Beta Blockers - useful advice

[JezzaJezza]

Hi all - I wasn’t sure if I could post links, so I have pasted the entire article.

There is a lot of misinformation and confusion about BBs and I thought this would help, especially the bit about being ‘beta blocked’. I am a male, 55 with history of SVT and palpitations. I take Dronedarone and 2.5mg of bisoprolol and between them they have been extremely effective at stopping the attacks. I have full bloods checked every 6 months and all are fine (thyroid, cholesterol, vitamins etc etc). I have always had low resting heart rate of circa 55 but now firmly 40-45 and at night sometimes as low as 36. My cardiologist is perfectly happy because I do not have any symptoms of bradycardia. Here’s the article….

An article by Dr Edward Leatham, Consultant Cardiologist, author of The Naked Heart a series of simple blog and video explanations covering all of the main common medical conditions that can affect us, as we age.

Beta blockers work on the beta receptor situated on the surface of cells that are affected by circulating adrenaline which the body releases in times of stress. Small amounts of adrenaline circulate, even at rest and help determine the resting heart rate and cardiac output. They also have a direct action on the Sinoatrial node which sets the heart rate and the AV node, which becomes very important in patients prone to atrial fibrillation and flutter. Beta blockers have been developed over 50 years and are used to treat a wide range of conditions, including palpitations due to arrhythmia, high blood pressure, anxiety, migraine to name just a few. For a cardiologist, beta blockers are a commonly used medication, possibly because we live in a high stress world and patients come to us with symptoms that are often improved by taking blockers. Cardioselective beta blockers are more popular as they are far less likely to trigger bronchoconstriction or asthma. Here are a few points that are often raised by our patients.#cardiologist #afib #beta-blockers

Cardioselective Beta Blockers

work by competitive inhibition of beta receptors on the heart, which normally bind adrenaline

This ‘blocks’ or dampens adrenaline activation of the heart

Beta blockers thus lower the heart rate as well as peak contractility of the heart pump.

They are widely used to prevent and moderate heart rhythm disorders and to treat heart failure.

They also work as a ‘chill pill’ to lower adrenaline effects caused by anxious thoughts

Dose range

Everyone is wired differently, so to find the best dose, your doctor will often oversee a trial of various doses to find one that suits. The optimum dose of beta blocker to take varies between individuals For Bisoprolol (Cardicor) it varies from 1.25 mg to 10 mg once a day. It is normal when starting to notice a few days of slowing down as the body adjusts Upto 1 in 20 people find even the smallest dose makes them feel lethargic.

How do healthcare professionals (HCPs) find the best dose?

For Bisoprolol, we often start at the lowest dose of 1.25 mg taken every morning on 1st rising. Due to its long half life, it will then take up to 3 days to be steady state Assuming a normal pre treatment pulse or heart rate in range 60-90 beats per minute (BPM), we then look for a drop in heart rate to roughly 45-55 BPM. If the pulse rate exceeds 55 BPM your HCP may then advise you to increase by an extra 1.25 mg each morning.

Whats the dose range of Bisoprolol used in my patients?

As a rough, non audited or precise guide, I would say that the most popular dose is Bisoprolol 2.5 mg for woman and 5 mg for men, however there is a wide range of repsonses: 20% of patients only manage 1.25 mg once a day. 10% of patients require 10 mg once a day:

I have a low resting heart rate, can I take beta blockers?

Your resting heart rate is determined by several factors including the vagal nerve. Some people have high resting vagal nerve activity which produces low resting heart rate. You can tell, by assessing how your heart rate rises on exercise (when vagal tone is switched off). This means that some patients with low resting heart rates will still be offered beta blockers (only after an ECG) to moderate symptoms of palpitation or to temper heart rate response to exercise

Be aware

Once you take a betablocker it is perfectly normal for your heart rate to drop as low as 35 BPM overnight during sleep. Heart rate monitoring devices like Apple watch will often alarm if the heart rate drops. Providing there is no heart block showing on your regular ECG and you feel fine, there is no need to be concerned about low heart rates at night. Your heart rate response to exercise will be damped

If you are taking too much

If the dose is too high or you are intolerant to beta blockers you will feel less well after day 2, in which case its best to go back to the previous dose you felt fine on, or stop it until advised If you have blackouts or major dizzy spells you should get urgent medical advice and may need to stop the beta blocker

If you are taking too little

If the dose is too low you will notice very little change in your resting heart rate. Only when your pulse rate drops from your normal into the range 45-55 BPM have you reached the effective beta blockade zone.

