Metoprolol vision changes? Or is this something else? Graying out of vision in one eye only

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Honestly, I think the right hand is not talking to the left with my two cardiologists. There are just not that many people with rheumatic mitral stenosis in the US and I feel like I am getting "usually" answers when I am not a "usually."
A bit off topic, have to mention how I came home from school maybe 3rd or 4th grade, Radio was on and within minutes the DJ said congratulations to me for winning the contest. My mom had correctly named the song "I'm Not A Usually" by Tom Jones and asked them to use my name instead of hers.

Thanks for triggering the memory ;-)
 
Had follow up with neurologist today for the amarosis fugax. He underlined that this was a TIA, that it was likely valve related and that I should be anti coagulated indefinitely. For future forum miners yes, this specific vision pattern with vision obscured and / or retuning like a window shade is “classic” for amaurosis fugax / retinal TIA and an emergency.
 
Had follow up with neurologist today for the amarosis fugax. He underlined that this was a TIA, that it was likely valve related and that I should be anti coagulated indefinitely. For future forum miners yes, this specific vision pattern with vision obscured and / or retuning like a window shade is “classic” for amaurosis fugax / retinal TIA and an emergency.
sorry to read this ... are you still functioning on the valuplasty?

Reach out if you want a hand with INR management, but I'll assume that you're well covered with a clinic an all.

Best Wishes
 
Had follow up with neurologist today for the amarosis fugax. He underlined that this was a TIA, that it was likely valve related and that I should be anti coagulated indefinitely. For future forum miners yes, this specific vision pattern with vision obscured and / or retuning like a window shade is “classic” for amaurosis fugax / retinal TIA and an emergency.
I don't know how one could say that the TIA is valve related when A. Fib is also present it could be either. Also there was a mention of already being on Eliquis when these episodes occurred. That would make me a bit nervous that the next episode might not be transient. An antiplatelet drug might be considered also if these events are still happening even while on anticoagulation with Eliquis. Also there are different dose regimen with Eliquis. If you are still having these episodes and are on the lower dose regiment possibly adjusting the dose should be considered. Check with whoever is prescribing the medicine about these issues.
 
I'm nervous too, vitdoc; my Eliquis compliance was perfect. I have not had a recurrence of the amaurosis fugax since my ER visit. Neurologist considered adding aspirin but was worried about bleeding risk. I have an appointment with my cardiologist on 8/29. I am hoping that he will order the TEE that I (and the ER doc, and the on-call cardiologist who read my June echo) thought I should have had weeks ago. I just had the stress echo he ordered instead and gradient was bad enough that they aborted the exercise part. I will definitely ask him about on the dosing. Unless you think I should message before then. I have not had much luck with that, unfortunately, even though they seem to encourage it.

I do still have my native valve. Pellicle, I will definitely turn to you if they put me on Warfarin instead of Eliquis. They all seem to think it's the better choice, even though Eliquis hasn't actually been tested for moderate to severe mitral stenosis (left out of the trial due to elevated risk, just like mechanical valves).
 
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Hi!

Also experienced the same visual change as you described (one eye; my right only). This occurred ~2-4 weeks after my aortic valve replacement and I was on Warfarin/Robaxin/Metoprolol at this time.

I took my blood pressure when these episodes occurred and always saw an orthostatic drop of ~20-30 systolic and 10-15 diastolic which rebounded back to normal when my symptoms subsided (anywhere between 20 seconds to 2 mins).

Saw both my cardiologist and ophthalmologist who ran a head/neck CT with contrast. No vascular insult, no signs of acute stroke, all normal. They concluded it wasn’t a TIA and could have resulted in my muscle relaxer (Robaxin) use or too high of a metoprolol dose. They decreased the dose from 50mg 2x day to 25mg 2x a day and discontinued the muscle relaxer and it has not reoccurred since.

So who knows. I am chalking mine up to the high metoprolol dose and thankful it hasn’t reoccurred.
 
Hi!

Also experienced the same visual change as you described (one eye; my right only). This occurred ~2-4 weeks after my aortic valve replacement and I was on Warfarin/Robaxin/Metoprolol at this time.

