The skeptical cardiologist saw a patient recently who had undergone stenting of a 95% blocked right coronary artery. Mr Jones had presented a year ago to our ER 2 days after he first began experiencing a light pressure-type discomfort in his left shoulder and scapular region. This pain persisted, waxing and waning, without a clear relationship to exertion or position or movement of his shoulder.
Upon arrival in the ER, his ECG was normal but his cardiac enzymes were slightly elevated (troponin peaking 0.92), thus he was diagnosed with a non-ST elevation myocardial infarction (MI).
He’s done great since the stent procedure fixed the coronary blockage that caused his infarct and chest pain, but during our office visit he related that since his hospitalization he had been feeling “logy.”
Being a lover of words, my ears perked up at this new-to-me adjective, and I asked him to describe what he meant by logy. For him, loginess was a feeling of fatigue or lacking energy.
Indeed, the online Merriam-Webster dictionary defines logy as sluggish or groggy. It is pronounced usually with a long o and a hard g.
The origin is unclear but has nothing to do with rum:
Based on surface resemblance, you might guess that “logy” (also sometimes spelled “loggy”) is related to “groggy,” but that’s not the case. “Groggy” ultimately comes from “Old Grog,” the nickname of an English admiral who was notorious for his cloak made of a fabric called grogram – and for adding water to his crew’s rum. The sailors called the rum mixture “grog” after the admiral. Because of the effect of grog, “groggy” came to mean “weak and unsteady on the feet or in action.” No one is really sure about the origin of “logy,” but experts speculate that it comes from the Dutch word log, meaning “heavy.” Its first recorded use in English, from an 1847 London newspaper, refers to a “loggy stroke” in rowing.
Fatigue is a common, nonspecific symptom that we all feel at times. It is more common as we age and it can be challenging for both patients and physicians to sort out when it needs to be further evaluated.
Occasionally, fatigue is the only symptom of a significant cardiac condition, but more frequently in the patient population I see it is either noncardiac (low thyroid, anemia, etc.) or iatrogenic.
When a patient tells me they are feeling fatigued I immediately scan their med list for potential logigenic drugs.
In this case, my patient had been started on a low dosage of the beta-blocker carvedilol (brand name Coreg) after his stent, and I suspected this was why he had felt logy for the past year.
In cardiology, we utilize beta-blockers in many situations-arrhythmias, heart failure, and heart attacks to name a few, and they are well-known to have fatigue as a common side effect. There was a really good chance that Mr. Jones’s loginess was due to the carvedilol.
It’s important to review all medications at each patient visit to check for side effects, interactions and benefits, and in the case of Mr. Jones’ carvedilol, loginess.
Do All Patients Post-Revascularization or Post-MI Need To Take Beta-Blockers
Beta-blockers (BBs) are frequently started in patients after a stenting procedure or coronary bypass surgery, and continued indefinitely. However, the evidence for their benefit in such patients with normal LV function long term is lacking.
If any post-revascularization population benefits from BBs, it is those, like Mr. Jones who have had a myocardial infarction (MI, heart attack) prior to the procedure, however the smaller the infarct, the less the benefits.
And with the widespread use of early stenting to treat MI, infarcts are much smaller and dysfunction of the left ventricle (LV) less likely.
In those patients with minimal damage and normal LV function, the benefits appear minimal. For this reason in the last 5 to 10 years I’ve been stopping BBs in this population if there are any significant side effects.
An “Expert Analysis” published in JACC in 2017 noted that:
A 2015 meta-analysis of 10 observational acute MI studies including more than 40,000 patients showed that beta-blockers reduced the risk of all-cause death However, the benefit of these agents was not found in all subgroups and seemed confined to the patients with reduced LVEF, with low use of other secondary prevention drugs, or NSTEMI.
In a study of almost 180,000 patients post MI with normal LV systolic function in the UK between 2007 and 2013 there was no difference in mortality at one year in patients discharged with or without beta-blockers.
The only way to answer this question definitely would be with a randomized controlled trial and, to my surprise and delight, such a study (CAPITAL-RCT (Carvedilol Post-Intervention Long-Term Administration in Large-scale Randomized Controlled Trial) was published in PLOS One in August of 2018.
