There are a number of drug treatments that can be used to either reduce the heart rate and control the heart rate. They’re called rate control measures and then there are other drugs, which are given usually by specialists, that can also actually restore or help to maintain the normal rhythm once it’s been restored. So, in general practice, we often use rate control medications like beta blockers or calcium channel antagonists or digoxin to control the patient’s heart rate and that often relieves a lot of their symptoms. And, when their symptoms are relieved, the next question is whether this person needs to be started on blood thinning treatment to reduce their stroke risk.

There are drugs used which are largely in the remit of specialists and I’m thinking of drugs like amiodarone and dronedarone and also drugs like flecainide, which are prescribed and initiated in a specialist setting. They have side effects that all need to be discussed with the patient. It needs to be clear what the purpose of the drug is, whether it is to stabilise the heart or simply to control the rate. Some of these drugs are only used in the situation where the more commonly used drugs have not succeeded in controlling the heart rate. In other situations they’re used to stabilise the heart and make the cardioversion treatments, where the heart rhythm is restored electrically, to make that process more successful.

Yes, I mean I can have it and I know I’ve got it, but I just carry on. I don’t, you know, it doesn’t, it’s not as debilitating as before when I was, [gasping] you know, really breathless, really clammy and any exertion was just too much. Now it’s, obviously the medication has taken those symptoms down to a level where I can I can function. Normally, I can function with it, with, I mean obviously, I don’t sort of jump about and running and doing things like that. I don’t get very active, but I can carry on normal every day activities without it causing me any problems, yeah.

Yes, there are some side effects. Beta blockers, for instance, are quite commonly associated with the feeling of tiredness and lethargy and an inability to exercise as well as the person could previously. And that’s quite a common quite a common problem, quite a problem for some people. Similarly, calcium channel antagonists can often cause swollen ankles, which is a problem. Either of those two drugs can reduce the blood pressure and that can sometimes be reduced further than is intended so that can cause dizziness. Either of those two can also reduce the heart rate, which, of course, is the purpose of giving them but there’s always some risk of it going down too low. And then for digoxin there are a number of other side effects, which are quite likely to occur if the dose is too high for the patient. So it’s very important to be, if you’re using the drug digoxin, to make sure that the patient isn’t getting too much of it and, as the person gets older and their kidney function perhaps reduces over time, then the dose of the digoxin needs to be reviewed to decide whether it’s still appropriate.

So what sort of side effects might people expect on digoxin?

Well, quite a common side effect is nausea and loss of appetite and weight loss and sometimes this occurs in people who have been taking digoxin for some time and those sorts of symptoms, obviously, can be caused by lots of different conditions but if other conditions have been ruled out, you always need to remember that those symptoms can be related to that drug. And it then may be necessary to either reduce the dose and see whether the person feels better or to actually check their blood levels.

I don’t like being on the beta-blocker very much and it’s all right at the amount I’m on now and I take it at night to minimise the effect on, because I don’t like that kind of glass wall that beta-blockers put between you and the rest of the world.

In what way? How do they, what do you mean by that?

Well, a friend of mine, who used to take them for, when he was facing stressful situations, he called them, don’t care a damn pills’ and that’s what it’s like. It’s as if you’re detached from. From life and I don’t like that. I’d rather feel.

I was sent home on high dose of sotalol and they gave me terrible side effects. It was horrible being on sotalol. I felt so tired, really exhausted, depressed and but fearful as well that I had to take that medication, because well, it was a preventative sort of measure and there was nothing else that they really would do to me, because my heart rate had reverted but to a to a normal sinus rhythm. But after a few months, after a couple of months, one evening, there it was again, it popped up with, I was on sotalol at the time. And so off I went to hospital again, off I was admitted again and I was, my sotalol levels were increased so I was on such a big dose of that stuff, feeling horrendous with it. I was I was sent home. It was around Christmas time. I was sent home with the heavy, heavy dose of sotalol, and my GP was going to like sort it out. So every three days I the sotalol was increased, and I just felt horrendous with it, until my heart rate reverted again.

