diastolic hypotension from verapamil

[fizzixgal]

I'm a 49 y.o. female, athletic, never smoker, recently developed and was diagnosed with idiopathic RVOT ectopy (frequent pvcs often in trigeminy, no VT). My EP suspects resolved mild myocarditis as the cause. TTE was normal except for mild left atrial dilation; mibi stress test went to stage 5 Bruce and 98% maximal predicted HR, normal perfusion; cardiac MRI was also normal. I am scheduled for ablation in July. Currently I am on Verapamil SA 180mg b.i.d. which suppresses the pvcs fairly well, however I experience frequent mild weakness (never to the point of presyncope) that disappears with exercise and have questions about its effect on my blood pressure. Before starting verapamil and on low dose beta blockers, my bp was 130-140/80-90, occasionally a little higher in the office. Now at home I measure 116-130/56-62, typically 126/60. My systolic pressure often varies by 4-8mm over several seconds and I need to reinflate several times to get an average reading.

Q1. Is this an abnormal response to verapamil? If so, what does it indicate?

Q2. Should I be concerned about this high a pulse pressure and if so, why?

Q3. Could diastolic hypotension account for the weakness I experience?

Thanks in advance for your answers.

[Momto3]

I hear ya on the flecainide. I took it for about 4 months, but it had negative effects on my central nervous system - hand tremors, shakiness, WEIRD dreams....Switched to rhythmol and had much better luck, but had to take it 3X/day instead of twice. Good luck at your next appointment. Keep us posted!  Connie

[Gaspipe]

Thanx for your info yeah I'll going to bring up the EP idea at my next visit but besides the aggravation of the skips I,ve not had EF changes to date. Iwas on Flecainide in the past which was very effective but went off it and they slowly returned to the present annoying level. I guess I could do the flecainide thing again but I just don't like taking the stuff . thanx Gaspipe

[Momto3]

Has the doctor recommended an ablation?  I had two last year and my QOL has been remarkablely improved.  I still don't think they are for everyone, but in my case...a miracle indeed!  I was at 24% ectopics, but no VT per se, lots of bigeminy, couplets, etc. Now, I have an occasional "blip."  I keep waiting for the other shoe to drop, but no real evidence of a "new" problem...Keeping my fingers crossed.

Are you taking any medications?  Over the years, I was on/off beta blockers and more recently tried antiarrythmics...For me, and only after MUCH deliberation, the doctor and I together decided to try an ablation. Turned out to be a good idea. I was multifocal so it took more than one procedure, but well worth the effort.  Good luck!  Here's hoping they just disappear on their own : )

connie

[fizzixgal]

Without medication, my PVCs would be so frequent that my quality of life would be close to zero. Back in April, nearly 10% of my total beats were ectopic and it was getting steadily worse. It turns out that they are likely unifocal and so I'm given a better than 90% chance of success with a single ablation procedure.

[Gaspipe]

I'am in the same boat regarding PVC frequency as you but to date I've learned to live with them. I've hesitated on the abalation thing because of what seems like the significant chance of developing other irregular beats.i'd really like to know how you make out in July and best of luck.

[fizzixgal]

Doc, thanks for your reply. Yes it is consistent trends that I try to look for, and the weakness began after the switch to Verapamil SA. This was only a 40mg increase in 24 hour dose though and it was on the tail end of an apparent viral illness (headache, nausea, normal WBC) so there may be no relation. It is probably too soon to say.

I was actually more concerned about why my diastolic pressure was affected so much more strongly than my systolic and whether the wide pulse pressure was an indicator of arterial wall inflammation or could lead to long term damage. If neither is outside of normal limits then I won't worry about it.

[Gaspipe]

No it has not however I've never pursued it. But I will check into it at my next visit. Maybe at least I can get my heart mapped if thats the correct phrase and see if I am a good candidate.I've been on atenonlol for years controls BP well but does nothing for PVCs even though years ago it did help it no longer does. My concern is that I've have to travel to a clinic where the Docs were well versed in the procedure

[Momto3]

I will be interested to see if your doctor thinks you should consider an EPS and/or ablation.  Are you seeing an EP?  If the pvcs are not bothering you and are not causing you any harm, I am inclined to think the doctor will dismiss the notion of either.  When I brought up the idea after my holter revealed 22,000 ectopics, the doctor said "we can talk about it," but it wasn't until the pvcs were thought to be causing a drop in EF that the ablation idea resurfaced.  

I'm not positive, but I don't think I've ever taken atenolol, just inderal, Ace-butolol, tenormin, flecainide and rhythmol. On the beta blockers I had the same experience -- worked, then I began to have breakthroughs...Pluto had the same experience. Beta blockers are great first line treatment, but it seems as tho they lose their effectiveness over time. Aren't there any major medical centers around you?  I would definitely suggest a center that does a LOT of EPS' and/or ablations if that's the route your doctor suggests.

Hi Pluto : )

I definitley feel very blessed to have been the "victim" of a successful ablation. Last couple of weeks, I had some SOB, a few random runs of pvcs and was a bit more tired than usual. I'm hoping that something else (besides life) is not getting stirred up...I am scheduled to see my EP in August and if things continue on this way, I'll be sure to mention it. Otherwise, I'll assume that 2 kids graduating from college and a full house is what's at the helm of my newly acquired zzzzzzz's.  Sure hope you are doing well!

Enjoying the beautiful sunshine in Ohio : )
Connie

[Gaspipe]

Why are you getting an abalation??

[Cleveland Clinic]

fizzigal,

thanks for the post.

Q1. Is this an abnormal response to verapamil? If so, what does it indicate?

Verapamil decreases blood pressure. The amount varies by the individual and dose. Your response is not that marked, but a decreased blood pressure is a normal response.

Q2. Should I be concerned about this high a pulse pressure and if so, why?

A wide pulse pressure can be a normal finding and a sign of a normal or healthy cardiac output.  There are some disease states that can also increase it. Your numbers are not outside of the normal range.

Q3. Could diastolic hypotension account for the weakness I experience?

Your pressures seem to be in a normal range. I would not expect them to really be significantly associated with symptoms.

My systolic pressure often varies by 4-8mm over several seconds and I need to reinflate several times to get an average reading.

This is a normal finding related to the variation in the ventricular filling with respiration.


Try not to get too overly caught up in the minute to minute details.  Really you should observe consistant trends.  For example, everyday if you are tired after your verapamil, and your blood pressure is in a general range that will help.  Noting these longer trends will be of more help to your doc in finding the cause.