Who Understands How Rate Response Works?

I have posted a couple of questions on this site. One I commented on an older post from three years ago. Unless I go to my own postings I don't see it showing up in the General Topic. Anyway what I would like to know, is who on this site would be able to help me intepret my readings on my Interrogation. I am starting to think I have a pacemaker rate response problem and not what my cardiologist said. He said my body just needed to get acclimated to having a normal heart rate on exertion. I just had a Nuclear Thallium Stress Test and Echo that came back looking great, so no heart block. Any help would be appreciated. i apologize if I don't have the correct terminology. Having a pacemaker is a new experience. Thanks!

27 Comments

Get a new Tech

by ebfox - 2012-09-06 10:09:09

From personal experience, plus reading many similar experiences on this website, it is not unusual for PM techs to not understand how to set up Rate Response. And the ones that don't understand are the ones that say things like "you just need to get used to it..."

Get a PM tech that will put you walking on a treadmill (or jogging if that is what you do). It is very important to individually tune it for your level of activity. If you don't, you will be over and under paced frequently (which is no fun as you are already finding).

One other possibility- from your post I could not tell but are you sure that you are cronotropically incompetent (meaning that your intrinsic rhythm doesn't react correctly to exertion)? If your heart is not CI, then you probably need Rate Response turned off. Otherwise your natural rhythm will fight Rate Response (and this is no fun either).

Best of luck and let us know how it works out-

EB

History and Parameters report

by tachybrady69 - 2012-09-06 10:09:18

I wrote a posting called Jaw and Left Arm Pain. I had my PM implanted July 10, due to mostly Brady. I also had Tachy, too. I had a couple of years of episodes of AFib. I didn’t start going to ER until this Jan when they seem to get worse. I had an ablation in March which worked for a while for Atrial Flutter. Then I had an episode of AFib that they had to Cardio Convert me, It was then I was told that I could wait no longer tom have the PM put in,

It took longer for the incision to heal because the swelling lasted longer. I started walking at about three weeks. I would walk at a steady pace, not too fast but not too slow. I wanted to condition myself to go back to work, which involves commuting by a train and bus. Within 5 minutes after I was walking, my jaw and left arm started hurting, My heart also felt like it was pounding. I know what those signs can mean so I stopped. As soon as I did the pain went away. So I thought okay, I’m not having a Heart Attack. I did not have SOB. I had an EP visit coming up that Friday, so I figured whatever was going on I could find out then. I didn’t go walking the rest of the week.

I went for my first Interrogation that Friday, July 27. Due to an emergency I saw my EP’s associate, not the EP I hired. Now I don’t have any idea what is happening. This is my first time for this. The nurse actually did the Interrogation. She said I was pacing 99% of the time. I asked her isn’t that going to wear the battery down? She said not necessarily. I happened to have worked in electronics and knew she was full of it. So she won no points with me, Anyway, the EP comes in and I explain how concerned I was about the swelling, the pain, not being able to sleep. He seemed unconcerned. He said the swelling not going down, could be because I have blood that may have pooled under the incision. It would go down within a month. He said everything is fine, The PM is working fine. I don’t have to see you for three months. I was upset to say the least. At that time I decided I would never let him examine me again. I went to the secretary and said I wanted to make another appt to see my EP. She made it for the following Monday.

That Monday my EP calls me. He couldn’t understand why I wanted to come in see him since I was seen by his associate the Friday before. I told him what was going on. He ordered me more pain meds, said it is not a big problem that I was still swollen and he would see me as soon as he got back for vacation. His nurse couldn’t get me in until Aug 17 when all was said and done. He has three different offices.

Meanwhile I decide to go walking again. The same thing happens so I stop. I didn’t have problems just walking around the house; it was just when I walk for any length of time and got my HR up. I saw the EP on the 17th, and ended up being very disappointed. He did another Interrogation and said everything looked fine. He did tweak something a bit but didn’t tell me what. I did ask him for readout of the report which he gave me. He should me that my activity level was 2.97% at that time. He said I was otherwise being a couch potato. I told him why I hadn’t been more active and he said it was not a PM problem and I should see my cardiologist.

I talk to my cardio the following Monday and he orders a Thallium Nuclear Stress Test and Echo done. I see him the following week and he says my test came back great. I have no blockage, and my ejection factor was better than before I had the PM put in. He looked at my Interrogation report, which I brought with and said it all looked good. He said I have had a lot done to me in the last 12 yrs and I seem to heal slower. He said my HR was always in the low 40’s and sometimes 30’s and maybe my body needed to adapt to my HR being normal now. He gave me another month off work as I told him there was no way I could travel to work at a snail’s pace and having the pain. He said the pain was not associated with angina or a heart attack so I just needed to keep walking and build up my endurance.

