Dr. Sagar Ramesh Makode
Cardiology
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Patient's Query
Helllo doctor,
My father is 79-years-old and has been diabetic for the past 30 years. He has had a bypass in the past and also a stroke. He feels a little dizzy after getting up from bed for the past week, or even sometimes when the changes position while sleeping. His BP is usually in the 145/60 mm of Hg. Our doctor has prescribed Stugeron 25 mg twice a day for three days and Vertin 24 mg once daily for seven days. We took his BP readings, it was 140/60 mm of Hg in the lying position, 135/55 mm of Hg in the sitting position, and 131/56 mm of Hg while standing. His heart rate is usually in the early 60 seconds. We consulted our cardiologist, and he has asked us to stop Metolar XR 25, which he has taken once in the morning for five years. He has also advised us to monitor his BP and then do an ECG after a week. I hope stopping Metolar will not cause any issues, and his dizziness will go away. I hope there is nothing to worry about. He is taking Mixtard Insulin 30/70, 50 units in the morning,13 units at night, Glycomet-GP twice daily, Linagliptin 5 mg once a day, Fibator 10 mg once a day, Metolar 25 one tablet per day, Dynapress 0.4 mg once at night, Arreno twice a day, Ecosprin 75 mg once a day, Thyronorm 25 mg one tablet from Monday to Thursday and two tablets from Friday to Sunday, and capsule Uprise once a month.
Hi,
Welcome to icliniq.com.
This is usually not a problematic issue and is due to a decrease in blood supply to the brain on getting up due to the effect of gravity. This is due to the combined effect of falls in blood pressure (BP) with standing and unable to increase heart rate due to Metoprolol. Now, stopping Metoprolol would help relieve his symptoms, but there are a few things to consider here. Now, if his heart rate is staying at 55-60 beats per minute at rest, it is ideal for heart patients, and Metoprolol has multiple other benefits. Also, stopping Metoprolol may lead to a rise in blood pressure slightly. So, it is a necessary medication but may be stopped if symptoms are significant, and other medicines may be added for blood pressure if necessary. The next thing is to obtain a fresh electrocardiogram (ECG) to see if there is any heart block, like first or second-degree heart block. If present, then it is necessary to stop Metoprolol. You have not attached any ECG; all files are Echo files (attachment removed to preserve the patient's identity). To summarize my opinion, fresh ECG should be obtained. If symptoms are not severe, then Metoprolol may be continued, and some behavioral modifications should be made, like avoiding sudden movements like getting up from sleeping or sitting position. Instead, he should sit up in bed for a few minutes and then stand up. Stand up to see if he develops dizziness and then start walking. And if symptoms are severe, then Metoprolol may be stopped, and BP needs to be monitored regularly. If he is not having any shortness of breath, then water intake daily should be increased by 200-300 mL, which may be helpful. Also, compression stockings over the calf would be beneficial. Pulse and BP should be monitored regularly as high BP may cause dizziness sometimes. Stugeron (Cinnarizine 25 mg) and Vertin (Betahistine 8 mg) are unlikely to be helpful. Of course, it may be tried if the doctor feels it necessary. I hope this helps you and get back if you have any doubts.
Patient's Query
Hello doctor,
I will attach an ECG, which was done six months back. He has no shortness of breath. If BP does not increase after stopping Metoprolol, is it fine to discontinue it? Also, he has been taking Dynapress 0.4 mg for five years for BPH. Could this also be responsible for postural hypotension? Will the pulse increase after stopping Metoprolol?
Hi,
Welcome back to icliniq.com.
There was no heart block in the previous echocardiogram (ECG). So yes, Dynapress (Tamsulosin) may cause postural hypotension. Withholding Metoprolol is fine if blood pressure (BP) remains normal and pulse will increase. But as I mentioned above, Metoprolol also has other beneficial effects like maintaining heart function to a normal level. So we usually try to continue it unless contraindicated. Anyways, it may be stopped temporarily, and later attempts should be made to reintroduce it, maybe 12.5 mg. All the best.
Patient's Query
Hello doctor,
My father's dizziness has improved. As per the doctor's advice, we made Metolar XR from 25 to 12.5 mg, but still, his BP was in the range of 150 to 135 mm of Hg systolic and 62 to 58 mm of Hg diastolic. His pulse was also from 60 to 62. We did a fresh ECG; also, the doctor put him on Telma 20 and asked us to stop Metolar totally. For two days, he is taking Telma 20 once in the morning, and now his BP is in the range of systolic 135 to 150 mm of Hg, and diastolic has improved to about 69 to 70 mm of Hg. His pulse has also improved to 65 bpm. So please have a look at ECG. Is Telma 20 fine, and is 150 mm of Hg systolic high for him? Will it improve, or can it get higher? These readings are when he is sitting. Please let me know if all is fine.
Hello,
Welcome back to icliniq.com.
ECG is abnormal (attachment removed to preserve the patient's identity), but changes are similar to old ECG only, and these are all old changes only. So nothing to worry about it. Next thing, diastolic is not important as long as it stays less than 90 mm of Hg and to whatever extent on the lower side. Our target is systolic. The ideal target for systolic is 110 to 130 mm of Hg, but considering the age, less than 140 would be fine. Resting pulse rate if going more than 70 beats per minute, it would be wise to start him on 12.5 mg once daily. The target for pulse rate would be 55 to 65 to 70 beats per minute in his case. Now 140 to 150 is not very alarming, but we would want it to be less than 140 mm of Hg over the long term for best results. So you may wait for two to three days as Telmisartan may take some time for full effect. And if the blood pressure (BP) remains in this range (that is, crossing 140 systolic frequently), then better to increase it to 40 mg once daily. So 20 mg is the minimum dose of it. All the best.
Patient's Query
Hello doctor,
As the systolic BP was ranging from 130 to 150 mm of Hg. Diastolic was from 58 to 70 and pulse from 58 to 70 beats per minute.Our cardiologist has asked to take Telma CT half a tablet instead of Telma 20. I hope it will be fine and not lower the diastolic more.
Hi,
Welcome back to icliniq.com.
Diastolic is not necessary at this age; it will not cause any harm at whatever low level it may go. So the target is systolic only. The ideal systolic would be 110 to 130 to 140 mm of Hg is also acceptable. In my opinion, Telma 40 would have been a better option rather than taking Telma CT (Telmisartan 40 mg and Chlorthalidone 6.25 mg) half tablet. Anyways, does not make much difference. The benefit of having Telma (Telmisartan) 40 mg is that you do not have to break it, and secondly Telma CT component may slightly elevate the sugar. And also, half of Telma CT is unlikely to be of significant benefit.
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