He reduced the beta-blocker because that would, five, certain beta-blockers and a certain strength of beta-blocker will give you cold hands, cold feet and cold extremities, and that was very true and I just wasn’t sleeping. I was getting pins and needles at night. It was horrible actually. When I think about it, considering I didn’t have cancer or, you know, some horrible disease that that that kills people, I was still feeling absolutely terrible. From going from feeling fit and healthy one and a half years ago to being dependent on all these drugs and getting, you know, feeling freezing cold in my hands and feet at night, when I never was before, and getting pins and needles all the time and severe palpitations, horrible.

Amiodarone, I was on that from twelve months, from December two thousand ten until December two thousand and eleven and then, as I say, in the middle of December last year, they decided for me to, [coughs] excuse me, to come off it. You know, so as I say, the only thing with that is it takes six months to go through your system.

So are you still getting side effects?

I’m still getting side effects from amiodarone. The worst side effects are nightmares, dry mouth and also theres, the worst side effect of all with amiodarone, is you’ve got to watch direct sunlight. If direct sunlight gets on your arms or your legs or your face you can you can burn your skin. So you be very, very careful when you go out in the sun that you’re well wrapped up, in fact, you know, which I was last summer and I was well you call it creamed up, as they said, you know, with sun cream every time. I got arms, legs, head everywhere, neck everything, even the top of my head, I was putting it on as well.

I know that dronedarone, which was a new AF drug, which everybody was raving about, which it was hoped would be a replacement for amiodarone, but which hasn’t lived up to its expectations. There have been some side effects. I know there was one person who died of liver failure. I think it was liver failure. But generally speaking, all of these new drugs have to be assessed over time, where some of these problems are not going to be manifest until you’ve had them in clinical practice for quite some time.

I used to try and, in fact, what I didn’t say, which was quite a feature of the early my early days with AF, that I had the kind of feeling that I could control it if only I did it better. So from time to time, I would stop all the medication, just like that. I can manage this. I can I can deal with this, I would say to myself. I’m all right. I don’t need it. And then, well, I don’t know how long but then it would all start up again and I’d realise that actually it wasn’t within my control. It kind of felt as though it was but it wasn’t.

I had a value that I didn’t want to be on medications. I didn’t want to be on drugs. That was my own personal value, you know, was I wanted to be free from medication. I had to work through that and accept that, in fact, quite the reverse I’d say I was right to have them. I’m from a part of the world where we have access to medication and it’s free and all that so I’m okay. I think it was almost like a grieving process for losing my independence.

Losing my life without medication, if you know what I mean and probably I think it was a grieving process and part of me in denial and then part of me maybe fighting against it as well.

But now I totally accept my views of well, sure, if you can take something that keeps you stabilised, why not.

So for about a year I was on digoxin only. However, I found that my ankles were swelling and then I was put on a diuretic as well and my hands were swelling. I couldn’t wear rings and I didn’t know what it was but I discovered that it was the digoxin, even though that they said they don’t give it, some of the medics would have said, No, it wouldn’t cause that. But I reduced the digoxin myself very, very slowly to an amount that was working okay but my swelling and everything else went down. So this time I went on it I went on a lower dose and along with the sotalol, it works pretty well. And I don’t have any swelling of my ankles from it.

I’m meticulous about taking the sotalol too. And the other thing I wanted to tell you, I take it on an empty stomach. I took the view that if I take it, it says you can take it with food. I took the view that that would slow the absorption and might even prevent some absorption, because food sometimes combines with a drug and it doesn’t get absorbed, especially if you had a lot of bran or something. So I read on an American website that you should take it one hour before food, and I try to do that. And I think half an hour is long enough actually, and I’ve got better results with it. So I, these things you discover as you go along to make the most of the small dose.