Hi, I have recently been diagnosed with Paroxysmal AF. Drug regime includes, Apixaban, Bisoprolol, and Liptor. I have been given Flecainide in case of need but I am concerned about some of the side effects so have not used it so far.
My question is about experiences with Bisoprolol. I was originally given 2.5mg daily. But this dosage resulted in a resting heart rate of 47bpm, side effects of tiredness and lack of motivation. GP reduced dose to 1.25mg daily but this resulted in the return of AF. I am now, upon my own decision and in consultation with the GP, alternating between 1.25mg and 2.5mg daily. Heart rate is still low at 49bpm. GP is satisfied with this but I am not.
Any ideas on boosting heart rate?
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SStu
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I didn't tolerate 1,25mg bisoprolol which made me a bit dizzy when I would stand up and my resting hr would come to around 45, once 42. So we agreed to stop bisoprolol all together. Luckily I didn't experience any Afib during that time even though I was only on propafenone. I'm 6 months post ablation, all good for now. The problem is everybody responds differently. I didn't tolarate 1,25mg and there are people who are taking 10mg daily and they're ok.
We are all different but my experience of Flecainide was good considering any meds I take causes tum probs, I tolerated it well. As for the Bisoprolol my friends experience was the same as yours fatigue, so GP lowered the dose and she it now ok
I have found that strangely, there unfortunately isn’t a lot of difference in HR between 1.25 and 2.5 mg of Bisoprolol as I have been on both. I’m currently on 1.25 mg. Bisoprolol doesn’t stop episodes, it keeps HR down if you do get an episode and it might have been that you would have got an episode break through on 2.5mg.
I too wouldn’t be happy with my HR going to 49, mine goes to 54 regularly and makes me feel tired.
There isn’t anything you can do, to raise it, apart from trying perhaps a different beta blocker, or even a calcium channel blocker to see how your heart rate is in those and you may feel better.
I was diagnosed with the same paroxysmal AF as you this July having been diagnosed in October 2023 of AF. I’m on verapamil only when in AF and blood thinners. I was in A&e today as my AF came back overnight to trial pill in pocket flecianide with a heart monitor for the first time of taking and it worked and no side effects.
In Jan 2010 ( aged 65 ) when originally diagnosed I was put on Bisoprolol 5 mg. to be taken in the morning. It gave me some very unwelcome side effects notorious coldness of limb extremeties, hands and feet and fingers. I stuck it out and beat it and even managed to deal with the massive tiredness. My daytime waking HR was around 60 bpm and my night time sleeping HR would often ( more than I would have liked ) dropped to around 45 bpm. I also managed to have frequent full flow random nose bleeds with Bisoprolol. Initially I figured it was related to the Warfarin I was taking but my locum GP at the time said take the Bisoprolol at night. Nosebleeds stopped and I've never had one since and am still on Warfarin.
After some 12 years - maybe 13 - I found it giving me unacceptable levels of tiredness and so my GP changed me to Nebivolol 5mg. Early 2024 I began to see the return of other AF issues and so chose a new Cardiac Consultant and paid for a private consultation and he switched me to Sotalol 80mg daily taken at night.
The Sotalol still gives me the tiredness ( not as bad as Bisoprolol ) but for me anyway is a damn brilliant controlling drug for BP and HR ... currently averaging 126/75 with a HR of around 72 daytime and 60 ish at night. I'm 80 next month. Even so at my next Consultant review in late September I'll be seeking a reduction in Sotalol, maybe 20 mg in morning and 40 mg at night or just 60 mg at night.
