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Suggest Treatment For Hypertension And Fast Heart Rate
Question: My age is 62. I have moderate hypertension and a fast heart rate. When not on a beta blocker my resting heart rate goes over 110. Note, I always have sinus rhythm and heart functions check out OK (had complete checkout at Mayo clinic including stress test this Spring). With resting heart rates over 80 it saps my energy and I spend many afternoons on the couch. Was doing great on Nadolol for 5+ years, heart rate 60-70, BP normal, had plenty of energy. Then about 1.5 years ago started getting Raynauds, especially in my feet and some in fingers & nose. Lead to stinging pains in feet. I worried about diabetic nerve pain, but they say no, since my glucose is always 95-100.
They recently switched me from Nadolol to Verapamil. Works for BP, but it only lowers HR to about 90-100. The Verapamil is improving the circulation in my feet as they feel warmer, and as a side benefit it has helped my colitis! I now only have 1 BM per day, something that has not happened with me for many years. BUT, now after a few weeks on Verapamil I have developed an all body rash and swelling of face especially around lips. Went to doctor yesterday and they put me on prednisone to see if the rash will go away. As of yet, don't know if I will be able to stay on the Verapamil.
I can't keep living with the fast heart rate because it makes me exhausted by mid afternoon. I Wanted to try the combination of an ARB such as Losartan along with ivabradine to slow the heart, but local doctors are not willing. They say it would be an off label use for ivabradine at this time. Pretty sad because its used around the world to slow heart rate.
1. Do you think I will be forced to go back on a beta blocker to slow my heart rate?.
2. Which BB will slow the heart rate the most? (from my resaerch I'm thinking Zebeta)
3. Assuming the rash goes away and I can stay on Verapamil, can I use a combination of Verapamil and Zebeta so as to further lower the heart rate?
4. Is there some other solution you know of that I should consider???
Thank you very much for your consideration. XXXX
They recently switched me from Nadolol to Verapamil. Works for BP, but it only lowers HR to about 90-100. The Verapamil is improving the circulation in my feet as they feel warmer, and as a side benefit it has helped my colitis! I now only have 1 BM per day, something that has not happened with me for many years. BUT, now after a few weeks on Verapamil I have developed an all body rash and swelling of face especially around lips. Went to doctor yesterday and they put me on prednisone to see if the rash will go away. As of yet, don't know if I will be able to stay on the Verapamil.
I can't keep living with the fast heart rate because it makes me exhausted by mid afternoon. I Wanted to try the combination of an ARB such as Losartan along with ivabradine to slow the heart, but local doctors are not willing. They say it would be an off label use for ivabradine at this time. Pretty sad because its used around the world to slow heart rate.
1. Do you think I will be forced to go back on a beta blocker to slow my heart rate?.
2. Which BB will slow the heart rate the most? (from my resaerch I'm thinking Zebeta)
3. Assuming the rash goes away and I can stay on Verapamil, can I use a combination of Verapamil and Zebeta so as to further lower the heart rate?
4. Is there some other solution you know of that I should consider???
Thank you very much for your consideration. XXXX
Brief Answer:
I would recommend as follows:
Detailed Answer:
Hello XXXX!
Thank you for asking on HCM!
I passed carefully through your medical history, and would like to explain as follows:
(1) The most important clue to control your racing heart rate is to identify the right triggering factors of this HR exacerbation.If an etiological treatment is properly instituted, then several heart rate controlling therapeutic options would be acceptable ( respecting first their safety profile). Beta-blockers seem to have provoked an important adverse affect (Raynauds phenomenon which is encountered in about 50% of beta-blockers use). If a alternative beta-blocker would be tried, I would recommend a try of those with intrinsic sympathomimetic activity, such as Oxprenolol, Acebutolol, Carvedilol, etc, that have been shown less active regarding Raynauds exacerbation. In my opinion, I would be vey reserved to try beta-blockers again.
(2) If we would not be restricted to Raynaulds, I would mentioned some beta-blockers wit himportant negative chronotropic effects, like Atenolol, Bisoprolol, etc.
