very interesting Barny12, thank you for sharing. I had my suspicions that being put on daily Bisoprolol over 18 months ago by the EP who considered my mid-70s resting heart rate in NSR too high led to me going into persistent AF 14 months later. I’m on Verapamil now but a bit too late for me!
Thanks for posting I’m seeing my Cardiologist next week have been on very low dose Beta Blocker for 10 months apparently to suppress the adrenaline spike which might bring on AF. I’ve been in Sinus most of that time and my heart rate at rest was mid 60’s due to my exercise before BB. Now it’s 55-60 at rest with BB.
That is fascinating. I have read differently and that beta blockers (and some antihypertensives, even when given without high BP) do protect the heart, but you have sent me back to look again. I suspect the root cause of the arrhythmia is important.
This makes sense. I was really unwell on bisoprolol 1.25mg per day. I have PAF and normally a very low HR. So the bisoprolol pushed my HR into brachycardia and I was taken off it. The calcium channel blocker may be better fit for me.
Thanks for the heads-up on bisoprolol, my mother was on this for her last four years, and it made her into a bedridden invalid. The cardiologist wanted me to have it and a pacemaker as my PAF which isn't painful or noticeable mostly and my resting HR of below 40 would I think make me the same as my mother.
I had a successful ablation, 18 months ago, been in NSR since. But my cardiologist kept me on v low dose of Bisoprolol, Ramipril and Spironolactone, as I was reduced LVEF with my AF. Although in NSR, I have ectopic beats and he kept me on the Bisoprolol to keep them under control. I suffer from dizziness and tiredness, also left upper abdomen pain. I sought a second opinion, came off the Spironolactone and the abdominal pain disappeared. Just tried weaning off the Ramipril and not quite straightforward, felt uncomfortable after 4:5 days off., but having read the paper I’m coming off the Bisoprolol today, as I feel v likely this is cause of dizziness and tiredness and will show my new cardiologist next week. He did give me a funny look when I told him why I was in the Bisoprolol… Thank you for sharing the paper.
If you do come off the Bisoprolol, I do advise you speak to your dr first about the best way to do so, as it’s best to wean off them very, very slowly and they can give you advice on how best to do it safely. Perhaps you intend to do this, but your reply above suggested you were coming off today, so just wanted to make sure you were aware 😊
Thank you Teresa. Well, that’s how I felt when I read it😀, My wife is medical, she’s keen for me to titrate off the meds. I’m only on 1.25mg of Bisop a day, so hardly worth cutting in half, and I can easily keep an eye on my heart rate. It is a drug that’s used as a pill in a pocket, so I think ok to come off it now, I’m seeing my cardiologist on Tues….
Honestly, even on 1.25 ( I’m on that as well) you need to cut them…and they will cut, I’ve done it myself with a pill cutter from Amazon 😳 even if you do it over a week or so, it’s better than stopping altogether in one night. I’ve tried stopping before when I was on 2.5 to nothing and my cardiologist said I could do it over 2 weeks. I’d only been taking it for 6 weeks. Coming off the 1.25 to nothing was the hardest. Those pills even though small are still powerful…I went straight into afib. A few months later, I successfully reduced to 1.25, over 4 months - I was taking mouse’s nibbles off and weighing with jewellery scales ( wasn’t taking any chances!) my heart didn’t even notice.
No, I haven’t had one - yet. Earlier this year, I was told by an EP, that I could have one if I wanted to, but we’ve decided to do a ‘watch and wait’ as I’m having only one episode a year. I’ve had Afib for 18 years, so I’m thinking, if it was going to progress further, it might have done before now, but I know you can never know, with this horrible condition. It still has a hold on me though 😳 I also know it’s not likely to ever go on it’s own. The fear is an ablation could make it worse too.
It’s amazing how everyone is different, hopefully you can keep your’s under control without the need for an ablation, it sounds like you are🤞. Yes, I had a cryo 28 months ago. I’ve been in NSR since, but struggle with recovery from exercise. Eg I can play golf fine/do Pilates, but next day I struggle. Just have to manage that with work and other exertion. But i did a treadmill test three weeks ago and no issue with rhythm. It’s odd that I don’t have symptoms whilst exercising, so I’m sure it’s to do with the drugs and most likely the Bisop…just need to bottom this out with my new cardiologist.
It is certainly interesting how we are all so different. I can see why you want to try and come off the Bisoprolol. Well done in being in NSR for so long now, that sounds so promising.
I hope you manage to agree a way forward when you see your cardiologist in sorting out your issue of recovery,
Just to be clear, I think what the article is saying is not that rate control is not useful - it obviously is, to control tachycardia and prevent damage to the heart from being over-worked etc; it is saying that beta blockers are perhaps not the optimum way to do this. By slowing down the heart more than is necessary they can cause extra stress to the heart walls.
Calcium channel blockers such as diltiazem or verapamil seem to be a much better option due to their only working at high heart rates not when slow. "Calcium-channel blockers have little effect on sinus rate, filling pressures, and wall stress (which may) explain why the progression towards permanent atrial fibrillation may be slower and why they are better tolerated than beta-blockers."
" I think what the article is saying is not that rate control is not useful - it obviously is, to control tachycardia and prevent damage to the heart from being over-worked etc; it is saying that beta blockers are perhaps not the optimum way to do this. "
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Yes, but it's also saying something perhaps more important in terms of the treatment cycle many of us are on. and that's (quote from the article) "In addition, it was never established that beta-blockers reduce the risk of atrial fibrillation in patients in sinus rhythm."