My AF was originally diagnosed after a massive fall in BP ( 136/80 ish down to 76/50 ish ) in less than 6 hours . So I always closely monitor my BP too, not just the heart rate because the HR alone is not a good enough means of assessing heart health and response to drugs. I recommend this approach if you have a BP monitor or can afford to buy one.
in my experience I don’t need much metoprolol which is similar to your Biso to keep my HR in the 50’s at rest. The equivalent dose to Biso for me was 2.5mg which also dropped me into the 40’s and even lower when I started daily Flecainide 7 months ago. My pre drug HR at rest is around 65bpm
We tweaked the dosages of both and now I’m on equivalent to Biso around 1mg twice daily and 20mg Flecainide. What you need to understand is that it can take a while maybe months for you to get a steady level of the drugs in your body. I found things settled after a couple of months and no more bumps and jumps of the heart. We are all different. I also have a daily exercise regime and only decaf and very little alcohol. I also supplement for the blood levels I was low in like Vird3 magnesium and coq10
Very helpful, thank you. Yes, I want to test the current drug regime for 3 months then ask for a review. I will try taking the Bisoprolol at night instead of in the morning. Like you I am implementing an exercise regime. I never drink coffee (perhaps I should!) and only drink caffeinated tea up to midday then decaf or rooibos thereafter. Don't drink alcohol.
My issues were I had too much wine or too much coffee, it stayed in my system so if I got up at 6.30 for a run I could flip into AF. Fast forward 31 years and instead of every 5 years I’ve had AF 3 times since 2022. You have to still enjoy your life but know your triggers and avoid them. I’m a real believer in a healthy body and mind will help you mitigate and manage AF better
The vast majority of AF sufferers in the UK take bisoprolol, I guess, and despite the side effects felt by some, looking at clinical reports and patient experiences, the majority likely tolerate it well. I suspect the problem is sometimes from the heart and its arrhythmias itself, rather than the drug, especially with such variability in these conditions and the associated symptoms.
Do you know what your normal resting heart rate was before you began bisoprolol and when in NSR? The rates you report now seem far from unusual, and are broadly what I get, although my daily rate varies. I get many daily ectopic beats and AF perhaps fortnightly (not overly symptomatic these days, with an average rate <100bpm, range 85-125bpm).
I seem to have had a generally similar experience to you with a similar reduction in heart rate when taking bisoprolol. I can't say I developed easily identifiable side effects when I doubled the bisoprolol to 2.5mg, but my heart rate went lower and I had more light-headedness. My doctor reduced it back to 1.25mg, though, and that is where I am now.
I also have something called left bundle branch block (LBBB), which seems to cause me to have a lower resting heart rate, also. I mentioned moving to another beta blocker or a calcium agonist drug but he assured me that I was on the best drug for AF and my heart.
In the end, I have concluded that the AF element (i.e. I get far more ectopic beats than AF episodes) is somewhat independent of things, or at least, the AF element waxes and wanes with no connection to the bisoprolol dosage.
I have since had a cardiac MRI to see if it’s safe to take flecainide, which I can, but after taking one and feeling rather strange with heavy beats, I have left it for now.
I'm another with LBBB which wasn't identified by the hospital initially but was seen on my ECG by a consultant whom I saw privately whilst waiting for my first clinic appointment. I also went to my GP to reduce the bisoprolol because I was getting a low HR which consultant immediately saw was because of my stage one heart block. For me the solution has been to give me a pacemaker which doesn't allow my HR to drop below 60. I'm really fortunate to have the pacemaker because my AF has worsened and they have been able to increase the dose of bisoprolol significantly, I now have a mix of that with a low dose of digoxin although it's taken a couple of weeks to settle things, I'm actually feeling much more like myself and have more energy despite being on 5mg of bisoprolol morning and evening, whereas I couldn't tolerate 2.5mg before.
Thanks for writing as your post was most interesting and helpful. I wonder if you have LBBB along with first stage, i.e. as it is more usually called "first-degree") heart block? LBBB is different from the usual heart blocks and isn't given a "degree" type classification?
A pacemaker was suggested to me as one scenario so that I can take more bisoprolol to control the AF without it causing symptomatic bradycardia (but not a resynchronisation PM for the LBBB as it was deemed not needed), the other options being ablation (for my ectopic beats and AF), taking flecainide or having a "pace and ablate" pacemaker fitted. I have been given flecainide but, so far, have only taken it once and am on an NHS waiting list for an ablation.
