Pulse Pressure and BP

Clinical pharmacology studies have demonstrated the beta-blocking activity of Metoprolol, as shown by (1) reduction in heart rate and cardiac output at rest and upon exercise, (2) reduction of systolic blood pressure upon exercise, (3) inhibition of isoproterenol-induced tachycardia, and (4) reduction of reflex orthostatic tachycardia.

??In an earlier reply I gave the reason why your most important blood pressure for survival is the Mean Arterial Pressure(MAP) and not your systolic (peak) blood pressure.

?In reducing your heart rate with Metoprolol? it is most likely to be reducing your cardiac output  and therefore not only reducing your systolic blood pressure but also your diastolic blood pressure. The end result is reduction of your MAP to below normal levels.

 

?This does support your thought that a change of medication might be in order.

?As you are worried about your MVP I would have expected your cardiologist to have confirmed that this is not affecting your symptoms by telling you your heart's Ejection Fraction (LVEF) which should be between about 50% and 75%.

?I think a more detailed analysis of your heart function and medication side effects need to be established before further attempts at diagnosis of your symptoms.

I have read the other response and you have been very informative, thank you so much. I will definitely consider a change of medication. Do you know of any beta blockers that doesn't have these effects? But it sounds like all of them would have these problems. I might just go for natural remedies. Hibiscus, garlic, and hawthorn work pretty well for me.

My doctor did not tell me my Ejection Fraction. I'll make sure to ask him once I have my appointment.

I will be getting an angiogram, I just have to wait for my insurance. Is that test good enough to analyze heart function or are there other tests?

I really appreciate the information, all of this has been stressing me out and finally I see some light. Thank you. I'll keep the MAP in mind as well.

Before the angiogram they usually do the echo cardiogram, or stress-echo, have you done those?  Angiogram is very informative but more invasive and expensive, I'm not sure what it takes these days in the US to qualify for one.  More than BP complaints, I think.

Yes I’ve had both of those done, and all clear. But I was still getting the ocassional chest pain and shortness of breath so i think my cardiologist just wants to be thorough. He told me that my chest pain doesn’t sound like angina but just have an angiogram to be on the safe side. Since I have MVP maybe an angiogram would tell the doctor more about it?

"Chest pain" can also be gall stone or even kidney stone, among other things.  I'm curious what data modern medicine can get from an angiogram that the echo doesn't show, I'm sure there's something.

I'm so waiting for the Star Trek medical tricorder, they just wave it at you and everything is known!

>Do you know of any beta blockers that doesn't have these effects?

Short answer is no - I don't have any experience of other beta-blockers.

However I think you are right to conclude that they will all work in the same sort of way but in tests metropolol has resulted in more side effects than others.

?I am using bisoprolol but then I am much older than you and male - the effect has been similar

 though with resting heart rate reduced from 80 bpm to 55 bpm but it is stable at that rate.

?

>I will be getting an angiogram, I just have to wait for my insurance. Is that test good enough to analyze heart function or are there other tests?

?I mentioned resting heart rate earlier and that mine had gone down dramatically with bisoprolol.

?Resting heart rate is quite informative and can be taken by yourself by feeling the pulse on your wrist over a timed period e.g. 15 seconds and multiplying by 4 to get your heart beats per minute.

?However it is important that you do this in a comfortable and fully relaxed state in an armchair with your feet on the ground and your arms supported and after maintaining this state for at least 5-10 minutes without interruption or talking.

?Can you do this and link this measurement to a beta-blocker dosage?

Regarding the link I sent about Resting Heart Rate (RHR) measure for heart function from Harvard, here's an image showing how I use the CMS50D+ to monitor my Resting Heart Rate after being seated comfortably for about five minutes.

?My heart rate, blood oxygen level and blood flow waveforms are shown on the device whilst connected to my finger. The display in attached image is what is shown when it is connected by a cable to a computer and is a bit more informative.

