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Old 04-16-2018, 06:49 PM
 
Location: SF Bay Area
7,539 posts, read 5,572,485 times
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Quote:
Originally Posted by Travelassie View Post
I've taken a beta blocker ( metoprolol) for many years, began taking ig in 2001 after a nonstop episode of supraventricular tachycardia( with a sustained heart rate a little over 200) landed me in the ER where they stopped it ( or at least slowed it down ) with an adenosine IV. I'd had episodes of SVT since I was a teenager but they were few and far between and had always stopped on their own after a few minutes before this last episode. I was informed that unless I submitted to a cardiac ablation to "cure" the SVT I would have to take the beta blocker to control it for the rest of my life. I refused the ablation and opted for the metoprolol.

I took 100 mg of metoprolol succinate ( generic for Toprol XL) per day for a number of years, then begged and pleaded with the doc to cut it back to 50mg/day, which he did, but added a calcium channel blocker to control my blood pressure better, as well as the SVT. I recall being tired as a side effect of the beta blocker, and I know it slowed my heart rate, but I wasn't aware of the heart rate being too low. It did a great job at keeping the SVT at bay, I had very few breakthrough tachycardic episodes- unless I forgot to take the meds. The same meds kept my blood pressure under control.

Fast forward about 14 yrs, on those same meds, I had another sudden episode of tachycardia, assumed it was SVT, after several hours when it wouldn't stop I went to the ER, where they caught about the last 15-20 minutes of the episode on an EKG before it slowed down and resumed a normal sinus rhythm. They all told me what they saw on that EKG was atrial flutter, which they group in with a-fib. I assumed they'd send me home, but they insisted I be admitted to the telemetry unit and see a cardiologist, so that is what happened.

The cardiologist I saw changed two of the medications I was taking, the metoprolol succinate ( long acting) to metoprolol tartrate ( shorter acting, taken twice a day, still 50 mg/day), and the losartan hctz to plain losartan, he said I didn't need a diuretic. He also said the shorter acting metoprolol was more effective in controlling the heart rate than the longer acting as the metoprolol succinate taken once a day tendef to "peter out" after 12 hours.

I noticed the metoprolol tartrate ( I took 1/2 of a 50 mg tab twice daily) had more of an effect on my heart rate than the metoprolol ER had, and there were times about an hour or two after I took it it did dip into the high 40's, but it didn't stay there. It also made me feel somewhat tired, but I got used to it within a few weeks. I believe when I checked my heart rate after that few weeks it was often in the high 50's, but I was also taking a calcium channel blocker ( a drug called Matzim LA, which is a substitute generic for Cardizem LA), which also acts to slow the heart rate, so I imagine there was a combined effect of those two drugs.

I continued on that combination for over a year, and noticed after I got a watch that tracked my heart rate that the resting heart rate would dip into the 40's, even the 30's at times, even during the day, and I'd feel pretty wonky at times. Again, those heart rates wouldn't stay there, they would go back into the 50's, 60's with activity.

I discussed this low heart rate with the cardiologist during a visit, and he noted that my blood pressure taken at the office was also low, he assumed this was due to the combination of the metoprolol and calcium channel blocker, and instructed me to stop taking the calcium channel blocker. He informed me that my heart rate would go up, perhaps I'd need more metoprolol to control the tachycardia, and to let him know if I needed more.

Well, the slow resting heart rate continued, not every day but pretty often, and after a couple more months I started having frequent episodes of what turned out to be more SVT and long runs of PVC bigeminy. Interestingly enough, my heart rate didn't go that low when I was having the arrthymias, but it would on a "good day"when I wasn't having any. These went on for several months till I finally cried uncle and contacted the cardiologists office.

The cardiologist increased the dose of metoprolol tartrate from 50 mg/day to 150 mg/day, with the option of increasing even further to 200 mg/day to suppress these arrthymias, and while I was leary of taking more beta blocker with the low heart rate I'd had at 50 mg/day, but I was so miserable with the arrthymias I'd have eaten cow patties at that point if that would get rid of them.