It's good to read of the success of the interventions your doctor has made. I was given once digoxin for my atrial flutter, which is where I started this journey back in 2019 (cured by an ablation later that year). It was the only drug that slowed my heart as bisoprolol wasn't that helpful at all.
Hi, Just got my notes out and you're correct, described as atrial flutter with 2.1 block +LBBB. tbh not exactly sure what that means except there is a slight pause between atrium and ventricle because electric pathway is a bit faulty. When admitted to A&E in July with flutter/ fib and SVT , a week after having my pacemaker fitted, I was given 3 lots of metrolol, a dose of dixogin and eventually a titrated large dose of bisoprolol and after 15 hours my HR dropped and stabilised. I went in for an ablation to stop the flutter in 2021 but ended up having a cardioversion (flutter was atypical ie on right not left) which worked really well for nearly two years but now I'm on the list for pace and ablate although tbh I have been feeling pretty well for the last 2 or 3 days.
Aha - I don't think you have heart block, in that case; you have, like me, only LBBB. The "2:1" block is what most people with AFl have (in 2019, that's what I had). Atrial flutter is when the heart's atrium, i.e. its upper two chambers, beats rhythmically but at an excessive rate of c. 300bpm. Luckily, the heart's own natural ventricular pacemaker, the atrio-ventricular, or AV, node, nearly always steps in and blocks some of the excess from activating the ventricles. Sadly, it only does so at a fixed ratio of 2;1, 3:1, etc. . This allows a heart rate of 150, 100, 75, etc. The odd and unique aspect of AFl is that the rate steps up and down between these fixed ratios, rather than smoothly as occurs in NSR or even AF. This makes AFl harder to treat than AF, apparently.
Thanks, I now remember the consultant explaining that to me when he first saw me but I'm not sure if I've gone back to flutter or now have fib or if I get both! I definitely get ectopics though and I think that's when it feels especially unpleasant.
Yes, my ectopics feel different from my AF, and, like you say, are unpleasant and, I find at times, harder to cope with because they create an irregular and unexpected "thud". This occurs, I gather, because the valves have to close more forcefully (it's the valves closing, not the heart pumping, that creates the pulse we feel).
AF, to me, and I have had it much of today and still on and off as I type, with rates from 85-155bpm, feels less uncomfortable, although it can make me feel light-headed and "distant". I think the LBBB can also bring on similar symptoms without any ectopic beats, too. I was told this is because the ventricles are much less efficient at those times and the brain, essentially, is made short of oxygenated blood.
That's so helpful to know and explains the symptoms I sometimes experience of feeling "spaced out" or disconnected (which is really worrying!) I feel I've got a good consultant, because I've seen him privately as well as on the NHS I feel he knows me as a person not just a patient but I still sometimes find it difficult to explain what I'm feeling and it can be difficult getting an ECG which shows what's going on. My recent A&E experience was worrying as I had 15 hours of just about everything going crazy so I was confined to bed, wired up with a defib machine at my side. One doctor told me that they had had a team meeting about me and they were totally perplexed but not to worry although of course I did. I'm sorry you are having a difficult day, fingers crossed that you have a better night. Thanks for all your info.
It was the first symptom that I remember and it was a good while before my first arrhythmia (atrial flutter). It was during a family Christmas lunch when voices started to seem elsewhere.
I was thinking that you likely received the best treatment as the doctors were fascinated by you!
I did receive excellent treatment, absolutely no complaints but I| think they were flummoxed rather than fascinated. Worryingly I was recognised by three nurses that I came into contact with because I'd spent 2 weeks on a surgical ward in January following a fall off a dressage horse fwiw blood thinners and a crashing fall are best avoided! I also had amazing treatment then with fantastic pain relief, NHS at it's best but I've seen too much of hospitals this year!
It sounds as if you have. Let's hope you see no more. My experience of the NHS has been excellent, which is amazing considering the backlog following covid pandemic.
I did mention the "spaced out" or "distant" feeling to the specialist I saw and he said it wasn't unusual and could be down to slow heart rate, the LBBB or the arrhythmia - all of which affect the ventricles and their ability to pump efficiently.