I’ll save readers the details, but the bottom line is that patients treated with optimal contemporary therapy for acute MI, whose LV function was not significantly impaired, did not benefit in any way from treatment with carvedilol, the beta-blocker my patient was taking.
It’s rare that we get such definitive evidence for a change in treatment that reverses what is in current guidelines. This has the potential to affect tens of thousands of patients and improve their quality of life. It should be trumpeted far and wide. The cynic in me suspects that if it were a study demonstrating the benefits of a new drug, physicians would be bombarded with the new information.
Helping Patients Feel Less Logy
We will be ordering an echocardiogram on Mr. Jones, and if his LV function is normal we will stop his carvedilol and see if he feels significantly better.
I feel like stopping a drug that is not beneficial and that is causing a lifetime of loginess is an incredibly important intervention a cardiologist can make. It’s not as life-saving as stenting for acute MI, but saving quality of life is something this non-invasive cardiologist can do every day for every patient.
Skeptically Yours,
-ACP
N.B. The summary of the recent CAPITAL-RCT:
STEMI patients with successful primary PCI within 24 hours from the onset and with left ventricular ejection fraction (LVEF) ≥40% were randomly assigned in a 1-to-1 fashion either to the carvedilol group or to the no beta-blocker group within 7 days after primary PCI. The primary endpoint is a composite of all-cause death, myocardial infarction, hospitalization for heart failure, and hospitalization for acute coronary syndrome. Between August 2010 and May 2014, 801 patients were randomly assigned to the carvedilol group (N = 399) or the no beta-blocker group (N = 402) at 67 centers in Japan. The carvedilol dose was up-titrated from 3.4±2.1 mg at baseline to 6.3±4.3 mg at 1-year. During median follow-up of 3.9 years with 96.4% follow-up, the cumulative 3-year incidences of both the primary endpoint and any coronary revascularization were not significantly different between the carvedilol and no beta-blocker groups (6.8% and 7.9%, P = 0.20, and 20.3% and 17.7%, P = 0.65, respectively). There also was no significant difference in LVEF at 1-year between the 2 groups (60.9±8.4% and 59.6±8.8%, P = 0.06).
17 thoughts on “Is An Unneeded Beta-Blocker Making You Feel Logy?”
Hi! I am a 53 female who since pandemic has was started on timolol eye drops due to high IOP and some optic nerve damage 🙁 (prostaglandin failed to lower pressure). I run, road cycle, play ice hockey plus workout to be able to do these activities. I have never taken any meds.
I have been feeling really tired/gained weight/no motivation, can’t skate hard or bike hard anymore. I attributed it to isolation and pandemic (I am a very social person). I couldn’t get my heart rate up to what I typically do when I exercise. (I have garmin watch).
Now I realize that I have systemic side effects from the beta blocker despite punctal occlusion so we are trying to figure out different medication/surgery for my glaucoma issues.
Two Questions:
1) In a person like me can using a beta blocker when I didn’t need one for cardiovascular issues cause any long term negative side-effects to my cardiovascular system? I am really worried about this!
2) When I was on the beta blocker and really pushing myself – trying to skate hard/ riding to summit of mountain (not having been told it would cause reduction if heart rate) can that cause problems due to beta blocker?
Thanks so much for all your information 🙂
Steph
Steph,
Good questions. Not many patients and even doctors know that some glaucoma eye drops contain beta blockers and can have systemic side effects including bradycardia and fatigue. I’ve solved a number of consults for bradycardia/pacemaker by changing changing the eye drops.
Re #1) No long term side effects of beta-blockers. Once you stop them any side effects go away.
#2) No problems from pushing yourself on the beta-blocker. I take one and when I push myself maximally my heart rate is about 10 BPM less than if I didn’t take them.
Dr. P
Thanks so much for responding to me I feel relieved to hear this! While I wait for medicine change I am being really certain to do punctal occlusion for 5 minutes.
