Why beta-blockers in my case?

[Jerry_D]

I had a heart attack in February 2017, 2 stents fitted and all subsequent control visits confirm no stenosis anywhere. I'm 66, otherwise very healthy and very fit. My resting heart rate before and after the attack was/is between 50 and 55 and my resting blood pressure around 110/65. I exercise 5-7 days/week (7 km Nordic walking or an hour on elliptical bike or swimming). My cardiologist's stress tests always complete perfectly. I was prescribed 2.5 mg daily of Bisoprolol and I never really understood why. Can you shed some more light on that?

[Chappychap]

Hello Jerry, welcome to the forum.

Even though something like 90% of heart attacks happen to people with obstructive heart disease, that still leaves a not inconsiderable one in ten who have a heart attack with no arterial obstruction. Did your cardiologist say if you're in this category?

You also mention "no stenosis anywhere", however the threshold for classification as "obstructive stenosis" is the somewhat arbitrary figure of 50% . Do you mean literally "no stenosis" or just that it fell below this 50% threshold? It's always struck me as an odd criterion, in that something like half of all heart attacks happen to people with less than 50% arterial obstruction, which in medical parlance is often translated as no obstruction.

It's one of the many surprising elements of heart attacks. Quite a lot of people can get to 95% or higher levels of stenosis, be almost crippled by angina, but never have a heart attack. Other people can have negligible levels of stenosis, indeed levels that are so low they're actually quite difficult to measure, and yet have multiple heart attacks.

It seems the very nature of the plaque in peoples arteries can be very different, some people have extremely stable plaque that quickly becomes calcified and will almost never rupture, other people have more liquid plaque that remains liquid for years and is much more prone to rupture. As soon as this liquid plaque contacts the bloodstream it solidifies, blocking the blood supply and causing a heart attack. The fact that you had two stents suggests your heart attack followed this pattern, as stents are generally used to open a blockage and relieve the heart attack.

Just one other thing that you might find useful to explore. Even though we normally associate heart attacks and atherosclorosis with things like smoking, lack of exercise, or obesity, there are actually many other causes. Just to suggest a few; disrupted sleep or sleep apnea (for example shiftwork or regular long haul flying) can cause heart disease. Gum disease is a common cause of heart disease, especially if you carry the Interleukin-1 gene. Or there are nearly 20% of the population who are especially sensitive to alcohol and dietary fats, so you could be skinny as a rake but if you fall into this category then you're still at risk.

The fact that you've gone four years with no repeat heart attack is good news. Perhaps your Bisoprolol has contributed to that? Personally I'd be in no rush to change a winning formula!

[Milkfairy Heart Star in reply to Chappychap]

Great reply.A clarification about myocardial infarction non obstructive coronary arteries MINOCA,

The most common causes are vasospastic angina, microvascular dysfunction and spontaneous coronary artery dissection.

In these cases there is very little build up of plaque. These conditions are more common in women. There growing evidence that suggests women have an even distribution of plaque in their arteries rather than large clumps of plaque.

Women also have different risk factors eg pre eclampsia.

Heart disease is complex

Heart attacks are not just about blockages.

[Hidden in reply to Milkfairy]

Does Pre Eclampsia increase the risk of HA in women then MF? My sister in law had it years ago.

[Milkfairy Heart Star in reply to Hidden]

Having pre eclampsia increases a woman's chances of developing both obstructive and non obstructive coronary artery disease.

pubmed.ncbi.nlm.nih.gov/212...

[Hidden in reply to Chappychap]

Great reply, tell me more about this stable/unstable plaque have you got any links?

[Chappychap in reply to Hidden]

I originally came across stable versus unstable plaque in the writings of two American cardiologists, Amy Doneen and Bradley Bale. They run an influential cardiology clinic in Washington State, this isn't too far from Vancouver, Canada, where my family is from, consequently I plan on visiting the Bale Doneen Clinic for a consultation. If I find out anything interesting I'll report back here. They have also written a book "Beat The Heart Attack Gene" which digs a lot deeper into this area.

In terms of research links here's a selection,

heart.bmj.com/content/90/12...

This is from the British Medical Journal and includes this neat summary of stable/unstable plaque ,

"we learned that not all plaques pose a threat. A non-obstructive plaque with a thick fibrous cap rich in smooth muscle cells and poor in inflammatory cells and activated or apoptotic macrophages may be a man’s best friend. It covers up a blemish in the arterial wall, namely a deposit of cholesterol (formerly alluded to as fatty streak), with aggressive metalloproteinases ready to erode the surface to get to the lumen. Such a plaque will remain incarcerated for ever—it is sealed. On the other hand, the active (vulnerable) plaque with activated macrophages, few muscle cells at the surface forming a thin and brittle cover, and many inflammatory cells and destructive enzymes near the surface represents a deadly menace."

