I began with paroxysmal AF, but it showed signs of increasing aggressiveness after three years and I was referred to an electrophysiologist for an assessment to see if I was a candidate for catheter ablation. Meanwhile, for five years, I was initially on metoprolol and apixaban (rate control and stroke prevention respectively). A week after my index ablation, I was on amiodarone because my heart was running at 180 beats at times and I was in both flutter and AF, but not concurrently.

Metoprolol and other beta blockers, and calcium channel blockers, are more about keeping the heart subdued, but NOT keeping it out of arrhythmia. They're rate control, not rhythm control. And, when they are given for a while, and if the dose rises over time to keep the lid on the rate during AF, there can be periods with bradycardia, or low heart rate. In my case, I was getting tingling around my neck and jaw, and I felt I might faint. Turned out I was getting too much metoprolol. I was told to cease it immediately, and the ER put me on amiodarone for eight weeks...only. This was because they wanted to put a Holter monitor on me at the 10 week mark to get a veridical picture of what was going on. The amiodarone has a strong residual value for weeks afterwards, so it had to be stopped for two weeks before the Holter.

There are other drugs such as diltiazem for rate control. For rhythm, there are many options. Most start with something mild like Sotolol, Multaq, maybe propafenone. Flecainide is often given, but it must be carefully monitored because some can't take it without other problems, including yet more arrhythmia. Taken with metoprolol at the same time, it can lead to long pauses between beats and bradycardia. It's good, for those who can tolerate it, as a PIP. or pill-in-pocket to have with you if you break into AF, but are otherwise not taking it.

As a general rule, AF is progressive. It will advance and evolve over time, and drugs will lose their potency. Before your left atrium enlarges, which it will do if left in AF for weeks and months, and before the AF evolves to persistent or permanent forms, consult an electrophysiologist, and make sure he/she is the best in 100 miles. You want the busy ones who do 15 ablations each week and have been doing it for at least five years...ideally. Get a first consultation in and see if an ablation might be the best way ahead, and sooner rather than wait for the AF to begin to act up more aggressively as your drugs lose their efficacy.