New to a PM and ironing out the bugs

From reading through these forums I think I have a feeling where the answer to these questions may lie but it would be nice to get peoples feedback!

I had a pm fitted about 10 weeks ago for 3rd degree AV Block (total block) after never having any other symptoms except for collapsing and being bradycardic for 12 hours (maybe linked to radiotherapy 19 years ago). Its a Biotronik EVIA DR-T MRI dual lead unit. Initiall everything went fine and I never felt it doing anything at all. Been regularly walking all year and been getting fitter. After the PM this was going well.

Then I started to notice what I assumed was my PM working (funny beat feeling in chest) and started struggling on up hill walks that I was finding easy - and yes I did get that "pacing feeling". I had a routine treadmill stress test last monday and basically sucked once they went over the first setting. Pacing feeling started and then Short of breath, feeling not good. No typical "heart attack" pains however. Normal day-day activity rarely gives a problem but hills or a higher level of exertion does. Very frustrating considering I was doing much better only a short time ago.

There was also a curious incident 3 weeks ago where my blood pressure dropped so far it triggered a faint with really bad sweating/clammyness, visual effects and a trip in an ambulance. No reason was really established for the incident. PM was checked as fine (no problems logged). BP is typically v good but I am on Olmetec and Spironolactone to get it that way!

My "regular" cardilogist who did the stress test (seen him for 3 years) is in a different practice to my electrocardiologist (seen for 10 weeks) and I've just followed up to get the report sent to him. The report seems to indicate the PM needs adjusting as much as they will tell you anything on the phone. Certainly it wasnt flagged for other more serious problems like valve function and ischaemic heart issues (both of which I also have - ?Radiotherapy).

I see the electrocardio for a echo in a week and a review in 2 weeks. I'm off to Canada for a ski trip with the family mid december so I am pushing to get this resolved as soon as possible.

I havent yet been told much about my PM settings although one tech mentioned something about rates being set at 60 or 80 to 120 but the more detailed info I currently lack - something I plan to remedy after the next appointment.

I'm looking for any thoughts from members on possible areas to discuss/push with my electricardio on the next visit. Having a background as a Chemical Engineer I also like to thoroughly familiarise myself with any process - especially when its in my own body!

Thanks
Grant

6 Comments

Sounds familiar

by ElectricFrank - 2011-11-04 02:11:28

Definitely sounds like a setting problem.

Some background. In the normal heart there is a natural pacemaker (sinus pacemaker) which causes the atrium to beat at a rate determined by exertion, excitement, and a host of other things. When the atrium is made to contract it empties its load of blood into the ventricle. Simultaneously the message goes down the AV bundle and stimulates the ventricles to contract pumping its new load of blood into the arteries to supply the body.

Your 3rd degree AV Block means that the atrium to ventricular bundle of nerves is no longer conducting. This leaves you with a situation where the atrium beats normally, but the ventricles don't get the message. Fortunately the ventricles still beat at a very slow (20-40) rate which keeps us alive, but not very functional. To correct the problem a pacemaker senses the atrial beat, inserts an appropriate time delay, and then paces the ventricle. This puts everything back to normal and all is well.

Now the problem. There is an option in the pacemaker that sets the upper HR limit at which the pacer conducts the atrial beats. It is called the Upper Tracking Rate in my Medtronic and other manufacturers may use a different name. It enforces the upper rate by causing the heart to skip beats if the atrial rate exceeds the limit. For reasons that get complicated in people with a relatively even beat pattern this can cause the HR to suddenly drop by 1/2 when the limit is reached. From your description I'm guessing that your upper limit is set at 120bpm. So when you exercise until your HR reaches 120 it suddenly drops to 60. It does this at a time when your exercise level needs the higher HR so you feel out of breath and weak.

It is common for the pacemakers to be shipped from the factory with the Upper Limit set to 120. Depending on your physical condition yours needs to be increased to at least 140 and maybe 150. I had the same setting problem with mine and at 74yrs old at the time had a bit of a bru ha with the cardio getting mine increased to 150. I don't push myself that high, but I want to be in charge of it, not the pacer. It made all the difference.

One other issue to check on. There is a function call Rate Response that is usually turned on from the factory. It also needs to be turned off for simple AV Block. The best way to tell is that the Pacing Mode should be something like DDD. In any case the letter R should not appear in the mode designation. I won't try to go into the whole Rate Response scenario unless yours is turned on.

Hope this all makes sense. If you have any more questions let me know.

frank

Hi Grant!

by Hot Heart - 2011-11-04 04:11:05

There are loads of people on here who are very experienced and knowledgeable, but I see you have already heard from our guru of all knowledge, Frank. He is amazing and knows so much.

I struggled with walking uphill until I got my rate response turned on. It was like someone stuck a rocket in me! lol. One minute I was tired and finding walking uphill difficult, the next I could run up the hill.

Get your rate response checked out!

HH

Thanks

by nicbridge - 2011-11-04 08:11:40

Thanks Frank and HH - that helps put my mind at ease and gives me an avenue of attack if the Doc doesn't do anything (new to him so I have no idea what he's like).

Will update this thread after appointment in 10 days!

Grant

Timely

by Sunny70 - 2011-11-05 02:11:26

Gee, thanks for the info Frank. I too am having the problems with exercise and walking up hills. I have an appt. monday to try to figure it out. This will be a big help when I talk to them. Im 70 and had my pacer put in in July and have never been back to where I want to be. They keep adjusting but decided to bring the rep from Biotronik in monday for my appt. i just want to get back to as much normalcy as possible.. Plan to zipline in February and need to have some wind to climb the hills. I take Zumba dance classes and have had trouble completing them lately due to fatique. Hope it gets resolved this time. Your info should help.

Sunny 70

Rate Response

by Heidiglassmeyer - 2011-11-06 12:11:07

Hi Grant,

Just to add my experience as it relates to yours as well. My AV node was ablated during an EP study almost 2 years ago and have gone through SEVERAL changes in my settings. At first I was having the same symptoms as you. Initially my upper limit was increased however I was still having symptoms during maximum cardiac output. We went back and forth with increasing my upper limit however my EP would not agree to leave me at a high uppetreats so we decided to turn on the RR with a higher max than my regular settings. Many people have found with an AV block that it is not effective however, it has worked extremely well for me. It did take several "tweaks" in office with the RR for it to be "perfect". I happen to be fortunate and have an awesome tech who is an athlete herself and I think that helped. I say this because I had tried the RR "on" before with a different tech and it did not work as well.
So, keep at it until they get it right. Mine is working so well for me now that whenever I have anything done that relates to my PM I get paranoid and make them verify that my settings were not changed in any way :)

Heidi

An update

by nicbridge - 2011-11-09 10:11:24

I have just had an echo and seen the Biotronick rep. I don't get to see the PM cardiologist till next week and my other cardio till the week after but according to the rep my PM has hardly done anything of note but as we dug through figures it had logged ectopic heartbeats (app 4000 since ?). The symptoms of an ectopic beat certainly fit and it's hard to argue with the PM rep that if the pacemaker hasn't been doing anything then it's not causing the problem!

The echo was good too...a reasonable amount of calcification of the valve but no loss of function and all other parameters good!

Any comments anyone?

thanks
Grant

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