(3) Combination of Verapamil and Zebeta would be a potent alternative to lower your increased heart rate, but I am afraid of any excessive dangerous bradycardia. You should discuss with your doctor t o find an appropriate dose adjusted combination.
(4) My only advice in all this story is to carefully check thyroid function level, as it may be an important source of your persistent tachycardia (facing the fact, you are being treated with thyroid hormone supplements. Probably a dose adjustment is necessary. You should talk with your doctor about this issue (IMPORTANT). .
Hope to have been helpful!
Feel free to ask me whenever you need. Greetings! Dr. Iliri
I would recommend as follows:
Detailed Answer:
Hello XXXX!
Thank you for asking on HCM!
I passed carefully through your medical history, and would like to explain as follows:
(1) The most important clue to control your racing heart rate is to identify the right triggering factors of this HR exacerbation.If an etiological treatment is properly instituted, then several heart rate controlling therapeutic options would be acceptable ( respecting first their safety profile). Beta-blockers seem to have provoked an important adverse affect (Raynauds phenomenon which is encountered in about 50% of beta-blockers use). If a alternative beta-blocker would be tried, I would recommend a try of those with intrinsic sympathomimetic activity, such as Oxprenolol, Acebutolol, Carvedilol, etc, that have been shown less active regarding Raynauds exacerbation. In my opinion, I would be vey reserved to try beta-blockers again.
(2) If we would not be restricted to Raynaulds, I would mentioned some beta-blockers wit himportant negative chronotropic effects, like Atenolol, Bisoprolol, etc.
(3) Combination of Verapamil and Zebeta would be a potent alternative to lower your increased heart rate, but I am afraid of any excessive dangerous bradycardia. You should discuss with your doctor t o find an appropriate dose adjusted combination.
(4) My only advice in all this story is to carefully check thyroid function level, as it may be an important source of your persistent tachycardia (facing the fact, you are being treated with thyroid hormone supplements. Probably a dose adjustment is necessary. You should talk with your doctor about this issue (IMPORTANT). .
Hope to have been helpful!
Feel free to ask me whenever you need. Greetings! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you.
Yes we have kept close eye on thyroid. Mine was nuked with I-131 back in 1996, and it is dead. Surviving on synthroid. We check free T3, free T4, and TSH twice a year. They stay in range at 150mcg synthroid.
The Verapamil seems to only lower my resting HR from 110+ to between 90-100.
So..............
You mentioned Oxprenolol, Acebutolol, Carvedilol. Would one of these be an alternative to Verapamil or added with Verapamil?
Which one would be most effective to treat both the Raynauds and fast heart rate at the same time?
Much relies on whether I have to get off the Verapamil (if the rash goes away). How about giving me a plan of action for two scenarios to lower my heart rate:
1. With Verapamil.
2. Without Verapamil.
Note: I haven't mentioned my BP much because it seems as though just about any combination of meds works fine for keeping my BP down, its the fast HR thats really getting me down.
Thank you, XXXXXXX
Yes we have kept close eye on thyroid. Mine was nuked with I-131 back in 1996, and it is dead. Surviving on synthroid. We check free T3, free T4, and TSH twice a year. They stay in range at 150mcg synthroid.
The Verapamil seems to only lower my resting HR from 110+ to between 90-100.
So..............
You mentioned Oxprenolol, Acebutolol, Carvedilol. Would one of these be an alternative to Verapamil or added with Verapamil?
Which one would be most effective to treat both the Raynauds and fast heart rate at the same time?
Much relies on whether I have to get off the Verapamil (if the rash goes away). How about giving me a plan of action for two scenarios to lower my heart rate:
1. With Verapamil.
2. Without Verapamil.
Note: I haven't mentioned my BP much because it seems as though just about any combination of meds works fine for keeping my BP down, its the fast HR thats really getting me down.
Thank you, XXXXXXX
Brief Answer:
Carvedilol would be a safe option.
Detailed Answer:
Hello again dear XXXX!
I am totally trusting thyroid function follow ups, but i repeatedly insist to explore the possible cause of sinus tachycardia, as that is the Achilles heel for controlling the situation.