So it's now been about two months since I've been on 150 mg/day ( that's 75 mg in two doses) of metoprolol, and I definitely felt the side effects-feeling basically like I spent my day slogging through mud, no energy and low heart rate that would go as low as the low 30's, and on occasion into the 20's , but again it would climb back up into the 50's, 60's with sustained activity, although it seems to hang out in the 40's frequently at rest. I've gotten more used to the meds, I think, and interestingly enough don't feel all that bad even witb the low heart rate. I've checked my blood pressure during those low heart rates and it's not low, and the pulse oximeter (guess we're a family of techy nerd hypochondriacs here, LOL) shows O2 levels i the high 90's, so I have to assume even with the low heart rate the perfusion is ok. And even with some side effects, I still feel so much better with the SVT and other miseries more or less under control, and know they'd come right back without the meds (there is some breakthrough even with it), I'm willing to put up with some side effects. I will get the cardiologist's take on the low heart rate at my next visit, however.

It's a good idea, as you have mentioned, to discuss your low heart rate on the beta blockers with your doctor, he/she should know they're occurring, and can either reassure you that this is harmless, or can adjust your medication, whatever is indicated.
Wow! Thank you so much for this thoughtful and thorough response. You certainly put some work into this and I much appreciate it!

My case seems pretty mild and tame compared to what you've been through. But I've had episodes of arrhythmia (PVCs technically, I believe) that scare me to death. I don't care how harmless lots of different sources say they are, they (combined with bouts of very HBP and heart rate) have sent me into panic attacks on several occasions and I spent this last weekend in the hospital following another episode on Saturday.

Long story short, I'm doing fine, they say.....after an echo-cardiogram and another EKG. But they wanted me off the edarbyclor because its strong diuretic component lowered my sodium and potassium levels a little too much for comfort. I had long felt that I was probably a good candidate for a beta blocker, though I really wanted no part of them with their inherent downsides. But they agreed....it was time to start a beta blocker after these repeated episodes of PVCs/panic and my propensity for adrenaline-driven strong reactions to certain stresses. Hopefully I won't see the inside of the ER again any time soon. (Never would be nice! )

So it would seem that the heart rates in the high 40s I've seen are nothing at all to worry about. I hope they don't go lower. 30s would freak me out, justified or not.

I had been thinking that I would be more comfortable starting out on the lower 25mg dosage and see how that goes before any increase. Funny that the doc at the hospital had second thoughts about that as well, because I got a phone call earlier today saying that she wanted to cut the dosage to 25 and sent over a new prescription for that. She insisted that I don't split the 50 mg pills, though they are scored for splitting and the pharmacist said there was no problem with splitting that drug. I'm guessing she just doubts the ability of her patients to do the splitting competently. But I have an excellent pill splitter for just that purpose. I got the new prescription, but I'll split the 50s later if my dosage doesn't need to increase.

Best of luck to you and thanks again for that most helpful response.

Last edited by CrownVic95; 04-16-2018 at 07:26 PM.. Reason: added missing word
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Old 04-16-2018, 09:13 PM
 
Location: SW Florida
9,055 posts, read 6,233,292 times
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Quote:
Originally Posted by CrownVic95 View Post
Wow! Thank you so much for this thoughtful and thorough response. You certainly put some work into this and I much appreciate it!

My case seems pretty mild and tame compared to what you've been through. But I've had episodes of arrhythmia (PVCs technically, I believe) that scare me to death. I don't care how harmless lots of different sources say they are, they (combined with bouts of very HBP and heart rate) have sent me into panic attacks on several occasions and I spent this last weekend in the hospital following another episode on Saturday.

Long story short, I'm doing fine, they say.....after an echo-cardiogram and another EKG. But they wanted me off the edarbyclor because its strong diuretic component lowered my sodium and potassium levels a little too much for comfort. I had long felt that I was probably a good candidate for a beta blocker, though I really wanted no part of them with their inherent downsides. But they agreed....it was time to start a beta blocker after these repeated episodes of PVCs/panic and my propensity for adrenaline-driven strong reactions to certain stresses. Hopefully I won't see the inside of the ER again any time soon. (Never would be nice! )

So it would seem that the heart rates in the high 40s I've seen are nothing at all to worry about. I hope they don't go lower. 30s would freak me out, justified or not.

I had been thinking that I would be more comfortable starting out on the lower 25mg dosage and see how that goes before any increase. Funny that the doc at the hospital had second thoughts about that as well, because I got a phone call earlier today saying that she wanted to cut the dosage to 25 and sent over a new prescription for that. She insisted that I don't split the 50 mg pills, though they are scored for splitting and the pharmacist said there was no problem with splitting that drug. I'm guessing she just doubts the ability of her patients to do the splitting competently. But I have an excellent pill splitter for just that purpose. I got the new prescription, but I'll split the 50s later if my dosage doesn't need to increase.