There is an interesting article on Medscape titled The Tyranny of Beta Blockers basically saying they are prescribed indiscriminately. Just because they are frequently prescribed des not mean they are effective for all and maybe doctors need to be a lot more selective as to who would or not benefit.
Quote; Stop the beta-blockers on your patients so they can meet their exercise goals and get healthy!
Such pithy enthusiasm discounts physiology's complexities. When blunting our patient's heart rate response with beta-blockers, we also increase diastolic filling time, which increases SV.
Patient Variability in Beta-Blocker Response
In addition to left ventricular function, there are other factors likely to drive variability at the patient level. We've treated the response to beta-blockers as a class effect — an obvious oversimplification. The impact on exercise and the heart will vary by dose and drug (eg, atenolol vs metoprolol vs carvedilol, and so on). Beta-blockers can also affect the lungs, and we're still debating how cautious to be in the presence of asthma or chronic obstructive pulmonary disease.
In a world of infinite time, resources, and expertise, we'd CPET everyone before and after beta-blocker use. Our current reality requires the unthinkable: We'll have to talk to each other and our patients.
Thanks for reminding me of that. Someone here posted the link to the study a few weeks ago and I read it with fascination. The idea of excessive ventricular filling sounds worrying to read but I have no idea whether it is medically important.
I often wonder whether a lot of bisoprolol and similar isn't prescribed (and rather like statins) for potential prophylactic benefit, i.e. in the hope of preventing a future irreversible deterioration or conditions such as HF. BB drugs are said to be a cornerstone in the treatment of that very much undesirable condition.
Most studies seem to show them to be quite well tolerated, perhaps surprisingly so given the comments on this forum, but those many who cope are unlikely to post. My own experience is that they are fairly benign and that my arrhythmias in themselves produce many of the effects I feel. This graphic is snipped from a recent study:
Steve
from CURRENT MEDICAL RESEARCH AND OPINION
2024, VOL. 40, NO. S1, S55–S62
I stopped bisoprolol altogether because of its negative effects. It lowers both heart rate and BP. Now taking Lisinopril for BP but no rate control. I simply put up with my occasional PAF if and when it occurs, because it reverts to NSR within minutes and Bisoprolol didn’t alleviate the symptoms when it did occur. Fortunately I know my main PAF trigger is pushing my exercising heart rate over 150bpm, and I can avoid that without a beta-blocker.
I was same and after I was in hospital with a HA, hospital took me off Bisoprolol as heart rate too low - I feel fine in the 50’s but not in 40’s - was originally on 2.5mg but got doc to reduce to 1.25mg as like a zombie - AF continued until I had an ablation Dec 23
Cryoablation did it for me and subsequently stopping Bisoprolol boosted again, see my bio. I still have higher rate 9 months on but I believe it can still reduce more as the heart heals. I feel better and believe a lot of that is down to the increase in HR.
They will tell you it’s only a low dose of Bisoprolol but it can still have a dramatic effect on HR which can be very helpful if you’re in high rate AF a lot but when you are NSR most of the time it certainly reduces your performance. It can get more tolerable with time. I also think there is something in the thinking that bradycardia can actually trigger AF in some when the HR is so slow it allows the rogue beats to take over.
I can’t tolerate beta blockers so take Diltiazem instead, together with Flecainide twice a day. My resting heart rate is usually 47-53 so quite normal for me on these meds. It was much higher, about 72, before medication..
I take 10mg bisoprolol daily. When I first started my hr regularly dropped to low 40s but cardiologist wasn't concerned as I wasn't being affected in any way. Now 5 years later my average is 65 bpm with very occasional drops to mid 40s as my body seems to have adapted to the dose.
Hi, it seems different doc have different views about low HR. Ones I've encountered seem more worried about HR under 50 that if it is 80. Have you had any heart scans. My low HR was due to leaky heart valve and low EFR. Had valve repaired and pacemaker inserted, now EFR back to normal and PM stops my HR going below 60. Sorry about abbreviations.
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