As an aside if I can’t get medicine change I am also considering getting a tonometer because I am on the max dose of .5% timolol twice a day (doctor never started me slowly) and from what I have read on dosing, sometimes that is overkill anyways since for some reason these beta blocker drops don’t have much effect at night. Had I done my research beforehand I would have asked to start more slowly at .25% and from research sometimes people respond well to smaller doses. There is also research that shows that once you are on beta blocker drops and it builds up in eyes (4-6 weeks) that you can drop down to once a day and still maintain iop reduction. But, since I only get checked pressure checked every 3 months at doctors, having a tonometer would be helpful to make sure I don’t have increase in pressures. Can you tell I am type A ha ha!
Thanks again for taking the time to respond to me!
Steph
Excellent observations. I have learned from your research. Perhaps you’d like to write a guest post for the skeptical cardiologist on this topic!? These are good things for glaucoma patients (and doctors) to know
HI Dr Pearson thanks! Hmmm maybe I could do that. I obviously would want to cite where I read everything. Where would I submit? I am guessing it would need to be submitted and then reviewed first before you put it on the site? I am not a professional writer and it might take me a while 🙂
Thank you,
Steph
Steph,
You can send your piece to me at drp@theskepticalcardiologist.com. I’ll review it , perhaps adding some of my wise editorial comments and if you agree I post it and thousands of skepcard readers become enlightened.
I, like you, am not a professional writer but has not stopped me for writing profusely!
Dr O
This is welcomed information, been searching for answers after being on 50mg of Cardiviol a day -for well over a decade given by a PCP which has long since retired. New PCP’s in the same network of health care facility has just added additional medicine to cure side effects which over the years has caused a toxicity storm for me. I’m just now getting order to a cardiologist, seen him once he increased lisinopril from 20mg to 40mg for my BP. Just had been lisinopril a month prior by PCP from previous mentioned network. Cardiologist 1st. Visit also added Vascepa 1mg 2 aday with Zetia 10mg 1 a day. With a CTA scheduled. He didn’t adjust the Cardiviol. I’ve gotten all the side effects listed for Cardiviol but until the added lisinopril which seemed to add to my extreme issues I’ve realized the Cardiviol is a culprit. I’m 3 days discontinued ,most of the fluids has eased on my mid. Heart racing pumping hard one minute, slow another, out of breath with major fatigue all the “logy” feelings are less now.
I feel like my body is in a state of healing from that medication. Even my extremely high bp has been better since using the lisinopril 20mg. My weight fluctuated sometimes 8 lbs up then 8lbs down in a month to weight all the sudden. I’ve experienced high elevated trylc. In my lipid test. In fact was reason for order to Cardiologist. to very low levels in possium. Levels blood sugar high but none consistently after further observation, confusing to say the least and being strict vegetarian with no smoking or drinking, maintaining a clean lifestyle, I still felt like I was doing wrong due to my symptoms. I’ll be starting the Vascepa with Zetia and 40mg. Lisinopril 40mg. However, due to the 1000+ trygl. Level at Cardiologist lipid panel test, I’ll be taking 2nd. Lipid in 90days. Soon as the Cardiviol side effects have subsided and continue the 20mg. Lisinopril. I feel the Ace Inhibitor is working better for me than beta blocker. I’m hoping the trylc.go down, in another blood test my thyroid was abnormal which was given Levothyroxine 25mg. 1 a day. I’m interested to know how much Cardiviol could cause after all these years. For age 54.
I feel if all Doctors would take your approach and start with the list of medicines, it could save so many.
Hello, not sure if this is a good thread to add on to pertaining to Beta Blockers but I’m 6 weeks post CABG and I’m curious if both beta blockers and channel blockers will be required for the duration of my life. I’m a 52 year old Maile and prior to my CABG I was largely asymptomatic only exhibiting shortness of breath in the most extreme hiking conditions. My BP averaged 120/80 to 135/85 with the higher figure usually occurring at the end of work days. Now with the meds, my BP is 110/70. I had no MI prior to surgery I was proactively following up on a CT angio screening when a cath showed severe stenosis of the Left Main…. Just wanted to see if any there are any opinions out there on meds post CABG with out any MI. I’m fine taking them but if I can hold off until my BP requires it that would be great.
