Mohammed's Journal

Rose Madura  There is An App called Medscape that has an interaction checker.  If something shows an interaction, I would check with your doctor.

Marie Myers  Omega -3 supplements might increase your bleeding time, so I would ask your doctor. Eating fish is a safer way to get your omega 3 levels higher.

Deena Z  Marie- thanks; didnt know that re: omega 3.  Plus a lot of us also take a daily baby aspirin, which can increase beeding.

Marie Myers  There are a lot of supplements can can increase bleeding time, so if you have an elective surgery scheduled, it is a good idea to stop all supplements at least 2 weeks before surgery of any kind.

Marie Myers  Correct. The omega-3 supplements may increase your bleeding time. I would check with your doc to see if he thinks it is okay to take them while on warfarin/ Coumadin type anticoagulants.

Marie Myers  Yes, it is possible to have other surgeries after having  a mechanical valve. Your doctor will substitute a shorter acting anticoagulant drug for your warfarin (Coumadin) so they can prevent major bleeding during another surgery. It is often called “heparin bridging “ here in the US, and your warfarin will be restarted after your surgery is completed  and you are stable. Hope that helps.

Susan Lynn  Marie - Your expertise is so valuable on this site!  I don't know what we'd do without you.  
Very helpful answer to this question! 

Mohammed Abdulrahman  Thank you Marie
It is valuable answer.

so the major problem just for blood bleeding , and for suspected problems in the heart itself? 

Marie Myers  Yes, the major concern is the possibility for bleeding in a patient on warfarin. It takes careful preoperative and intraoperative management of the medications for a successful outcome.  I imagine your heart is working well with the new mechanical valve, so there may only be  some antibiotics used to prevent infection. Hope that makes sense!   Hopefully you will not need any other surgeries, but if you do, the doctors know what to do!

Mohammed Abdulrahman  Thank you Rita, take it alone or with vitamin K2? 
I have read that vitamin D3 is active with K2 , as K2 help to take calcium to bone and teeth 

Rita Savelis  I've never taken vitamin K2. No doctor has ever mentioned it and the form of vitamin D I take does not have K2. Vitamin K is present in many foods especially green vegetables and tomatoes so that's a way to get it.

Robert Miller  You really need to discuss this with your doctor. There are many different blood thinners that interact differently with vitamins and food. Just as an example, if you are on warfarin/coumadin, you need to watch your K2, both as a supplement and as food intake. I am on Xarelto and that one doesn't have any interaction with K2. But Xarelto isn't for anyone with a mechanical valve. My point is, there are many factors and you should discuss this with your doctor. 

Marie Myers  Robert is correct. If you are on coumadin( warfarin) you should discuss the Vitamin K question with him/her. Vitamin K2 will work against warfarin, and could cause clots to form.

Robert Miller  You really need to address this to your doctor. But to my knowledge, there is no interaction between D3 and blood thinners including Warfarin. K2 is the bigger issue. But consult with a doctor. 

Yumiko Ishida  D makes your blood thinner, so it will affect your INR. When I was on Warfarin, I added it slowly into my routine while monitoring my INR weekly. After surgery, my surgeon prescribed a multivitamin that included K, so when the prescription ran out, I came up with a supplements regimen that included K2. As long as you discuss it with whoever is managing your warfarin dosage, it is possible.

Robert Miller  It's probably obvious but "blood thinners" don't "thin" your blood. They reduce the ability of clotting. On one hand that's a good thing if you have a mechanical valve or are in AfiB but it leads to bleeding to take longer to stop, more bruising, etc. Unlike "baby aspirin", vitamin D isn't considered a blood thinner but it might actually affect how warfarin works. K2 has a bigger influence. The important part is that you keep the intake of vitamin D and especially K2 somewhat constant and as Yumiko mentioned, measure your INR. Initially, you probably want to measure your INR frequently. Once you figure it all out, you don't need to measure it that often. 

Marie Myers  My cardiologist recommended magnesium Threonate for me. He said it may help to stabilize my blood pressure. The directions on the bottle recommend 3 per day, but I just take 1 in the morning. . I also take one magnesium glycinate ( 120 mg) at night to possibly help with sleep.  Too much magnesium (especially citrate) can cause loose stools/diarrhea, so start low and see how you do. 