Another interesting piece of research is this, which contains some interesting diagrams of the plaque development process.

academic.oup.com/eurheartj/...

Finally here's some research which digs into the risk factors for unstable plaque. As I've looked into the research it's sobering just how lethal nicotine can be in forming unstable plaque, and that includes nicotine in the form of vaping or nicotine patches, and also secondary smoking simply by being in the presence of smokers. I quit smoking many years ago, but then spent twenty years happily chomping on nicotine lozenges-with the express endorsement of the doctors at my annual company medical. Ho hum!

ncbi.nlm.nih.gov/pmc/articl...

[Hidden in reply to Chappychap]

Thank you very much for the above Chappy - I will give them a read. I did find a good article this morning where a Doctor was going over the different types in detail, which is at least a start. I did know of the two types but had put them to the back of my mind, as I think the only way of telling the difference might be to have a CT scan, if it is possible to do so in the UK at the moment, even privately. However, even if the results came out as unstable, there is not much I could do about it other than worry, so maybe it is not worth it. I live in hope that as I did not have a HA, just a 96% blockage that caused Angina, which I am assuming will have just built up over the course of my life, as opposed to a bit of plaque which either breaks off or causes a clot and seems to cause a total blockage resulting in a HA, that mine might be stable. It will soon be 3 years since I had the stents fitted with no recurring problems. As with most of us I guess, it is always there and always will be, that nagging doubt every time I set off on a run or swim that the increase heart rate/BP/blood flow and so on may cause such an event to happen, but if it does it does, I can't just sit and watch telly for the rest of my life, and I do believe that keeping as fit as I can will outweigh any such events, especially if I am lucky enough to have stable plaque. As I said earlier, there will have been maybe loads of people lining up at the Park Run this morning who have plaques of both varieties and they don't even know it, at least I am "on the radar" and being treated as well as is possible. What do you aim to discover or do if you go to that clinic? Thanks again anyway, much appreciated - Paul

[Jerry_D in reply to Chappychap]

Thank you very much for your invaluable contribution and especially for the wealth of information presented in the attached articles which I will peruse with great interest.

[Jerry_D in reply to Chappychap]

A fantastic answer! Thank you very much for taking the time to provide such a detailed input and highlight so many important points!

Indeed, the “no stenosis anywhere” is of course wrong and is due to my medical ignorant’s hasty interpretation of the following (all are quotes from official Norwegian and Spanish medical reports, translated by myself so please forgive the errors):

- Two months after the intervention, in April 2017, the cardiologist repeated the coronary catheterization (I’ll come back to the reason for that). Result: Coronary arteries without significant angiographic lesions. Stents without restenosis.

- November 2017 Cardiac MRI result: Ischemic heart disease with preserved volumes and biventricular function despite a near-transmural necrosis in the LCx territory and focal in the LAD territory, with perfusion gaps in the territory of the LAD and mid-distal LCx (to be correlated with coronary anatomy, probably the marginals have developed).

- February 2020 SPECT rest/stress test result: In the post-stress tomographic sections, a moderate inferior hypoperfusion is observed, predominantly at baseline, which reverses almost completely at rest. Mild anterobasal hypoperfusion, with total reperfusion at rest. No other significant disorders suggestive of regional myocardial hypoperfusion. The study of LV motility shows correct systolic function, with an estimated EF value of 67%, with no alterations in motility or systolic thickening of any of the myocardial walls. Scintigraphic examination showing signs of mild anterobasal ischemia and mild inferior ischemia. Good LV systolic function.

- June 2020, coronary catheterization result: Common trunk without significant stenosis. Anterior descending with permeable stents without significant restenosis, rest of the vessel without significant stenosis. Circumflex with permeable stents without significant restenosis, rest of the vessels without significant stenosis. Dominant right, without significant stenosis.

The reason for all this testing was that about ten days after the heart attack and fitting of stents I started experiencing strange chest pain episodes about an inch left of the center and at the approximate height between the 3rd and the 4th rib counted from above. These pain episodes have continued and are still appearing. This pain is completely different from that experienced during the heart attack. It is very localized, covers a very small area (like a medium-sized coin) and it has all the characteristics of a muscular pain similar to those I remember from my soccer days and the blows to the muscles I then sometimes received during the game. The pain comes and goes with no obvious pattern of any kind, lasting anything from a few seconds to a few minutes and is quite mild – I would say never more than a 2 on a 1-10 scale. The episodes are sometimes very few and far between, at other times very frequent and lasting for hours and going on for several days. This pain has no connection to my physical activities or states of mind or diet or anything else that I can think of. All the medical studies and many tests I’ve done since, have eliminated the possible cardiac, pulmonary, rheumatic, GE, muscular etc. causes and four years later I’m none the wiser.