Once on beta blockers, the normal algorithms used to calculate target heart rate for aerobic exercise are messed up, and cannot be used.

As a guide, exercise to high level to get hot and sweaty, red in face, take your pulse- insead of 150-160 it may only be 90-110 BPM.

Thats your new target heart rate to work to!

[Garthboy]

Thank you for sharing. I am 2 weeks in to taking Bisoprolol 2.5 due to ectopics which have scared me so much. Also taking the beta blocker has took a lot of courage. Been very fit and active I was worried of the affects it might have but this has helped 🙏

[JezzaJezza in reply to Garthboy]

I hated the ectopics but the bisoprolol 2.5 absolutely sorted them. I miss high intensity exercise and HIIT but nowadays I stick to power walks. At flat out walking (8m:30s per km) the most I can get my HR to is 103. My cardiologist is happy for me to go back on the rower (I have a Concept2) but she asks that I keep it to steady state work. I have an Apple Watch for day to day and I also wear a HR chest strap for the rower.

[Garthboy in reply to JezzaJezza]

There awful 😞 how long did it take for beta blockers to faze them out ?

I haven’t been told to not run / train as all my test came back normal ( ecg , echocardiogram, chest X-ray & bloods )

Still don’t know how and why I get them I was getting over 200 a day now I get 10-15 a day !!

[JezzaJezza in reply to Garthboy]

I would say a couple of weeks maximum. I get the odd one now and again. I have an Apple Watch and I use an app called Qaly to interpret the ECGs (really good app).

I was VERY fit and was doing a lot of C2 rowing at the anaerobic threshold. I had mental endurance and VO2 Max. I also realise I was addicted to it and not in a healthy way.

I sometimes wonder if all the exercise caused the SVT and ectopics? But the heart is a fickle thing and after a heart MRI I’m very happy to know that I don’t have any heart disease, my condition is electrical.

[Garthboy in reply to JezzaJezza]

Will look at the app thanks.

I can relate to that I know I am addicted to exercise I am a Pt / martial arts instructor mine came on when I was on holiday thrashing it out in the heat. Been over a year now , my echocardiogram showed a healthy heart but these still freak me out.

Thanks

[Ennasti in reply to Garthboy]

Be aware that beta blockers are only successful in stopping ectopics for some people. I’m not sure what the percentage is but I’d guess about 60%. Ectopics aren’t dangerous so that’s ok but I think people often think a BB will stop them and become even more anxious when they don’t.

[JezzaJezza in reply to Garthboy]

I’ve started practicing meditation using an app called Calm. Wish I’d started it years ago! So incredibly beneficial.

Also when the ectopics are bad try a breathing exercise of :

In for a count of 4

Hold for a count of 4

Exhale for a count of 8

Focus solely on the breath - do that for at least a minute.

[Garthboy in reply to JezzaJezza]

I started a breathing exercise around 4 weeks ago. I definitely agree 👍🏻 will give that a go.

I find my palpitations are also positional I get them when I bend over and squat ?!

When I ask my heart to work fast in clusters then they settle down.

It’s all a guessing game

[AmatureKnitter in reply to Garthboy]

For me, Bisop's ability to stop ectopics depends what's causing them. My experience:

My 2022 burden was 25% - 29k per day. Over the course of a year I was on 7.5mg Bisoprolol and I was still having them, I was given Flecainide too. No underlying pathology found so I figured it was something external to my heart. I had a raft of blood tests revealing extremely low vitamin D and macrocytic anaemia, so I fixed that and my PVCs diminished, I went down to 1.25mg and eventually stopped. 0% burden, just 3-5 PACS/day. I never took the flecainide, I'm waiting until I'm desperate. These drug stop working eventually, I'm only 49, I need headroom in my treatment.

Over the following year I occasionally popped a Bisoprolol when I was stressed. Brilliant, stopped within an hour - like putting thicker oil in a old car engine.

July 2024 saw a massive flare-up, out of the blue. The day after I came home from holiday I was 11%, overnight, brick in a tumble dryer stuff. The thumping pain, ugh. I reached straight for the Bisop, nothing, didn't work. The fatigue at 5mg was overwhelming, I considered the Flecainide, but didn't do it. So I had more bloods done - I'm iron deficient now. Several weeks on 400mg Ferrous sulphate and the Bisop is back in control at 1.25mg. Another month and I'll try stopping the Bisop, my iron should be on the way up by then.