Yumiko Ishida  I take magnesium in two forms most of the time - magnesium chloride in liquid form and magnesium bisglycinate as part of a cal/mag/D formula. As far as I know, the best form is the best you could tolerate. As Marie points out, it could cause digestive issues, so you definitely want to start low and gradually increase. I read that most people find magnesium glycinate easiest to stomach. I like the liquid magnesium chloride diluted in water because I could sip it in small quantities throughout the day. If I am traveling, I take magnesium glycinate for the convenience of its capsule form.

Jennifer Holly  I think the formula depends on the purpose of the magnesium. I use magnesium to prevent migraines and constipation so I use 400mg to 800mg of a combination of magnesium oxide and magnesium citrate. This is prescribed by my neurologist.

Marie Myers  I don’t think there is much risk of infection/ inflammation from swimming in a pool or ocean after heart surgery as long as all wounds are healed.

Marie Myers  Because the mouth contains many bacteria which can infect an artificial or natural valve. When the dentist causes bleeding through dental procedures or cleanings, these bacteria can spread to the valves through the bloodstream.

Robert Miller  Swimming is pretty hard on you rib cache so you want to be careful about this for about 3 months after surgery. For the first few weeks, there might be inflammation from the open wound. So be careful of this. Basically, take it easy for the first 2-3 months and then you should be able to whatever want to do (I was told 6 months for golfing). 

Sue Maize  Hi Mohammed, Im not sure what the waiting period would be to swim after minimally invasive surgery—I had open heart and had to wait 12 weeks so I’m sure it’s much less for you. Of course, the incision needs to close and heal sufficiently, but you won’t have the restrictions of someone who had their sternum opened—that’s the main difference, more to do with exertion of upper body muscles than the actual incision. Check with your doctor to see how much you can exert yourself. 

Mohammed Abdulrahman  Thank you Sue
I have been 18 months since surgery. 
I only wanted to make sure there was no concern related to precautions against bacterial infection in the pool area

Marie Myers  I would say flu will have respiratory symptoms like runny cough, stuffy nose, coughing. Endocarditis wouldn’t have the respiratory symptoms. Hope you can get some answers. It seems this is an ongoing problem.

Fidel Martínez Ruiz  I recommend that you go to the doctor. I was quite well and three years ago I had endocarditis. It is a very rare disease, but it happens without being able to detect the cause (previous surgeries, tooth extraction, etc.). Consequences: replacement of the mitral valve with a biological prosthesis in open heart surgery. My symptoms were: low-grade fever, feeling of tiredness and little desire to eat along with a loss of taste in food.


Most likely you have nothing, but it is worth seeing a good internist. Good luck and may God bless you.

Mohammed Abdulrahman  Thank you Fadel
how you did know  the endocarditis? , by blood culture or echocardiogram? 

Indeed, i did 4 teeth extracted , but i taken antibiotic before process.. i also went through root canal of tooth last week.. 
So, i sometimes felling frequent body cold/hot 

Fidel Martínez Ruiz  Hello Mohammed: In my case, after noticing this
fatigue and mild fever for a few weeks, I went to the family doctor, who
prescribed me a general antibiotic, which apparently solved the problem. I
resumed my walking (I go hiking), apparently without any problem. But after 15
days, I started to feel symptoms and went back to the doctor, who sent me to
the hospital, where they did a CT scan and found some "vegetations"
in the liver. After a blood test,  found a
bacteria (streptococcus viridians mitis). They did an ECG where detected mitral
insufficiency and I was on antibiotic treatment for 1 month until the bacteria
was eliminated. Afterwards, did other ECGs and saw that the mitral valve continue
been affected, and  scheduled me for
mitral valve surgery.


I hope the too long story of my illness helps you. May God
bless everyone.

Fidel Martínez Ruiz  I think in your case the best is doing a  very complete blood test in order to clarify if you have an infection.

Mohammed Abdulrahman  Thank you so much for your sharing
How many your body temperature was recorded?  


Have you made any teeth procedure? 

Fidel Martínez Ruiz  Hello Mohammed. I had no any teeth procedure, but I had a mitral valve deficiency, perhaps genetically (my father and brother were operated, having suffered both mitral replacement). When I had the endocarditis, the fever was low (37, 37,1, 37, 4 etc...). The sinthomes were mild fever accompanied
by reluctance and a feeling of great tiredness.