However, I am a seasoned scientist by training and experience, as well as by personal attitude so I never stop investigating. And no, I am not a hypochondriac. A psychologist friend has confirmed that 😊. I have over these years considered the possibility of this pain being a side effect of the chemical storm my body was suddenly exposed to. After a lifetime of extremely scarce contacts with the pharmaceutical products, four years ago at age 62 and because of the heart attack I suddenly started taking the beta-blocker, two antiplatelets (aspirin and Plavix), the statin, the anticoagulant, the PPI and all of them in substantial doses.

I have since, in agreement with my doctors, discontinued Plavix, the statin and the aspirin but I continue on the BB, anticoagulant and the PPI. I am now considering to try stopping the BB (yes, of course, slowly and gradually, and after talking to the cardiologist). It’s not just because of the chest pain. I’ve also had two episodes of AFib and then there is the frequent (almost daily) feeling of lightheadedness, fatigue, chills, episodes of runny nose, all of them very mild but very frequent and persistent.

And, I still do not fully understand why I need the beta-blocker. I’ve never had high pressure (always around 110/65 at rest) and my heart frequencies were and are very low (50-55 at rest and about 45 when sleeping).

[Hidden in reply to Jerry_D]

I can't really comment on much of the above, my heads spinning trying to take it all in. However, if it is any use, I too have experienced a very similar slight pain in just about exactly the same place. I didn't have a HA so don't know what it feels like, however when one of the stents was fitted I had an alarming pain in my chest which I was told was the procedure temporarily blocking the LAD. The pain I have been getting is nothing like that, and I am putting it down to the fact I have started to increase my swimming activity quite a bit and it is no doubt muscular. The way I see it is if it was anything serious you would probably know about it by now?

[PeterpPiper]

The bisoprolol is used to make it easier for the heart to do it’s job and help keep the heart in good physical shape long term .. it’s not just to lower heart rate, infact that may be seen as a side effect to the main job of the beta blocker

[Hidden]

What a great post! I find this very interesting, and I reckon this one will go on all day. Fantastic reply from Chappychap, I was not aware of a lot of the facts he has outlined, and when I come back from the Park Run I will have to give it more of a digesting, however as a quick reply I have to offer a slightly different opinion. If you look at my profile you will see I am similar to you but maybe one important difference is I didn't have a HA although yours must be in good nick from what you say. A lot of what Chappy says could be said of lots of other people who do not have heart disease or at least not aware of it yet? For me the Bisoprolol gave me 2 big problems, one outside and one inside. As I returned to exercise I became very aware how much it was holding me back, making me feel as if I was walking through treacle all the time, and generally foggy. It was also having a detrimental effect on the marital front. After doing the research, I went to see my GP, a great bloke who is also into running, to ask him if I could come off it. He looked at all the hospital records and after asking me why I wanted to, told me that in his opinion I should never have been put on them. I think it is accepted that they are just part of a "fix all" cocktail that each cardiologist will prescribe - probably rightly so as a lot of people will no doubt just sit and watch TV and eat Pizza afterwards. However for me they were literally stopping me from doing just the thing my heart needed - strengthening after a few years of laying off the exercise. I felt better (all round!) for coming off them and the thought of returning to them is dreadful, they are awful drugs in my opinion, for me. Obviously for people who do need them, I have no doubt they are very beneficial, so you may need to discuss this with your GP. Anyway I am off on my run and will look forward to a few more replies, hopefully. Bye the way I was only on 1.25mg as well! I would be wondering why you are on a bigger dose?

[richard_jw in reply to Hidden]

Absolutely spot on. Running through treacle sums up how I felt on 2.5mg Bisoprolol. And after I was wiped out completely for hoursInitially after the STEMI, there is a pretty much standard mix of meds you get put on. It varies somewhat but there are clear NICE guidelines. Bisoprolol is likely to be one of them.

BBs slow down the heart. Bisoprolol in particular acts on the Adrenaline etc. receptors to prevent the heart pumping too hard. So your pulse rate goes down and indirectly so does your BP

As the heart recovers from the MI, there is less need to protect it.