Best of luck to you and thanks again for that most helpful response.
I'm glad to hear you're doing better now, hope whatever meds you end up on do a good job at keeping your hypertension and heart rates under control!

Sounds like it was a good idea for your docs to stop the med with the diuretic in it, these can put your electrolytes out of whack, lowering your potassium and magnesium levels, and this can contribute to those PVC's. I know those are miserable, especially if they're frequent, although they generally say they're benign if your heart is structurally healthy. They will treat them even so, if they make someone's life miserable.

I don't know that a heart rate in the 40's is either good or bad, I'd also say your pharmacist is probably right that it's ok if you aren't feeling any lightheadedness, excessive tiredness or shortness of breath, and I'd add if your heart rate goes up with activity. You also may not realize that the heart rate normally goes down during sleep, and a rate in the 40's wouldn't be a big deal at that time. Still, it'd be a good idea to talk it over with your doctor. If your metoprolol is decreased to 25 mg/day that may well take care of your low heart rate.

I agree about a heart rate in the 30's being unsettling. I'm less than thrilled when I see those numbers on my watch, and realize my heart rate is pretty low, although most of the time it doesn't stay there too long, or it roams up and down between the 30's and 50's. And sometimes out of the % $#@&% blue it jumps up to 160-with no increased activity on my part, that's probably a breakthrough of an SVT episode. Or there's a pause or two and it's low again, not sure if that is a PVC ( plain or fancy) or whether all this is even that related to the metoprolol or is just my wierd cardiac electrical system.

About your doc not wanting you to split your pills-IIRC from your first post you mentioned taking 50 mg metoprolol ER- ( metoprolol succinate), which is the extended release tablet intended to be taken once a day. I had understood that extended release pills in general were not supposed to be split, but taken whole. I know metoprolol succinate tabs are scored, and especially if a pharmacist said it was ok to split it probably is ok to do so. But that may be the reason your doctor sent you a second prescription instead of just instructing you to split the 50 mg pills.

I do split the metoprolol tartrate pills I take, I have 50 mg pills, take 11/2 tablets twice a day. The evening dose does lower my heart, and makes me sleepy, but interestingly enough when I see the night's heart rates on my watch/ phone they're no lower than the resting rates during the day. So I'm not worried that the lights will go out for good, if you know what I mean.

In any case, best of luck and good health to you.
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Old 07-28-2018, 08:35 AM
 
Location: Mid-Atlantic east coast
5,106 posts, read 9,343,250 times
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Update--I'm now taking lisinopril and generic form of Norvasc-- Amlopine). That combo is doing a great job of lowering my blood pressure..however! (and with blood pressure meds, there always seems to be a "however," doesn't there?)

I'm now having ankle edema. This is annoying and not attractive, but I'm not sure how dire it is medically to have this? It goes away at night, gets progressively puffy during the day.

My Doc is now talking about switching me to another med such as Bystolic (but it costs $130/month and is another calcium channel blocker. Quite confused as the Bystolic also lists leg edema as a possible symptom. My Doc says the B. is a different class of calcium-channel blocker than the Norvasc...

I know I should discuss this with my doctor, and I do try, but she spends our visits mostly tap, tapping away on the medical data base she uses and doesn't have much conversation with me (she's a nurse-practioner). Seems to be all about the meds...

I'll ask a question and she goes tap, tapping away again without a straight answer. I've had great nurse practioners in the past but that office closed...

Anyhow, I'm confused bout switching to another CCB like the Bystolic..
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Old 07-28-2018, 08:50 AM
 
Location: SF Bay Area
7,539 posts, read 5,572,485 times
Reputation: 7397
Quote:
Originally Posted by LittleDolphin View Post
Update--I'm now taking lisinopril and generic form of Norvasc-- Amlopine). That combo is doing a great job of lowering my blood pressure..however! (and with blood pressure meds, there always seems to be a "however," doesn't there?)

I'm now having ankle edema. This is annoying and not attractive, but I'm not sure how dire it is medically to have this? It goes away at night, gets progressively puffy during the day.

My Doc is now talking about switching me to another med such as Bystolic (but it costs $130/month and is another calcium channel blocker. Quite confused as the Bystolic also lists leg edema as a possible symptom. My Doc says the B. is a different class of calcium-channel blocker than the Norvasc...

I know I should discuss this with my doctor, and I do try, but she spends our visits mostly tap, tapping away on the medical data base she uses and doesn't have much conversation with me (she's a nurse-practioner). Seems to be all about the meds...