?It does however show that my blood oxygen level (SpO2) is stable at 97% for a whole minute and my RHR is 53 beats per minute. The bottom display, which can also be seen on the device whilst on my finger, displays the blood flow at my finger from my heart which directly correlates with my blood pressure's systolic peaks and diastolic lows. I can spot heart waveform irregular beats on this display.

Hi again,

?There is another bit of information you should know about and which your cardiologist should be able to tell you.

?You haven't said if you are taking any other prescription drugs or food and drink like caffeine drinks which can stimulate your sympathetic system - these will act in opposition to your beta-blocker.

?These may raise your heart rate and possibly also elongate the QT interval of the heart waveform on your ecg. It is important that you should know your QT interval particularly as metoprolol may have been prescribed to reduce your QT interval and avoid symptoms of heart waveform irregularities particularly at tachycardic rates (>100 beats per minute).

?The attached graph will enable you to plot a point which is your QT interval when measured at a specific heart rate. If you are below the line you are OK but if near or over line then you must be careful if you are considering changing your medication or its dosage.

 

I read through all of the responses and thank you so much for the information. I wish I had gone to this particular message sooner since I iust left my appointment, and I must say, I feel absolutely dreadful. But I had an EKG done and while I didn’t get to ask the cardiologist what my QT interval is, I do have the EKG result. QT: 336, QRSD: 364. I can send you the entire picture if you need it.

My doctor prescribed me another beta blocker that starts with a D, I can’t read his writing. I was on Colchicine but stopped since the Pericarditis has apprentlyresolved (I forgot to mention this).

I have no idea what’s going on with me as I continue to have chest pain that radiates to the jaw, shoulder, neck, back, you name it, I have the checklist for heart attack. But every test comes out clear and I’m frustrated.

Today is once of my many worst days. I take the bus/trolley to and from. I was standing, waiting for bus to see my doctor when I felt dizzy and off balance again.  I went back home and found out my pulse pressure was very low. 18 PP. but everything else checked out okay. I ate some salty chips which brought it back up. I had to see the doctor though and did. But my body is not having any activity today. I feel sick and scared that I might get a heart attack. Or maybe I already had one. I don’t even know. I just have problems and I don’t know why. Not even the many trips to the ER were able to figure it out.

I’m scared.

Colchicine, whilst being an appropriate drug for pericarditis has been reported to have side effects of rapid heart rate and breathing difficulty as attached images show.

​As you may have taken two drugs either together or one shortly after the other, this needs to be taken into account when considering what is causing your symptoms.  Even more so considering they are both heart affecting drugs.

So I might have made things worse for myself? What do I do? Will the angiogram pick up anything like damage? And if the angiogram is clear, does that mean I’m okay? Should I get more tests to make sure my heart isn’t damaged from the medication? All of this is very mind-boggling I must say. It’s great information to know, but to also know that I’ve might have made the situation worse for myself... now I’m worried about the future.

I’ve stopped the Colchicine since the pericarditis has been resolved and I’m about to change my Metoprolol.

But thank you so much for your help.

Having received your full picture I have plotted your QT versus heart rate point in purple on the graph I sent previously as shown here.

?This is just part of a formal interpretation to distinguish between various diagnoses, one of which we have already discussed in private messages and for which I sent a link.

?Your latest EKG should be sufficient evidence to pursue further tests to establish how your QT value changes with heart rate and refine a diagnosis. Ideally, if you can be relaxed enough to achieve a heart rate of 60 beats a minute when taking an EKG  this would further clarify a diagnosis.

?The QTcH figure on your EKG is only an estimated value of your QT at 60 beats per minute. This is purely a guess at what it might be for people with generally normal QT values and is the red point.

?The red point on the graph is the rough dividing line between normal QT values and the Short QT range at 60 beats per second. As you can see it's right on the boundary but further EKGs showing how your QT changes with heart rate will be an essential next step. 

?Your doctor should be aware of the significance of your low value of QT, the need for further investigation and the impact of medication that alters your QT interval. Any deviation from the line between your purple point and the red point will be significant.