I took my blood pressure when these episodes occurred and always saw an orthostatic drop of ~20-30 systolic and 10-15 diastolic which rebounded back to normal when my symptoms subsided (anywhere between 20 seconds to 2 mins).

Saw both my cardiologist and ophthalmologist who ran a head/neck CT with contrast. No vascular insult, no signs of acute stroke, all normal. They concluded it wasn’t a TIA and could have resulted in my muscle relaxer (Robaxin) use or too high of a metoprolol dose. They decreased the dose from 50mg 2x day to 25mg 2x a day and discontinued the muscle relaxer and it has not reoccurred since.

So who knows. I am chalking mine up to the high metoprolol dose and thankful it hasn’t reoccurred.

Interesting, I was newly on metoprolol succinate when this occurred, only 25 mg once a day, but my blood pressure is naturally about 100/60 and on that dose it dropped into the high 80s / high 50s during routine checks at home. The worst time it happened it I was hiking on a very hot day, might have been a little dehydrated on top of that.

Not sure why low BP would only affect one eye or cause the "windowshade" feature but that would be great if metoprolol were the cause. I'll ask. Thanks for sharing. I'm off the metoprolol now.
 
Interesting, I was newly on metoprolol succinate when this occurred, only 25 mg once a day, but my blood pressure is naturally about 100/60 and on that dose it dropped into the high 80s / high 50s during routine checks at home. The worst time it happened it I was hiking on a very hot day, might have been a little dehydrated on top of that.

Not sure why low BP would only affect one eye or cause the "windowshade" feature but that would be great if metoprolol were the cause. I'll ask. Thanks for sharing. I'm off the metoprolol now.
Typically it’s not in just one eye- which is why my ophthalmologist suggested the head and neck CTA. His ruling after that came back all normal was no concern and medication and subsequent blood pressure related :).

Wish you all the best.
 
Very similar. Progressive greying out almost in a tunnel vision lasting 30 seconds to a couple minutes then receding back out slowly until no deficits remained.
Also I had the whole ‘half circle in the top of my eyes’ pre-surgery for years that you described that usually preceded a headache so my doctor attributed it to migraine based symptoms
 
Thanks for clarifying. The tunnel vision part sounds similar but then when it resolved, vision returned from the bottom of the eye going up in a perfectly horizontal, crisp line, like a curtain going up at a theater or a window shade going up.
 
I had this once - it resolved after 10 minutes or so.

The next day, having trouble breathing, I went to the E.R. I had covid.

I don't know if the two events are related or not.

As for using Eliquis - I'm not entirely sure that this has any real advantage over Warfarin - except for profits made by the holders of the patent.

Warfarin is much less expensive. It's pretty easily managed. Testing can show the effects on INR. Aside from the free dinners and tchatchkes that doctors get from the 'detail persons' (who were previously called drug reps) who push this stuff, and the idea that patient compliance may be better if the person on Eliquis only has to take one or two pills a day (as opposed to one or two or more warfarin once daily), I'm not sure WHY you can't be on warfarin. You would have been ten years ago, before Eliquis became available.
 
I do still have my native valve.
Right. Good to know.

Pellicle, I will definitely turn to you if they put me on Warfarin instead of Eliquis. They all seem to think it's the better choice,
Eliquis (apixaban) is, for sure inferior to warfarin.

on this point:
even though Eliquis hasn't actually been tested for moderate to severe mitral stenosis (left out of the trial due to elevated risk, just like mechanical valves)
it has ... many times been tested on mechanical valves ... actually even more recently on the magic On-X valve

https://clinicaltrials.gov/study/NCT04142658

Brief Summary
Currently, warfarin is the only approved anticoagulation for patients with mechanical valves. The purpose of this study is to determine if participants with an On-X Prosthetic Heart Valve / On-X aortic valve can be maintained safely and effectively on apixaban. Both the On-X aortic valve and apixaban have been approved for use by the US Food and Drug Administration (FDA) but they have not been approved to be used together.​