John,
I’ve noticed over the last decade that the CT surgery team wants to put everyone on a beta-blocker at discharge after CABG. it seems to be some sort of quality marker for them but in the absence of prior MI or LV dysfunction or a rhythm problem requiring BB there is no evidence that this is of benefit. Consequently I take lots of patients of beta blockers at the first or second visit post CABG.
If BP is the issue, I recommend meds other than beta blockers for most people.
Calcium channel blockers which slow heart rate like diltiazem are added post CABG if patient develops afib but are not required long term except if BP or rhythm problems develop.
I am so glad to see a cardiologist to talk about side effects of medications and how they can help their patients ,just listening and checking what drugs they are on. I was taking Exforge ( valsartan 160 mg and Amlopidine 5 mg) for hypertension, and I was in good control for 5 years, but I have developed a dried cough, and started to feel fatigue extreme , and shortness of breath at rest.. I went to several doctors, primary care physician, pneumologist, cardiologist, endocrinologist, gastroenterologist, allergologist, and refered to an interventional cardiologist which suggested a right and left catheterization because no of these doctors knew what was happening and did not check my medications for side effects. My Echo showed a mild pulmonar hypertension. The catherizacion was normal, however I continued feel as I was dying. I started to monitor my blood pressure and heart frecuency and I saw that I was bradycardic and my blood pressure was kind of low, diastolic under 60. Then I started I decreased my medication to half and whao……I felt better and then I stopped all. Every symptoms disappeared in days.
If just one doctor listened carefully to me, checked my prescription medications, I would have been saved of spent more that $ 5000.00 in no needed doctors appointments, and tests , that carry complications. Why it is so difficult to desprescript, or change treatment when the side effects are so adversed that affects the quality of life of the patient.
I would like to see doctors informing more to theirs patients about what side effects can expect from all this pharma drugs. I am so grateful that you touch this topic. Thanks.
my husband was put on carvedilol after the onset of PAF; his episodes are usually months apart and quite distinct — in other words he knows he is in them, and they typically last 3-5 hours. His various physicians disagree on whether being on continuous BB makes a huge difference in the fib episodes (i.e. whether a different med would make the same difference in regulating heart rate when one happens — we know that none of them would prevent it). But he definitely has the ‘logy’ effect; in fact it is making it difficult for him to get the extra exercise which is also part of the recommendation for his condition. The PCP (who is relatively anti-BB) has deferred to the cardiologist who considers the BB essential and will not even consider anything else. But I don’t feel solid that any of those opinions are particularly scientific. At least no one is interested in discussing it at that level.
I can’t give individual advice obviously but some general points to consider.
1. We don’t think BBs prevent afib in most people (although I have a few patients who have clearly AF triggered by stressful events in whom BBs prevent AF). You need antiarrhythmic drugs for most people to suppress AF. See my recent post on “Enlightened Medical Management of AF”
2. For those with paroxsymal AF, BBs can be helpful as you said to limit the heart rate response. You mentioned continuous versus intermittent usage and for some of my patients we utilize BBs only at the time that they go into AF
3. Options to limit HR response are calcium channel blockers verapamil or cardizem.
Fie upon thee! – for being so cynical about the lack of fanfare following that CAPITAL RCT.
;))
Very informative and concise blog post, Dr. P. This is information that will serve anyone well if faced with similar symptoms and cardiac history.
What is the range of normal ejection fraction? Is a BB appropriate at the first small increment below normal?
Traditionally, normal ejection fraction is 55-65%.
In the CAPITAL study I mentioned they were looking at patients with EF >40%.
i was put on metoprolol after elevated troponin levels, even though my tests showed no heart disease. i do have some mitral issues, but not bad. i felt terrible on the ‘bb’. because i have had extensive migraine history using a med called cafergot…at my next appt…i brought up the possibility that maybe i had a coronary artery spasm? the doctor thought it over and said possible…and that case a ‘bb’ is not good choice. i was switched that day to cartia xt and i can truly say i felt better immediately! i’ve had no problems other than some slight pain…which i traced back to my migraine med and now i am totally caffeine free and doing quite well! thanks for sharing this article!?