[mczz in reply to AmatureKnitter]

It's amazing how alot of our problems are due to low levels in vitamins and electrolytes and that complete blood tests are not done first. My son 23 was getting palpitations keeping him awake, we insisted on blood tests thinking B vitamins low ,turned out he had Vit D deficiency had a course of vit D and palpitations gone. Thankyou for article ,it's very interesting as I've been on Bisoprolol 5mg for 20 years now. No problems, but if i have a very stressful day and i notice extra beats, i do the breathing exercises and try to eat foods that are calming to the body. Also when I had a stress test my ectopics disappeared with exercise.

[JezzaJezza in reply to mczz]

I’m doing 10K power walks 5 times a week and I feel so much better. It banishes the lethargy, it makes me feel tired later on for proper reasons ie I’ve done exercise, it raises my HR, and it’s great for my heart health and blood pressure.

[mczz in reply to JezzaJezza]

Well done on the power walks ,I try to go out walking too for about an hour, but not always possible, but I feel better for it . Must try harder 🙂

[AmatureKnitter in reply to mczz]

Even when they do the blood tests, as long as results are in range you're told everything's "normal". In range does not mean optimal. I learned by examining my own results, chatting with other arrhythmia sufferers on FaceBook - there's a group of 16k of us, and researching optimal values for vitamins, minerals and electrolytes.

Lab ranges are a massive footprint, outside of which you cease to function - bit late. People struggle when in the lower third of most ranges. The values needed to to support busy lives, regular exercise, and for women a menstrual cycle, is greatly under-estimated.

[mczz in reply to AmatureKnitter]

Yes I agree, as I have found the same. You can be just 1 point in the normal range and they won't tell you to maybe take a certain vit so you don't go any lower. I also check the results myself.

[Garthboy in reply to AmatureKnitter]

Wow sounds interesting. I should maybe start taking vitamin D ? When my ectopics where really bad all 6 blood tests showed everything to be normal?!

Had a tape on for 48 hrs and most of the time my heart was in sinus mode. It did pick up my palpitations though. I am struggling to overcome the anxiety they have left me hence why I have started the beta blocker.

I train 5/6 times a week run 10mile a week also it’s my life and hobby to stay fit and active but these palpitations are taking the enjoyment away.

Thanks for the information

[El-Tel1990 in reply to JezzaJezza]

I’m 63 and on 2.5 Bisoprolol,20mg Atorvastatin and .75mg Aspirin. Gym 3 days per week, Golf 2 days per week and walk most days. I do a good bit of HIIT when in the gym and haven’t encountered any problems. I don’t have Afib but did have a quadruple bypass 4 years ago. Heart rate at rest is consistently around 54/55 bpm. When I exercise hard it can go as high as 140. The medics are happy with that.

[DWizza in reply to El-Tel1990]

Sounds like I’m in similar position , 4x CABG July 2023 following Nstemi. Was fit and strong 🤦🏼 low resting heart rate kept setting hospital alarm off on machine .. started on 3.75mg bisoprolol, went down to 1.25mg quite soon . Annual telecom with consultant and she said I could try coming off altogether 🤷… wondering what to do ..

[AmatureKnitter in reply to DWizza]

Try every other day for a bit, then increase the gap if you feel well, until you feel you can stop altogether. You can always go back to daily if you have a wobble. When I did it, there was a bit of adjustment, baseline heart rate increasing, increasing sensitivity to stress/adrenaline. It can feel weird, but it settles.

[DWizza in reply to AmatureKnitter]

Thank you , I didn’t realise their were side effects to coming off until reading others experiences on this forum. Not sure if it’s beneficial to stay on or come off ..

[AmatureKnitter in reply to El-Tel1990]

You're doing amazingly! Respect.

[RaisCrisp in reply to Garthboy]

Ditto, Garthboy, I was very worried about taking the same drug and dose as you , this article and the answers have helped

[Garthboy in reply to RaisCrisp]

The article is good and Dr Gupta on you tube shares some great reassuring advice about beta blockers and heart conditions.

I am only 2 weeks in and hope to not use them long term I just need to break this cycle as the palpitations have left me with horrible anxiety.

[Kbkk]

Thank you ….. very interesting & useful information .

[phollers]

Thank you for posting this. I have really struggled with bisoprolol over the last two and a half years and this post answers ALL my questions and gives me answers that my cardiologist did not have the time to give me. I make the last statement with no malice what-so-ever, I am eternally grateful to the health professionals that have saved my life on more than one occasion. They simply do not have the bandwidth to do the post life saving support that most of us need. As a result, most of us turn to google which is often not helpful at all, indeed, it is often extremely unhelpful.