In other words, the distinction is being made between being in afib and having afib. And if you simply have afib, but are not currently having an afib episode, very little evidence that either as beta blocker or a calcium channel blocker is doing any good. And yet, many stay on them for years, even while not having an episode and often with side effects hard to tolerate.
Hi Jim, yes and i find it incredible that cardiologists don’t seem to know this. I’ve sought a second opinion. I may be proved wrong, but having read the paper, I feel likely the Bisoprolol is causing my recovery issues, dizziness, tiredness…..
A lot of docs just keep doing the same thing over and over again, a lot of it based on the way they were trained even if that training was outdated. Ep's tend to be more updated than general cardiologists, but always good to do your own research to keep them honest. I've found most of them fairly reasonable when I've offered alternative meds/treatment approaches, backed by my own research. Diltiazem vs Metoprolol is an example. The knee jerk reaction is Metoprolol, but as soon as I say, I tolerate Diltiazem better, they say "OK"
Yes and interesting. I asked my EP wrt what to do with my meds after my ablation and he referred me to my cardiologist…..but he did say was that if I was 65 he would keep me on Apixiban……
Hi BarnyI concur with other subscribers in thanking you for pointing to this interesting article and for disclosing your well balanced view on this published article. I am tempted to research both groups of medication.
I was prescribed bisoprolol by cardio team but didn’t take it as my blood pressure is a healthy low and I didn’t want to mess with that. Discussed this with my EP who thought this was a sensible decision and suggested I try digoxin which is a cardiac glycoside rather than beta blocker. It worked very well for me, no side effects and kept my resting HR in low 60s while strengthening the heart beat so less breathlessness. I quite miss it now I’ve had an ablation plus CV and am back in NSR! We’re all different aren’t we - I’m sure bisoprolol is just right for some.
Personally I find bisoprolol a godsend. Its the only drug to help with my rate control over the past few years and with this condition you have to go with what helps. I had difficulty with Flecainide Propofenone and others and bisoprolol was incredibly useful. I learnt a long time ago if you don't like it , don't take it whatever that is.
Highlighting this report just goes to sow frighteners among those on this forum who are n a state of flux when it comes to AF medication. You have to go with what works for you.
For what its worth I just had a AcQMap ablation last week. Hopefully this will help with my issues.
Yes it is. Dr McCReady. Its a way of mapping the heart to highlight any anomalies to be corrected...Relatively new procedure, for people generally like me whose AF keeps returning.
Hope the ablation works out well for you. I’m now on rate control with Bisoprolol, and doing fine on it. It maybe suits some more than others.
Certainly some of these studies can add to fears. I have slightly reduced left ventricular function, so it’s likely that I fall into the ‘reduced EF’ category anyway. (It was fine before my AF turned permanent.)
Just been advised that I can try reducing the Bisoprolol a little, so crossing fingers.
Thanks for posting this paper, though I think there will always be exceptions to what has been discovered.
I have vagal Afib, with a normal ejection fraction and have been on Bisoprolol (1.25) for two years and my episodes dramatically reduced from monthly, to one a year. I’ve no idea how it’s happened, though my normal rate now is 5-10 beats slower per minute, than it was, but I never used to have a high HR anyway. I’be never been a die hard fan of Bisoprolol, believe me, but I’m reluctant to change it at the moment, as it seems to be preventing episodes, though it’s certainly food for thought.
Thing is you wouldn't change it if it's working for you.As they say if it can't broke don't fix it.
You'd only change from a Beta Blockers like some of us needed to if the BB was not working for you or making the symptoms worse.
The essence of the paper is that it has a lot to do with the root cause which caused your AF , Arrhythmia or any other heart rate / BP as to whether a Beta Blocker is best for someone or not .
Some people do better on beta blockers than they do on calcium channel blockers , its a very individual thing. Take care , Bee
Yes, I do agree with you. If anything happens in the future, I’d certainly remember the paper. I did notice too that part of the trial was with people who had hypertension as well, though it wasn’t entirely clear how many, but perhaps I didn’t read it fully enough.
Yes, I’ll stick with what’s working, for now anyway. Who knows what the future holds eh?
I had H/R Day of 187 with Metoprolol BB and 156 with Bisoprolol.
But introduction of CCB Diltiazem tweaked at 120mg AM brought down my H/R Day now a year down the track on it to 60s H/R.
My ECHO last week (whilst talking) shows 70-80H/R more than 2 hours taken Diltiazen (3.00pm).
ECHO results
1. Severe Left Atrium Dilatation.
2, Moderately Right Ventricle dilated with Systolic Normal.
3. Normal Left Ventricle size with Systolic Normal.
4. Moderate left triscupid regurgitation with normal pulmonary pressures.
Being in mind that I was left on the prior high BPM for 2 years post Stroke.
My Dr talked about drug Em.... I'll have to find it but only funded if I am Diabetic II or Maori! 1/2 tab 5mg for me. She said it would take 5 years to bring down the dilation. It has a diuretic in it.
Interesting Research.
Metoprolol was the worst! But all Stroke victims get Metoprolol, even though I said no. (Previous breathlessness with it).
Interesting that the Diltiazem made such a difference! Glad it helped.
Re "My Dr talked about drug Em.... I'll have to find it but only funded if I am Diabetic II or Maori! 1/2 tab 5mg for me. She said it would take 5 years to bring down the dilation"
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Diane
I need a simplistic explanation of difference between heart rate & rhythm 
'Sotalol is another beta blocker but it is no longer recommended for heart rate control'
Meds vs ablation 
Ablation vs med management?
Twenty seven meds a day, sometimes more.