Now I just looked at the Pacing Summary:
Mode: Rates: AV Intervals:
AAIR DDR Lower 60 bpm Paced AV 180 ms
Mode Switch: On Upper Track 130 bpm Sensed AV 150 ms
Upper Sensor 130 bpm

Pacing Details: Atrial RV
Rate Response 8 Ampitude 3V 3V
Activity Threshold Medium Low Pulse Width 0.4 ms 0.4 ms
Activity Acceleration 30 sec Sensitivity 0.6 mV 0.9 mV
Activity Deceleration 5 min Pace Polarity Bipolar Bipolar
Sense Polarity Bipolar Bipolar


AV Therapies
Rate Adaptive AV Off Arrhythmia Interventions
A. Rate Stabilization Off
A. Preference Pacing Off
Post Mode Switch Off
V. Rate Stablization Off

New tech

by tachybrady69 - 2012-09-06 11:09:28

I was thinking of getting a second opinion. Since I am new at this and not a veteran like some are, I wanted to believe that my EP knows what he is talking about. After having the testing done and knowing my pain when walking it isn’t due to a blockage, I just can’t help but think my settings are wrong. I have been all over this site and have been reading a lot about the settings. Like you said, the rate response needs to be set for me. Where do I find a tech that does the test with a treadmill? I didn’t seem to recall seeing one in my EP’s offices. That doesn’t mean they didn’t have one there. I was planning on giving it a week of walking just to see if the pain gets less and less, but my gut tells me it won’t. I do need to get someone to listen to me and fix the problem. The problem is not me! Now as to your other comment, I was thinking the same thing. Why do I need the rate response on? You are right, it could be hindering me, as it does seem like I am fighting with it during activity. Those are good points. I did post in answer to PacerRep above. I gave a history of what has been going on the past year.

You Won't

by PacerRep - 2012-09-06 12:09:20

It will not say on the interrogation report the type of sensors you have, but the Revo only has the accelerometer that we spoke of, no MV. The next question is..."is it turned on". Take a look on the report under the basic parameters section you should see something along the lines of VVI, DDD, AAI/DDD. Do you see the letter "R" after any of these? It would be in the same area as your heart rate settings "60ppm" etc

Medtronic

by tachybrady69 - 2012-09-06 12:09:39

I have a Dual Chamber Medtronic Revo MRI RVDR01 Where on the Interogation report would I find what sensors are on it?

Rate Response

by PacerRep - 2012-09-06 12:09:49

I can answer any questions you have about the activity sensors in your device. First it is helpful to know what sensors are in your device. There are 2 possible sensors. First is the Accelerometer, this works strictly off of "muscle noise". as in vibrations. There is basically a free floating "bar" attached to the circuit board of the device and as your stomping around doing your daily activities that "bar" starts to vibrate. The more movement on the bar translate to a faster paced heart rate. The second type is called Minute Ventilation. Many devices have both of these sensors where one or the other (and even both) can be turned on. MV works basically by measuring your breathing...how heavy and how fast you are breathing...Heavier faster breathing usually means activity.

Now there are ways to tweak these sensors if they are not set apropriately, thats where the diagnostics of the interrogation report come into play. What brand pacemaker do you have?

There is also a 3rd type sensor, but is only available in Biotronik models.

Also

by PacerRep - 2012-09-06 12:09:56

I should have asked you why you feel the sensor is programed inadequate? Do you feel increased fatigue during activity (walking, jogging, shopping, stairs etc)? Knowing a little bit about your physical abilities is helpful.

EB

by tachybrady69 - 2012-09-07 01:09:29

I wish I had realized I had a rate response when I talked saw him Aug 17th. I wouldn't have wasted all this time. I have to thank this site for being here because it is helping me out a lot. Why do the EP's just tell you that you are getting a PM but don't explain much about it or it's features. All I knew is that it was a Medtronic Dual Chamber MRI compatible PM. Now I need to try and get an appt to get in to see EP again. I'm calling right now! Thanks! If it can't be turned off at least I will ask him to change the setting.