I will try out the quicker walking thing today (it’s a stunning warm autumn morning here). I’ve chucked my I watch in the bin because of it constantly telling me I’m about to need urgent help, so I will take my pulse oxymeter with me and do the before, during and after thing. I suspect you are right and I will have a new heart rate target!

Next, can you post useful articles on ramiptil and eplerenone, these two are also difficult to find useful knowledge about!!!?

Thank you again, this was really helpful.

Peter

[jerry12953]

Barely a mention of the side-effects.......😱

[Myshebe in reply to jerry12953]

Hello everyone, just want to say, I had STEMI in 2023,age 61, total shock as eat well, never stood still, active, I was told by hospital that stress was a contributing factor, prescribed betablocker, Bisoprolol 1.25, about a week after starting beta blockers, I felt like I was glued to my seat, couldn't get myself up, felt absolutely wiped out ,giddy spells,mentally I feel very down, my mood is not good,,18 month's later, i am still suffering these side effects,I have discussed this with hosp, when I asked why I even need to take them? I was told , they are prescribed after heart attack, yet my heart is fixed with 2 stents, and hosp said my heart is strong, I am going to have another conversation with Dr, as I do not want to continue taking this drug with these horid side effects...

[jerry12953 in reply to Myshebe]

Stand your ground when you do see your Medic!

[Turkey_33]

thanks so much for posting this … very informative and insightful!… I’m just recovering ❤️‍🩹 from a heart ablation and 3 weeks being taken off beta blockers and channel blockers due to a VE burden percentage that was at 15% which was too high !… I do feel better already , no right chest or palpitations.. I’m now on 1 aspirin a day and taking 1x tablet of Verpalmil .. felt a bit sicky and groggy taking them at first but now seem to have adjusted to them … ECG f-up booked for 3 weeks and a 24hr heart ♥️ monitor to see my results and whether the ablation has been as effective as hoped !.. I cannot wait to start exerting again !! - any tips for when and what I can do ?? Many thx 🙏 😃

[PreciousLife]

Thank you very much for sharing!

[ForestryPine6]

Brilliant Post, Thank You 👍

[nilmonisikdar40]

Hi there, Thanks for sharing the comprehensive information about beta blockers. There is controversy about the dosage of Bisoprolol even among medical professionals . On 14.5.24 I suffered with first time seizures and admitted to ITU. The cause was multifactorial including hyponatremia, right sided pleural effusion, UTI and newly discovered hypertension for which I was put on Bisoprolol 1.25 mg which is a low dose. I have a cardiac pacemaker since February 2000 and improved to Biventricular pacemaker in December 2021. I came home and found the heart rate went low as 44 and even lower when asleep. As you have said beta blocker is a double edged sword. Although I did not have specific symptoms, I was very concerned. The doctor at the other end of NHS 111 said that bradycardia can't be due to beta blocker and he said that cardiologist also believed so. Attended G.P next day , Bisoprolol was stopped and replaced with Losartan 50 mg and since then my pulse rate was within normal limit . My query at this point was NHS 111 doctor was right in saying that my bradycardia was not due to beta blocker and there no harm in persisting with it or my G.P. was right in making a decision to stop it and changing to Losartan which of course is a different class of cardiovascular drug?

[IamMe2]

Interesting read. Thank-you for posting.

[abcom]

Hi, I am having sometimes under 40 heartbeats/min. I am glad that under 40 it is not bradicardia, so I am well too.

[JezzaJezza in reply to abcom]

Hi I’m not being pedantic but strictly speaking it is Bradycardia. Any resting heart rate below 60 is Bradycardia and any resting hr above 100 is tachycardia. The point is that it is the beta blockers that have caused it and that as long as you don’t have symptoms of bradycardia (dizziness, fainting etc) then it’s absolutely fine. Also at nighttime with BB’s the heart can sometimes drop as low as 35 - this is also expected.

Best wishes 🤗

[abcom in reply to JezzaJezza]

What can I do more than explaining and showing what is going on at those moments, please?

[Ersilia2 in reply to JezzaJezza]

Thank you for the post, relief to know that a RHR on BB can be as low as the 30’s , with no symptoms is ok.

[RaisCrisp]

Thank you Jezza. I have just started taking Bisoprolol and am very against drugs due to so many side effects but this is a very helpful article .

[DiyChas]

These heart rate ranges are lower than my cardiologist uses.My HR got above 100 and I was put on 5mg Bisoprolol and HR dropped to ~70 but too much fatigue set. Then lowered Bisoprolol to 2.5mg and HR was ~80 and cardiologist ok'd.

Never indicated the lower rates in your post.

Wondering if age has anything to do with it. I am 79.

[Laurensophie]

very informative post. 👍