As you have a history of occasional night sweats and chronic morning cough, I would encourage (besides other body systems), to explore pulmonary function by means of (1) a respiratory function test and (2) arterial blood gas analysis.
Regarding beta-blockers option, I would recommend Carvedilol as it has shown a safer profile regarding Raynaud's (in a study of more than 19000 patients taking Carvedilol, Raynaud's phenomenon was shown only in 4 patient).
A combination of a beta-blocker (ex. Carvedilol) and Verapamil would be useful to avoid adverse effects of each component, by lowering both doses.
I am not giving you exact doses when a beta-blocker is used alone or in combination with Verapamil, as it should be decide by your attending doctor (it would be non-ethical by my side, and beside it is not allowed by general principles of this medical site). I strongly recommend to discuss with your doctor for the above mentioned suggestions.
Hope to have been helpful for you!
Best regards! Dr. Iliri
Carvedilol would be a safe option.
Detailed Answer:
Hello again dear XXXX!
I am totally trusting thyroid function follow ups, but i repeatedly insist to explore the possible cause of sinus tachycardia, as that is the Achilles heel for controlling the situation.
As you have a history of occasional night sweats and chronic morning cough, I would encourage (besides other body systems), to explore pulmonary function by means of (1) a respiratory function test and (2) arterial blood gas analysis.
Regarding beta-blockers option, I would recommend Carvedilol as it has shown a safer profile regarding Raynaud's (in a study of more than 19000 patients taking Carvedilol, Raynaud's phenomenon was shown only in 4 patient).
A combination of a beta-blocker (ex. Carvedilol) and Verapamil would be useful to avoid adverse effects of each component, by lowering both doses.
I am not giving you exact doses when a beta-blocker is used alone or in combination with Verapamil, as it should be decide by your attending doctor (it would be non-ethical by my side, and beside it is not allowed by general principles of this medical site). I strongly recommend to discuss with your doctor for the above mentioned suggestions.
Hope to have been helpful for you!
Best regards! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I believe we are honing in on a potential solution for me to suggest to my physician. First I would like your opinion on this. I'm a little confused when reading the clinical pharmacology on Acebutolol. It appears that it spares restriction of the peripheral arteries. Here is a quote from Rxlist:
"The β1-selectivity of Sectral (acebutolol) has also been demonstrated on the basis of the following vascular and bronchial effects: Vascular Effects: Sectral (acebutolol) has less antagonistic effects on peripheral vascular β2-receptors at rest and after epinephrine stimulation than nonselective β-antagonists."
1. Does this mean that Acebutolol would be similar to Carvedilol in helping avoid the Raynauds symptoms?
2. Comparing Acebutolol to Carvedilol, which would have the greatest heart rate lowering potential?
Thank you!
"The β1-selectivity of Sectral (acebutolol) has also been demonstrated on the basis of the following vascular and bronchial effects: Vascular Effects: Sectral (acebutolol) has less antagonistic effects on peripheral vascular β2-receptors at rest and after epinephrine stimulation than nonselective β-antagonists."
1. Does this mean that Acebutolol would be similar to Carvedilol in helping avoid the Raynauds symptoms?
2. Comparing Acebutolol to Carvedilol, which would have the greatest heart rate lowering potential?
Thank you!
Brief Answer:
I would explain as follows:
Detailed Answer:
Dear XXXX!
All beta-blockers that I mentioned above are acceptable options.
Both Acebutolol and Carvedilol have intrinsic sympathomimetic activity.
From my personal view, I would prefer Carvedilol, as its safety is more extensively studied.
It has also alpha-receptor blocking activity, and at higher doses exerts also calcium channel blocker properties (like Verapamil).
Nevertheless, it remains on your attending doctor's discretion to make the right decision.
Hope to have been helpful to you, and to have fulfilled your expectations.
Have a nice weekend! Dr. Iliri
I would explain as follows:
Detailed Answer:
Dear XXXX!
All beta-blockers that I mentioned above are acceptable options.
Both Acebutolol and Carvedilol have intrinsic sympathomimetic activity.
From my personal view, I would prefer Carvedilol, as its safety is more extensively studied.
It has also alpha-receptor blocking activity, and at higher doses exerts also calcium channel blocker properties (like Verapamil).