Fidel Martínez Ruiz  I recorded the temperature every day in one week and always was 37,  37,1, 37, 5, and so on nor lowering along all these days.

Mohammed Abdulrahman  Thanks Fidal for your clarification .
It seems that bacteria attacked congenital heart valves . Normal valves are not attacked by bacteria.

I was diagnosed with bicuspid aortic valve , i suffered from severe fever and cough for 4 months (on 2021). 

Then i went through open heart surgery to replace it with mechanical valve.

Robert Miller  I don't know but below is what ChatGPT o3-mini-high says. Don't rely on it...

1. Flu Attack (Influenza) Symptoms
• Sudden Onset: Flu symptoms typically appear abruptly.
• Fever & Chills: High temperature with chills is common.
• Respiratory Issues: You may develop a dry cough, sore throat, and a runny or stuffy nose.
• Body Aches & Fatigue: Muscle and joint pain, headache, and a profound sense of tiredness are characteristic.
• Gastrointestinal Symptoms: In some cases—especially in children—nausea, vomiting, or diarrhea can occur.
These signs indicate a viral influenza infection, which usually lasts from a few days to a couple of weeks. 
CDC.GOV


2. Bacterial Attack (Bacterial Infection) Symptoms
• Fever & Chills: A high, persistent fever accompanied by chills may signal a bacterial infection.
• Localized Pain & Inflammation: If the infection is in a specific area (like the skin), you might notice redness, swelling, warmth, and pain; pus may form in cases of abscesses.
• General Malaise: Fatigue, weakness, and sometimes swollen lymph nodes can occur.
• Site-Specific Signs: For example, strep throat often brings a severe sore throat with white patches on the tonsils and tender neck lymph nodes, while bacterial pneumonia might cause a cough with chest pain and shortness of breath.
These symptoms can vary widely depending on the infection’s location and type. 
MY.CLEVELANDCLINIC.ORG
MEDICALNEWSTODAY.COM


3. Endocarditis Attack (Infection of the Heart’s Inner Lining) Symptoms
• Persistent Fever & Chills: A lingering fever (sometimes with night sweats) is common.
• Heart Murmur: A new or changing heart murmur (often detected by a doctor during a physical exam) can be a key sign.
• General Malaise: Fatigue, weakness, and unexplained weight loss may develop over time.
• Vascular/Immunologic Findings: Look for small red or purple spots on the skin (petechiae), painful nodules on the fingers or toes (Osler nodes), painless red spots on the palms or soles (Janeway lesions), or splinter hemorrhages under the nails.
• Additional Signs: Shortness of breath, chest pain, or swelling in the legs or abdomen may indicate worsening heart function.
Because endocarditis affects the heart, these symptoms require urgent evaluation. 
MY.CLEVELANDCLINIC.ORG

Amy Minto  I haven't gotten my valve replaced yet but I just walked out of a neurology appointment, and my neurologist said her patients on Coumadin often report being cold at unusual times.

Robert Miller  I had valve repairs, i.e. no medical valve. When I talked to the dentist, she wouldn't proceed with testing the pocket size or do cleaning until the cardiologist confirmed I need antibiotics or not. The dentist submitted that request  assuming the worst-case scenario (drilling which I don't need, etc). I think my cardiologist is overly cautious but he said I should take antibiotics for 3 days before any procedure. So if I have to take antibiotics with just a repaired valve, I would assume you also have to take it with a mechanical valve. 

Rita Savelis  Hello Mohammed. I have 2 mechanical valves and take an antibiotic (prescribed either by my cardiologist or dentist) one hour before I have teeth cleaning (every 6 months). My dentist is able to tell me whether I need antibiotics as he is aware of the invasiveness of any procedure and the risk of an infection descending to my heart valves. Please ask your dentist and/or your cardiologist. Take care. And sorry about the root canal!

Mohammed Abdulrahman  Robert , i think you have repair valve and the cardiologist recommend you 3 days antibiotic before dentist procedure.. 
we have mechanical valve and the cardiologist recommends one time antibiotics before 30 minutes 

Susan Lynn  Yes. Premedication is required. I also do one large dose before the appointment.
I've had several root canals, the name is worse than the procedure. You'll do just fine.