But don't come off BS cold. There are (in my case) side effects. It seems as if the heart suddenly realises that here is all this adrenaline which I must do something with.

My heart went from 60-65 to 90ish or higher.

Which is pretty scary.

Also it's important to do the withdrawal with a cardiologist's agreement. The coronary arteries need to be clear, and the extent of damage to the heart as a result of the MI needs to be acceptable in the cardiologist's view

[pasigal]

Biso is a quite beneficial drug in that, as others have said, it lowers hr/bp, basically taking stress off your heart. A big "however," is that it can have some quite strong side affects. For me, it's insomnia and some loss of energy, as noted above. After CA and HA, plus family history of unstable plaque, I will likely be on it until I die. I can live with it, but I agree, the side effects can be tough. I'm on 2.5 mg daily...in general, I'd argue that less medication is better but a second opinion is never a bad idea...

[richard_jw in reply to pasigal]

Presumably you are on 80mg of atorvastatin or equivalent. the statin not only reduces bad cholesterol it also helps stop plaque detaching

[Hidden in reply to richard_jw]

We all hope so eh? I have mentioned this before on here but on my Rehab course there was a Chemist who actually worked at the hospital and had had a heart attack. He was involved in the development/trials of Atorvastatin and gave us all a talk on it, extolling it's virtues and stressing there was quite a bit of evidence to suggest it does at least stabilise plaque and maybe even reduce it over time. I often think about him as I am flogging myself round the Park run of a Saturday

[richard_jw in reply to Hidden]

My cardiologist recommended changing some meds inc. stopping BS, but also reducing statins to 40mg (because of possible side effects). When everything stables, might increase statins back to 80mg

[Hidden in reply to pasigal]

Could you expand on the "family history" of unstable plaque? How was this deduced?

[Hidden]

OK I have spent quite a bit of time today, on and off, looking into this, along with a few other points raised by CC, who I must thank for some great input. For what it is worth, my opinion on your original question has remained unaltered. I do accept that for a lot of people Beta Blockers are very important and no doubt even vital. Obviously they can help to remove the load from the heart by various means, slowing the heart rate, lowering blood pressure, relieving stress on it. The thing is, with such restrictions placed on it, how is it ever going to strengthen? I accept that if the heart is made to work too hard for too long it will eventually suffer and weaken, but for people who are able to make it work hard during exercise and then recuperate during "rest" periods, it will strengthen just like any other muscle. I for one would need a very very good reason to entertain going back on them, that is for sure. The articles I have read that CC provided links to, have even further reinforced my belief that Statins, particularly Atorvastatin, are an essential part of preventing further problems down the line and I would urge anyone who is sceptical or worried about side effects to think very carefully before discontinuing them.

[Jerry_D in reply to Hidden]

May I suggest the following reading on statins:

amazon.com/gp/product/B00IU...

amazon.com/gp/product/B01LZ...

The authors offer information and arguments which might influence your opinion about the statins.

[Hidden in reply to Jerry_D]

No I have never heard of them but no doubt they are members of a group who go under the acronym of THINGS along with another self styled expert called Malcolm Kendrick who as well as having been struck of Wikipedia for being a "quack" has been reported to the NHS and BMA I believe for his controversial comments on Covid and the vaccination program. I accept that particularly in the States there is a propensity to use Statins in a preventative role rather than concentrating on lifestyle changes which is rightly criticised by such Statin sceptics, however I feel that the overwhelming evidence supports the efficacy of them where they are indicated, and that to suggest that plaque build up is not as a result of cholesterol and lipid levels along with all the other generally accepted culprits is a bit like saying today is Saturday. As you might have deduced I will spend the money on a few sets of new strings, but thanks for the offer😀

[Jerry_D in reply to Hidden]

One of the two books I cited is in fact written by Malcolm Kendrick 🙂. It would appear you didn't even open the links. I am definitely not qualified to fully judge these two gentlemen's medical input, but being a scientist myself, I am fully qualified to judge their methodology and overall approach and that is impeccable. This has also been proven by hundreds of peer-reviewed papers they have both published. One can agree or not with their arguments but I would be very careful to call them "quacks" and discard their opinions without studying at least some of their works. Each of these two gentlemen has a very impressive professional background and many years of equally impressive experience in the field. It is really difficult to understand why one would call such persons "self-styled experts". May I suggest you have a peek, for instance here: pubmed.ncbi.nlm.nih.gov/?te...