Nevertheless, it remains on your attending doctor's discretion to make the right decision.
Hope to have been helpful to you, and to have fulfilled your expectations.
Have a nice weekend! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I think we are making good progress. You did not say which one (Acebutolol vs. Carvedilol) would give the greatest reduction in HR, but based on your responses and the situation I am in right now with the reaction (rash) from Verapamil, you have helped me hone in on the following plans of action:
Case A - If my rash goes away and I do not have to quit the Verapamil:
1. Stay on a low dose of Verapamil and add Carvedilol slowly until resting HR gets reasonable (60-75 bpm).
2. If HR won't get reasonable, try Bisoprolol instead of Carvedilol with the Verapamil.
Case B: If I can't stay on Verapamil due to continued bad reaction to it:
1. Use a combination of Losartan (for the Raynauds) and Carvedilol (for HR) adjusting the dose of each until HR and BP are reasonable.
2. If HR won't get reasonable, use a combination of Losartan and Bisoprolol adjusting the dose of each until HR and BP are reasonable.
Do you agree with my plans? I would really like to get then nailed down for when I go to my doctor next week. So, any help would be greatly appreciated.
Note: I am assuming that Bisoprolol will have a much greater HR reducing effect than either Carvedilol or Acebutolol. Was I correct on that?
Case A - If my rash goes away and I do not have to quit the Verapamil:
1. Stay on a low dose of Verapamil and add Carvedilol slowly until resting HR gets reasonable (60-75 bpm).
2. If HR won't get reasonable, try Bisoprolol instead of Carvedilol with the Verapamil.
Case B: If I can't stay on Verapamil due to continued bad reaction to it:
1. Use a combination of Losartan (for the Raynauds) and Carvedilol (for HR) adjusting the dose of each until HR and BP are reasonable.
2. If HR won't get reasonable, use a combination of Losartan and Bisoprolol adjusting the dose of each until HR and BP are reasonable.
Do you agree with my plans? I would really like to get then nailed down for when I go to my doctor next week. So, any help would be greatly appreciated.
Note: I am assuming that Bisoprolol will have a much greater HR reducing effect than either Carvedilol or Acebutolol. Was I correct on that?
Brief Answer:
Hope this could be helpful.
Detailed Answer:
Dear XXXX!
You are quite right on suggesting those reasonable alternatives. I would not make any changes form your written lines.
As I declared above, it depends on your doctor's discretion to make the right decision for you.
We are not trying to find the more potent HR lowering beta-blocker for you (as could be Atenolol, etc), but the safest option (facing you have Raynaud;s and rash).
I assure you that the best beta-blocker would be one with intrinsic sympathomimetic activity properties like Acebutolol, Oxprenolol, that may lower your resting HR, but do not compromise your exercise HR and overall performance.
Or Carvedilol which has several additional beneficial effects.
Regarding Bisoprolol, I don't think it is the best option when dealing with Raynaud's phenomenon.
Regards! Dr. Iliri
Hope this could be helpful.
Detailed Answer:
Dear XXXX!
You are quite right on suggesting those reasonable alternatives. I would not make any changes form your written lines.
As I declared above, it depends on your doctor's discretion to make the right decision for you.
We are not trying to find the more potent HR lowering beta-blocker for you (as could be Atenolol, etc), but the safest option (facing you have Raynaud;s and rash).
I assure you that the best beta-blocker would be one with intrinsic sympathomimetic activity properties like Acebutolol, Oxprenolol, that may lower your resting HR, but do not compromise your exercise HR and overall performance.
Or Carvedilol which has several additional beneficial effects.
Regarding Bisoprolol, I don't think it is the best option when dealing with Raynaud's phenomenon.
Regards! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. Based on your help, I am going to remove Bisoprolol from my list for now.
I can see that you highly value the ISA properties of the Beta Blocker for my situation. Please take a look at the chart on this website: http://www.medscape.org/viewarticle/420880_2
Notice the neutral ISA rating of (0) for Carvedilol, (+) for Acebutolol, and (+++) for Pindolol.