I'll ask a question and she goes tap, tapping away again without a straight answer. I've had great nurse practioners in the past but that office closed...

Anyhow, I'm confused bout switching to another CCB like the Bystolic..
Good Morning. Blood pressure drugs are sure a pain aren't they?

Bystolic is not a CCB....it is another beta blocker. Can you just drop the Amlodipine causing the edema?
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Old 07-28-2018, 09:29 AM
 
Location: Mid-Atlantic east coast
5,106 posts, read 9,343,250 times
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Quote:
Originally Posted by CrownVic95 View Post
Good Morning. Blood pressure drugs are sure a pain aren't they?

Bystolic is not a CCB....it is another beta blocker. Can you just drop the Amlodipine causing the edema?
Yes, you are so right -- BP meds are a pain -- and confusing. Each of us has different reactions/side effects to the same med. I understand why Docs have to try this and that...

I was wondering the same thing re dropping the Amlodipine...but the current dosage of Lisinopril (20 mg) alone wasn't lowering BP enough, nor was taking it with HCTZ (12.5 mg.) Thus adding the Amlodipine to the mix. (no more HCTZ).

Maybe I'll try taking 20 mg Lisinopril 2x a day and see what happens...?
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Old 07-28-2018, 09:31 AM
 
Location: SF Bay Area
7,539 posts, read 5,572,485 times
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One more word to the wise on beta blockers, as I have learned a lot - most of it the hard way - since I had last posted here in April.

Beta blockers can be very dangerous to those with slow heart rates....especially if you are prone to vagal parasympathetic responses as I am. You could wind up with a vagal afib episode as I did on July 2nd, sending me to the ER for the third time in less than 3 months. For me, it was the combination of a slow heart rate, Metoprolol slowing it even more, and dozing off lying on my left side right after eating - which for me significantly increases vagal pressures as well as direct abdominal pressures on my heart.

I woke up abruptly to the feeling of my heart going crazy and it obviously scared me to death. I came back to normal sinus rhythm within a couple hours at the ER using medication only and I have been fine ever since. I knock on wood every hour of every day. Never want to go through anything like that again.

I have dropped the beta blocker as it is just too dangerous for me, despite my otherwise being a good candidate for it. And I have trained myself to never roll over to my left side and never lie down soon after eating. So far it has worked (fingers crossed).

Here is an excellent video explaining vagal afib and how beta blockers are contraindicated for it.


https://www.youtube.com/watch?v=ivof8UUKW3M
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Old 07-28-2018, 09:37 AM
 
Location: SF Bay Area
7,539 posts, read 5,572,485 times
Reputation: 7397
Quote:
Originally Posted by LittleDolphin View Post
Yes, you are so right -- BP meds are a pain -- and confusing. Each of us has different reactions/side effects to the same med. I understand why Docs have to try this and that...

I was wondering the same thing re dropping the Amlodipine...but the current dosage of Lisinopril (20 mg) alone wasn't lowering BP enough, nor was taking it with HCTZ (12.5 mg.) Thus adding the Amlodipine to the mix. (no more HCTZ).

Maybe I'll try taking 20 mg Lisinopril 2x a day and see what happens...?
As of last August, you reported that you were on a beta blocker. What happened with that?
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Old 07-28-2018, 09:59 AM
 
Location: Mid-Atlantic east coast
5,106 posts, read 9,343,250 times
Reputation: 9396
Quote:
Originally Posted by CrownVic95 View Post
As of last August, you reported that you were on a beta blocker. What happened with that?
Didn't work out...couldn't take being outside in the heat (even if it wasn't very warm) -- poured sweat..Doc wasn't sure hit was HCTZ or BB...took me off both and put me on the Norvasc CCB along with the ACE...
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Old 07-28-2018, 10:24 AM
 
Location: SF Bay Area
7,539 posts, read 5,572,485 times
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Quote:
Originally Posted by LittleDolphin View Post
Didn't work out...couldn't take being outside in the heat (even if it wasn't very warm) -- poured sweat..Doc wasn't sure hit was HCTZ or BB...took me off both and put me on the Norvasc CCB along with the ACE...
Well, I'm not sure doubling your Lisinopril dose will do you much good - you could try it, though. I know much more about the ARBs than I do about ACE inhibitors. Lisinopril is an ACE inhibitor and there are several other drugs in that family available. Some might be more effective for you than others.