Robert Miller  @Mohammed, yes, I just have a repair. My point is, if my cardiologist says to take antibiotics, then someone with a mechanical valve really should take antibiotics. I just checked and I actually have to take the antibiotics for 2 days before the procedure. Each day 2000mg  (4 capsules of 500mg) of cephalexin.

You probably also have to stop blood thinner before the procedure.

Susan Lynn  The dosage depends on the antibiotic you're prescribed. There's a lot of conflicting information, but my dentist is a firm believer in premedication.
 https://www.mouthhealthy.org/all-topics-a-z/antibiotic-prophylaxis-for-heart-patients

Marcus Krauss  My cardiologist has prescribed me 500mg of Azithromycin to take one hour before any dental procedure or cleaning.

Rose Madura  I had a successful implant long BEFORE my surgery.  Just be sure you take antibiotics prior to each procedure. 

Mohammed Abdulrahman  Thanks rose for your response. 
I already take antibiotic (amoxicillin 1000 gm) before procedure 30 minutes. 

Marie Myers  I had a tissue valve in 2017, and had 2 implants with an extraction and bone graft last year. Everything came  out fine, and I expect them to last the rest of my life. 

Mohammed Abdulrahman  Hi Marie , happy to see your comment.

Marie, why you went through bone graft? Do you have specific problem in your jaw ?

Marie Myers  I needed the bone graft because the 2 molars had been missing since i was 18 years old. So over the next 50 years, the bone receded so much, there was not much bone to set the implant in. 
3 months after the bone graft there was enough bone growth to hold the implant. 

Mohammed Abdulrahman  Happy to hear this update.. I hope everything getting well

So , you taken antibiotics before the bone graft procedure? 

Marie Myers  Yes, before the bone graft and for 7 days, I believe. I also had an extraction done at that time with immediate implant. Then months after the bone graft grew new bone, I had the second implant placed in that second spot. Of course, I took more antibiotics for that too. But, it has been a year or so, and everything is good.

Robert Miller  What is your regular hear beat? Compare that to your 115. Sounds high to me. When I use the elliptical machine I get to maybe 130+. When I stop, my pulse goes down to 90 within 2-3 minutes. It takes a bit longer to go down to 60-70 but not one hour. Your resting HB should not be more than around 90. 

Robert Miller  Pamela makes a good point. I have a Galaxy watch (also tried iWatch) and they get the pulse completely wrong. You have to use the EKG function to get the right heart beat. Now, if your resting(!) heart beat (sitting for 5+ minutes/sleeping/etc) is between 80 and 95, that is rather high. I had this issue but after cardioversion it dropped a lot. 

Brady Busch  I may have taken low dose aspirin,when taking warfarin,which was after surgery for maybe a year.Then my cardiologist made Eliquis available,to replace it and he said to use aspirin also.He told me,that it helps with another part of the blood,the platelets,I think.

Marie Myers  Unfortunately, abnormal valves and replaced valves can be more easily infected by bacteria than normal valves. Dental problems can be a serious cause for valve infections, so  it is very important to take care of your teeth!

Marie Myers  I would guess that you might show high levels of C reactive protein or homocysteine. These are blood tests that can indicate inflammation in your body, along with a high white blood cell count which could indicate infection. Also, you might show symptoms such as fast heart rate, fever, chest pain. That is a question best asked of your cardiologist. 

Mohammed Abdulrahman  Thanks so much Marie for your valuable comments

To confirm, white blood cells is in range. 

May i will do CRP and homocysteine test this week for more confirmation

Rose Madura  I'm not a doctor but it sounds normal, I suppose. What is your usual resting heart rate? What does your doctor say about it?

Robert Miller  48 degrees it really high. That's like 120 Farenheit. Are you in Saudia Arabia, Death Valley, Sicily, or some place like that? Heart pressure looks normal. HP seems a bit high but it's 48 degrees so it might be ok After all, it falls to 86. What is your resting hear rate, though. Like when you laid down in your bed for some 15 minutes. Discuss this with your cardiologist. 

Robert Miller  @Mohammed That explains the temperatures. I suspects it's very dry.
You listed your stats when you were in the car but was that a car with an AC running? I would assume so as otherwise the stats would go up. 110/80 is quite good. 86 depends on what you are doing. If you lay in bed in a climatized room (like 80) then it's really at the upper limit. If you are moving around at elevated temperatures (like 90+) then I think it's normal. When you take a hot shower your heartbeat goes up, too. But don't take my word for it. Talk to your cardiologist. 