[Hidden in reply to Jerry_D]

Of course I opened the links! I can only say in my defence the second one pointed to several authors and I obviously missed his name. The OP was not to argue the point on Statins the post was about Beta Blockers and I was only trying to give you my experience of them and their effect on me. I have researched a great deal into both the drug (statins) and the arguments put forward by those who go against mainstream thinking and I have decided to take the advice given to me by those treating me rather than going against it - the options are unclear any way? I have watched quite a few videos that Malcolm Kendrick has done and I do not think he comes over very well to be frank, but that is just my opinion, it was Wikipedia who removed him for the reasons given not I who labelled him such. I think it is actually quite dangerous to promote things like a Keto diet to people with CVD as he does, something which goes against the very heart of all the advice we are given by the NHS and the vast majority of Cardiologists, however I will have a look at the last link you have mentioned. What are your thoughts on the Beta Blockers for the record?

[Jerry_D in reply to Hidden]

Hi there! I really do appreciate your kind contributions. I am not arguing for either side of the cholesterol/statin topic and continue to respect all the opinions, while keeping an open mind and listening carefully to all sides. As a principle I never discard the non-mainstream opinions. After all, human history is full of the breakthrough discoveries brought by "mavericks", from Socrates to Galileo to Einstein.

As to Wikipedia, while it is a somewhat valuable source of general information, it is also open source and not validated in any way and it is often highly politically influenced, perhaps even biased. I would be very careful to use it in any kind of serious analysis of any topic.

Regarding the beta blockers, I don't know what to think. I do understand their functioning and the benefits that they bring. What I miss is the application of these to my personal situation: what is the exact benefit in my case (a well-trained heart, low heart frequency, excellent response to stress and low blood pressure). After having asked that question to quite a few cardiologists, I am yet to receive an explanation that goes beyond the "it-makes-your-heart-work-less-and-lowers-the-blood-pressure" level of detail.

[Hidden in reply to Jerry_D]

Thanks for the reply, and I know you are not arguing for either side and to be honest the more I look into this I am not sure I am either. The more I look into it and prod around the more confusing it is becoming and you have to wonder if the medical profession, for whom I have the highest regard, do either. As regards the Beta Blockers, my view on them is skewed by my chosen lifestyle, I must admit. I love to try and beat my own records and push myself probably harder than I should, sliding past a 30 year old at the Park run finishing line or just beating my last 1 mile swim. It might not be a great idea and I might drop dead doing it one day but I would probably sooner go like that than finish my days unable to do the things I want to. I still feel as if I am 33 not nearly 63. The Beta Blockers certainly lived up to their name as far as I am concerned, just swap Beta for living. I know they are vital for some people but it will be a black day indeed if I ever have to go back on them. Following your messages I have actually been looking more into the Statin debate (again) and I accept it is not as black and white as I might have thought, although I still feel we are forced to make a decision and stick to it! Dr Kendrick does not really offer any alternatives as far as I can see, other than the doubt and uncertainty - I certainly do not support his views on diet.Of course the BB's make your heart work less and lowers your blood pressure, because they put a brake on your heart and basically stop it the same way mopeds are governed to 30 mph when they can actually do 50. But how can the muscle that is your heart develop when it is hamstrung? Push it as hard as you can, is my ethos, right or wrong. When it all starts going dark upstairs, you are probably going a bit too hard, but I was lucky and my heart was not damaged, other people were not and sadly have less to work with after their "event". I am absolutely convinced however, that exercising to the maximum of your ability is probably more important than anything else, both physically and mentally. There are loads of posts on here every week where the answer to the OP's problems are to get out and exercise but sometimes it is very hard for them to pick up the baton, as it were.

[Hidden in reply to Jerry_D]

Just to emphasise the point you actually made, following the digging around you might like to look at this ncbi.nlm.nih.gov/pmc/articl...

Your the scientist, pick the bones out of that and let me know? (just being a bit facetious BTW)

My only advice really is get yourself down the local Park run this coming Saturday and sod it.

Take care - Paul

[Jerry_D in reply to Hidden]

Will peruse with great interest. Thanks! And I'll definitely continue with intense physical activity. This weekend I'll do swimming. You too take care!

[Jerry_D]

Thanks again for your (another!) invaluable input. You are spot on when you say these topics are not black and white. That's the problem with our universe - it's too complex, and our human knowledge, with all the great achievements of science, has its limits. I like your thinking regarding the beta blockers and my own is very much on the same wavelength. I have made up my mind and will definitely engage my cardiologist in helping me to get off the beta blockers. We'll see how the old moped responds! 😎

[Hidden in reply to Jerry_D]

Mine always benefited from an Italian tune up.