...and an evaluation of that study is done here:

The trial was stopped after 863 participants were enrolled owing to an excess of thromboembolic events in the apixaban group. Most (94%) participants took aspirin. A total of 26 primary end-point events occurred, 20 (in 16 participants) in the apixaban group (4.2%/patient-year; 95% confidence interval [CI], 2.3 to 6.0) and 6 (in 6 participants) in the warfarin group (1.3%/patient-year;​
I am not a man of faith, I'm a man of evidence. Doctors love Apixaban because you don't have to monitor it ... as far as I know you can't readily measure its anticoagulation effect, and its marketed as a one size fits all. Well we know how that goes with shoes.

Basically, in my view, if you can't measure it its faith based. Since science just demonstrated that "it works" to be a flawed assumption I wouldn't touch it with your barge pole.

This underscores my apprehension (aside from the many discussions Ross and I had personally in the past)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9163724/

There is no established role for direct-acting oral anticoagulants (DOACs) currently in these patients with mechanical heart valves, regardless of the presence of other indications such as venous thromboembolism and non-valvular atrial fibrillation.1316 To prevent any ambiguity, the 2021 guideline update by the American College of Cardiology and American Heart Association clarified the term “nonvalvular atrial fibrillation” as not implying that VHD is completely absent; rather, “nonvalvular atrial fibrillation” indicates atrial fibrillation in the absence of moderate or severe mitral stenosis and mechanical heart valves—because patients with either of these two conditions were excluded from the key DOAC trials​

Eleqis is apixaban and it is a DOAC. There was a reason why it was excluded ... trials had already shown it to be inferior in cardiac use. This was the subject that Ross and I used to discuss commonly.

On the subject of how to measure anticoagulation effect:

https://www.vet.cornell.edu/animal-...rpretations/apixaban-anticoagulant-monitoring

yes, thats a veterinarian science posting (kinda how I feel about acitrom use)

How can I use the apixaban assay to guide therapy?
The apixaban assay measures drug levels based on its bioactivity as an inhibitor of Factor Xa (anti-Xa assay method). Measuring apixaban bioactivity will allow dose adjustment to prevent too much anticoagulant effect and risk for bleeding, or no anticoagulant action and inadequate therapy.​

If my dog needed ACT I'd use warfarin and test with my Coaguchek ... my livestock (cattle, pigs ...) no, I'd just use apixaban.


Best Wishes
 
The non warfarin anticoagulants are used because in the studies comparing them to warfarin there were proportedly more bleeding episodes with warfarin. These studies are used to justify the use of these drugs.
As far as I am aware none of these studies required self testing of INR levels on the warfarin side. So crummy INR control with warfarin may have more issues than these other anticoagulants.
You can be sure that the drug companies wanted this outcome. Whether better INR control would have had fewer problems was not tested.
So physicians faced with someone with AFib make their choice based on these studies which are constantly brought to physicians’ attention by the drug companies.
 
I will be discussing this with my doc again because I do have the (rare in the US) situation where I have (now severe) mitral stenosis and now afib, which I don't think has ever been studied for tx with a DOAC. I know they've tried DOACs (and stopped the study) with mech valves.

Of course this will all be a moot point if I am headed to surgery. I sure wish I would get a note on my tests already. It's pretty disconcerting to have them stop a test early, say you're much worse, and then radio silence for a week.
 
There's a lot of profit on apixaban -- the manufacturers of Coumadin stopped making it (afaik) once the patent expired -- no profit to be made there.

AFAIK - $8 a pill versus maybe a dime or two? It's certainly WORTH all the damned marketing for this stuff. It's also a shame that patients don't know enough to ask their doctors about warfarin when the doctor tries to prescribe apixaban. If any of us tried to get the word out, we'd be shut down in a few seconds.
 
Drug studies cost the drug companies a lot of money. The construction of the study is to maximize a positive outcome. So improving the warfarin side of the study with rigorous self testing when be counterproductive in terms of showing the new drug’s advantages. But to be fair, in the real world a majority of patients don’t do self testing.
 

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