Among the ARBs, which do the same thing but with a different mechanism of action, there is a wide range of strengths available. I just started on Telmisartan yesterday, as a result of the Valsartan recall. I used Edarbi samples for 10 days before that and was disappointed. It is the newest of the ARBs and is touted to be the most effective in lowering BP. But for me it didn't work as well as Valsartan, plus I didn't like the way I felt while on it.

Too soon to tell yet with Telmisartan how well it will work or me. But it is supposed to be stronger than Valsartan.

Of one thing I'm very sure, though. The ARBs as a class come with the least side effects of any of the BP drugs. I had none whatsoever with Valsartan. The only thing you have to worry about is your potassium getting too high - no other concerns for most people.
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Old 07-28-2018, 12:13 PM
 
Location: SW Florida
9,055 posts, read 6,233,292 times
Reputation: 12507
Quote:
Originally Posted by LittleDolphin View Post
Update--I'm now taking lisinopril and generic form of Norvasc-- Amlopine). That combo is doing a great job of lowering my blood pressure..however! (and with blood pressure meds, there always seems to be a "however," doesn't there?)

I'm now having ankle edema. This is annoying and not attractive, but I'm not sure how dire it is medically to have this? It goes away at night, gets progressively puffy during the day.

My Doc is now talking about switching me to another med such as Bystolic (but it costs $130/month and is another calcium channel blocker. Quite confused as the Bystolic also lists leg edema as a possible symptom. My Doc says the B. is a different class of calcium-channel blocker than the Norvasc...

I know I should discuss this with my doctor, and I do try, but she spends our visits mostly tap, tapping away on the medical data base she uses and doesn't have much conversation with me (she's a nurse-practioner). Seems to be all about the meds...

I'll ask a question and she goes tap, tapping away again without a straight answer. I've had great nurse practioners in the past but that office closed...

Anyhow, I'm confused bout switching to another CCB like the Bystolic..

Confusing, that's for sure.


As you're discovering, there are a number of different classes of drugs used to lower and control high blood pressure, and there are debates, studies, disagreements, you name it as to which is the best one for this purposes. I guess the conclusion would have to be that the best drug, or combination of drugs varies depending on the individual patient, considering the effectiveness in controlling the blood pressure, the side effects, and the cost over the long haul. It's a process of trial and error, sometimes trying different drugs, drug combinations over time till the one that works the best is found. It sounds as though this is the process you are going through at this time.


That said, as Crown Vic mentioned, Bystolic is a beta-blocker, and while the ankle/foot swelling is listed as a possible side effect of this drug, so it can happen, I'd hazard a guess that it's the amlodipine you're taking that is responsible for the ankle swelling you're experiencing.


Beta Blocker Medication


https://www.healthline.com/health/am...ne/oral-tablet



The amlodipine literature lists ankle/foot edema (swelling) first on their list of side effects, and I'm told it's very common. My husband was prescribed amlodipine for high blood pressure a few years ago, and had severe swelling, redness on his feet, ankles and legs, but he didn't make the connection to the amlodipine, at least not at first. He thought it must be venous insufficiency so when it didn't improve he went to a vascular surgeon about it. She did an ultrasound of the area, informed him that the blood vessels were fine, and asked him about his medication. She told him that likely it was the amlodipine causing the problem, and that he needed to contract his prescribing doc and stop taking it.


He is now taking lisinopril and triamterene ( a potassium sparing diuretic used to control blood pressure and other cardiac conditions), as well as a prescription strength potassium tablet. The swelling and redness in his legs, ankles and feet went away when he stopped the amlodipine, and it's never come back. His blood pressure is good and he doesn't seem to have any side effects from these drugs.


https://medlineplus.gov/druginfo/meds/a682337.html


As for your ankle swelling, hopefully it's a minor issue and won't get any worse ( and it might get better) if not perhaps you can live with it considering it's a tradeoff for good blood pressure control. That's a decision only you can make with the input of your provider- she should be made aware of it, as well as any other side effects you have. You should have input, though, as to what you're willing to live with, as well as matters of cost for your medication.



If your provider thinks a beta blocker would be a good medication for you, she must be aware that there are a number of generic beta blockers out there that are effective and don't cost a lot. Perhaps you can inform her ( as I know a number of people have done) that a brand name medication is too expensive for you to pay for on a long haul, and ask for a generic beta blocker instead. I guess I've been lucky in that the docs prescribing meds for me have gone the generic route, so I know they don't always go for the fancy and most expensive.


In any case, good luck with the process, you'll get there.
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