Brady Busch  Thanks for posting that,Mohammed.After looking further,the European Union,has all but banned these antibiotics,citing possible permanent nerve damage and other side effects.

Brady Busch  Mirza,this is from WebMD:
The fluoroquinolone antibiotics include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), and ofloxacin (Floxin).

Marie Myers  These antibiotics ( like Cipro) also increase the risk of tendon ruptures…Amoxicillin does not carry this risk.

Brady Busch  I'll do a Richard joke here.If anyone wants to give someone an antibiotic,with the word flox in it,get the flock out of there!

Mirza Baig  My RN prescribed Amoxicillin (4 tablets)for my dental appointment coming up soon- My TAVR was done on August 27,2024

Mohammed Abdulrahman  Hi Marie
I am taking Amoxcilin irregularly, just before going dentist, i seen that  Amoxcilin can interact with warfarin. Is there alternative to warfarin? 

Mohammed Abdulrahman  Hi Mirza
4 tablets you should take at one time? Or frequently? 
what are the amount of 4 tablets dosage? 2gm?

Brady Busch  Mohammed,I
was taking Warfarin,for maybe 3 months after getting a cow type aortic
valve.My cardiologist told me later,that Eliquis(Apixaban),was available instead.So,that is what I'm using.The thing is though,Eliquis is not approved for people with mechanical heart valves.My dentist wrote a prescription for the antibiotic,Azithromycin,which hasn't caused any noticeable side effects for me.

Marie Myers  There is no safe alternative to warfarin at this time. Like Brady said (above), Eliquis (or any other anticoagulant )is not approved for mechanical valves. Also about your question about  the four tablets of amoxicillin, 2 gm would be the correct dose for a one -time dose, like for a dental cleaning. Taking four 500 mg  tablets would give you the 2 gm dose. If you are on amoxicillin for 7-10 days, the dose would be one 500 mg tablet three times a day. Hope that helps!

Rita Savelis  I take Amoxicillan an hour before I see a dentist (for teeth cleaning) as I was told it could prevent infection that could travel to my heart. However, Amoxicillin can interact with anticoagulants so if you are taking it longer term you might need to test and possibly adjust your anticoagulant dose. It might be better for you to take tylenol (acetominophen) when you have a fever unless you are certain you have an infection. Your doctor or pharmacist should be able to advise you.

Marie Myers  Is the amoxicillin for an infected tooth? I remember you writing that you had some problems with your teeth. The only problem i can think of is like Rita explained in the above answer. Amoxicillin may prolong your bleeding time, so you may have to change your dose of warfarin if you are taking it for a longer time. 

Suzette Schear  I also take amoxicillin before going to the dentist. Is your doctor telling you you have an infection and need to take it?

Mohammed Abdulrahman  Hi Marie
Yes i went to dentist and he pulled out the tooth 
but i am felling with some pain and fever 
he told me you should take amoxicilin

Mohammed Abdulrahman  No , i do not have infection , i just went to denstist and he puled out the tooth and i am feeling with some fever and pain underneath the tooth 
he told me you should take amoxicillin, but i heard that amoxicillin not good for heart so why i am posted this question

Suzette Schear    I was always told to take amoxicillin before going to the dentist to help me prevent endocarditis. I never had to take them after.  I would call my doctor and double check if it’s okay.   The fever can be concerning 

Max Jam  Hello Mohammed, congrats on your surgery. At what age did you get your surgery? And i also see that you talked to Dr. Takayama. What did he say regarding repair? Not a candidate due to stenosis?

Brady Busch  After surgery and recovering in the ICU,there was sinus block for about 10 seconds.I'm not sure exactly what that is,but it was serious enough,for them to decide and install a pacemaker.

Yumiko Ishida  Are you on a bridge drug while pausing warfarin for your dental procedure? When I was on warfarin I had to be on enoxaparin if I had to pause warfarin for whatever reason. It’s an anticoagulant that is fast acting and doesn’t stay in your system for very long. Without it your INR could get too low for too long.

Rita Savelis  I don't hear my tick tick sound most of the time. In fact it's very rare that I hear it. I feel for you Mohammed. That first year after heart surgery one can feel nervous a lot of the time.