From your previous responses I think you feel that Carvedilol, even though it is neutral for ISA on the chart, would be good for reversing my Raynaud's symptoms, probably because of the alpha blocking component?
I need to know if the (+) for Acebutolol or the (+++) for Pindolol would put one of them above the alpha blocking of Carvedilol for my situation?
I hope you don't mind me pushing you on this, but I want to ask my physician the absolute least number of times for changes to my meds.
Thanks again, XXXXXXX
I can see that you highly value the ISA properties of the Beta Blocker for my situation. Please take a look at the chart on this website: http://www.medscape.org/viewarticle/420880_2
Notice the neutral ISA rating of (0) for Carvedilol, (+) for Acebutolol, and (+++) for Pindolol.
From your previous responses I think you feel that Carvedilol, even though it is neutral for ISA on the chart, would be good for reversing my Raynaud's symptoms, probably because of the alpha blocking component?
I need to know if the (+) for Acebutolol or the (+++) for Pindolol would put one of them above the alpha blocking of Carvedilol for my situation?
I hope you don't mind me pushing you on this, but I want to ask my physician the absolute least number of times for changes to my meds.
Thanks again, XXXXXXX
Brief Answer:
Close monitoring is necessary for whichever chosen alternative.
Detailed Answer:
Hello again!
I would explain that Carvedilol has resulted safe in large observational studies regarding Raynaud's phenomenon. From nearly 20000 patients only 4 developed Raynaud's, attributed to the beta-blocker use. This is the strongest evidence to avoid uncertainties about beta-blockers.
Nevertheless, careful dose titration and monitoring for possible adverse effects should be applied for whichever alternative chosen by your attending doctor.
Remember, first of all, you need a safe alternative, not only a spectacular medication effectiveness.
Best wishes! Dr. Iliri
Close monitoring is necessary for whichever chosen alternative.
Detailed Answer:
Hello again!
I would explain that Carvedilol has resulted safe in large observational studies regarding Raynaud's phenomenon. From nearly 20000 patients only 4 developed Raynaud's, attributed to the beta-blocker use. This is the strongest evidence to avoid uncertainties about beta-blockers.
Nevertheless, careful dose titration and monitoring for possible adverse effects should be applied for whichever alternative chosen by your attending doctor.
Remember, first of all, you need a safe alternative, not only a spectacular medication effectiveness.
Best wishes! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Iliri,
Thanks for your heart felt response. I really appreciate it. I just stopped the Verapamil on my own. I am feeling worse today and my face is getting more flushed and red. I was going to power through with the Verapamil until I can see my doctor this week and to see if the side effects go away, but I think I better not push my luck. I must be allergic to it. It's kind of disappointing because I am really enjoying the positive effect it has on my colitis, only going once a day!
I will try the Losartan and Carvedilol route. I was concerned about the side effects of CCB's over BB's and ARB's from the start, but since I never had bad reactions like this to any meds before, I thought I would be fine with Verapamil too.
It has really helped being able to discuss this with you before my appointment. XXXXXXX
Thanks for your heart felt response. I really appreciate it. I just stopped the Verapamil on my own. I am feeling worse today and my face is getting more flushed and red. I was going to power through with the Verapamil until I can see my doctor this week and to see if the side effects go away, but I think I better not push my luck. I must be allergic to it. It's kind of disappointing because I am really enjoying the positive effect it has on my colitis, only going once a day!
I will try the Losartan and Carvedilol route. I was concerned about the side effects of CCB's over BB's and ARB's from the start, but since I never had bad reactions like this to any meds before, I thought I would be fine with Verapamil too.
It has really helped being able to discuss this with you before my appointment. XXXXXXX
Brief Answer:
You are welcome!
Detailed Answer:
It's a pleasure to talk with a person opened to medical knowledge like you.
I wish your concern will be resolved after the appointment with your attending doctor.
If you have any uncertainties, feel free to ask me a direct question.
Regards! Dr. Iliri
You are welcome!
Detailed Answer:
It's a pleasure to talk with a person opened to medical knowledge like you.
I wish your concern will be resolved after the appointment with your attending doctor.
If you have any uncertainties, feel free to ask me a direct question.
Regards! Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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