Mohammed Abdulrahman  Hi Max

I get the surgery at 37 years old. 
My aortic valve was bicuspid valve with severe regurgitation, and when i talked with Dr. Takayama (Mar 2023) he recommended me to replace the valve , as he just recommend repairing tricuspid valves. 

Mohammed Abdulrahman  Hi Brady
I think pacemaker installed for those who have problem in heart rythem ( rapid or slow heart beat) accompanied with symptoms such as dizzy, short of breath , etc..

Mohammed Abdulrahman  Hi Rita
Do you have mechanical valve? 
All kind of mechanical valves produce sound like “clicking mouse” 

Rita Savelis  Hi Mohammed. I have had 2 mechanical valves (aortic and mitral) since 2015. I very rarely hear any clicking from them. Sometimes when it's very very very quiet - but usually I don't hear anything.

Rita Savelis  Mohammed, if a doctor listens to my heart with a stethoscope, of course he/she will hear my valves click and know that I have mechanical ones. Also if someone presses their head to my chest. And occasionally I can hear the sound if it is quiet. But everyone's heart is different and I am really not aware of the clicking sound of my valves. But I have had them a long time (9 years). At the beginning I was more aware. I know some patients are afraid that the clicking will bother them but it was really not something I worried about beforehand. There is so much else to worry about! Hope that you are feeling better and that your infection (from dental work) has gone away.

Ann T  I have a mechanical valve and have also noticed the visible beating at times. Notice it in my feet when I dangle my feet or sometimes arms too. I got nervous one day and called the after-hours line because I noticed I can now sometimes see my pulse bounding in my wrist. Im told as long as Im not in pain or short of breath not to worry about it. Im thinking it is just the way the blood flows now with the  mechanical valve and blood thinners. 

Marie Myers   you should do all you can to treat the gum and tooth inflammation. The new heart valve can be severely damaged by bacteria from infections in the mouth. You should see a dentist as soon as possible to take care of the infection. Have you seen your cardiologist recently? You should discuss this with the cardiologist. Good luck!

Grace Mason   Yes, I agree with Marie. You definitely need to address any teeth and gum issues as soon as possible. Heart health is directly related to gum and teeth health.

Rose Madura  Mohammed, I seem to get a different reading every time I take my blood pressure. I think it's pretty normal for it to vary each time.

Yumiko Ishida  Is there a typo? When you rest after walking the BP maybe 102/82? I think that is normal. Before exercise will be your base line and it goes up during exercise but then it drops right after you stop. Your blood vessels open up during exercise and remain open for a while even after you stop. Heart rate also takes a little time to return to base line.

Yumiko Ishida  I think it’s normal, unless by “a while” you mean hours. My BP takes a dip right after stopping the exercise but it returns to a slightly elevated state for maybe half an hour. Heart rate takes a little longer to come down, but at cardiac rehab they told me it’s ok to resume normal activities if it’s within 10 above the resting rate.

Jennifer Fuller  That sounds really great, but do be careful. I took a walk with my PT yesterday and he reminded me that you should be able to talk a bit while walking. You might be going a smidge too fast. Do you have a target heart rate for exercise?

Jennifer Fuller  There is a “target heart rate” for exercise. It’s based on your sex, age, resting rate rate, goals for exercise, etc. My PT gave me a target of 100 to 120. So when I’m exercising, I check my heart rate (I’m using a fit bit, but there are other options) to make sure I’m working hard enough to make progress, but not so hard that I’m putting too much stress on my heart.

Rita Savelis  You are normal Mohammed and doing very well for only 19 days. Give your body some time and you'll get there. 

Marie Myers  Several people on this site  have reported higher pulse rates after surgery. I bet yours will gradually come down with a little more time. Might be a question for your cardiologist next visit if you are still concerned about the rate.

Karen Hanna  I would definately mention this to your cardiologist.  It is not abnormal after heart surgery.  Pre-mitral valve repair surgery my heart rate was around 64bpm.  Post surgery it sat around 118-125.  Your heart needs time to heal and beating fast does not help.  My doctor put me on low dose Matroprolol and Corlanor.  Heart rate has settled to around 74bpm.  As you exercise more efficiently your heart rate should start to settle and meds can be adjusted.