I am so stressed!

by tachybrady69 - 2012-09-07 02:09:18

Thanks EB

I just called and talked to my EP nurse. I ask her about turning the RR off. She said that the RR runs the PM. If they turn that off I won't be paced at all because I have SSS. I am being paced 98% of the time. She said the RR only works if my heart tried to go below 60bpm which is what it is set at. She said the PM does not control how fast my heart wants to go. Even though my low is set at 60bpm and my high is set at 130 bpm. So then I asked her about changing the pacing settings. I said my activity level is set at medium to low. She had no idea what I was talking about. So I got mad and upset. She asked me if I wanted to make an appt with the EP. I told her only if he was going to be able my questions better than her. She did do my 1st Interrogation, so to me that is scary, that she did not know what I was talking about when I mentioned the Pacing Details. So I have an appt for Monday at 10am. This whole PM thing is driving me nuts. I feel like I am going two steps forward to understanding how the PM works, to one step backwards when I am talking to the nurse and doctors. My problem before the PM was low heart rate, They said I had SSS, significant pauses and of course tachybrady. I did not have a problem before the PM with my HR on exertion. I don’t get it. Anyway, I’ll post on Monday as to what happened. I may have to find someone who is willing to figure out the problem if my EP doesn’t help me.

TB

I am so stressed!

by tachybrady69 - 2012-09-07 02:09:19

Thanks EB

I just called and talked to my EP nurse. I ask her about turning the RR off. She said that the RR runs the PM. If they turn that off I won't be paced at all because I have SSS. I am being paced 98% of the time. She said the RR only works if my heart tried to go below 60bpm which is what it is set at. She said the PM does not control how fast my heart wants to go. Even though my low is set at 60bpm and my high is set at 130 bpm. So then I asked her about changing the pacing settings. I said my activity level is set at medium to low. She had no idea what I was talking about. So I got mad and upset. She asked me if I wanted to make an appt with the EP. I told her only if he was going to be able my questions better than her. She did do my 1st Interrogation, so to me that is scary, that she did not know what I was talking about when I mentioned the Pacing Details. So I have an appt for Monday at 10am. This whole PM thing is driving me nuts. I feel like I am going two steps forward to understanding how the PM works, to one step backwards when I am talking to the nurse and doctors. My problem before the PM was low heart rate, They said I had SSS, significant pauses and of course tachybrady. I did not have a problem before the PM with my HR on exertion. I don’t get it. Anyway, I’ll post on Monday as to what happened. I may have to find someone who is willing to figure out the problem if my EP doesn’t help me.

TB

She is wrong

by ebfox - 2012-09-07 06:09:37

This is the kind of thing that drives you nuts. That nurse doesn't know what she is talking about. When a patient is more knowledgable than the medical staff, well that's just not good.

Your pacemaker has a set low rate. With rate response turned off, your PM will pace you if your intrinsic rhythm is lower than the set low rate. If your intrinsic rhythm is higher, it doesn't do anything but act like a heart monitor. (There's some more things to it but that's the basics).

I also have a Medtronic dual chamber and that's exactly how mine is set. When I had RR on, it was driving me crazy too.

Surely your EP will understand-

I would advise you to have a drink, except alcohol is not good for SSS. Ask me how I know...

Good luck and let us know-

EB

Turning RR off?

by tachybrady69 - 2012-09-07 12:09:30

I thought about having the RR turned off but I think first I need to find out why it was turned on. Is it because I was diagnosed with SSS, TachyBrady. I had No problem before the PM with getting my HR up on exertion. My AFIB usually happened in the middle of the night which was before the PM. I would wake up and I would be racing 150 bpm. Does the RR help so that my HR won't try to go below 60? I also had significant pauses. Does the RR maybe help with that? I'm just fishing here. I want to be armed with knowledge when I call my EP. The last time I tried explaining to him my symptoms he said I needed to see my cardiologist. In otherwords I must not have explained my situation good enough to him, that my heart would start pounding on exertion. to him it must be a Heart Issue, not a PM problem. Now that the heart checked out okay, I know it has to be a PM issue.

Turn it off

by ebfox - 2012-09-07 12:09:40

Hey TB,

Sometimes I think they just have a "standard" set of settings and that's what they give you to start with (and that certainly is not a good approach). I think you have arrived at a reasonable conclusion; get them to turn it off and then you see if that doesn't most or all of your concerns.

If you turn it off and find that you get tired walking up the stairs or doing normal things around the house, then you need to go back, turn it back on, get the treadmill tuning work done.

Let us know-

EB

I Agree Too

by tachybrady69 - 2012-09-08 08:09:13

Ronaldo, I do agree that this nurse does not know what she is talking about. I really lost it with her when she did not know what I was talking about in reference to the activity threshold under pacing details! Really? An she is a nurse for an EP. Now EB why isn't a drink good for SSS? No one told me I couldn't drink, well actually they did. You know, women can have 1 drink a day and men can have 2 drinks a day rule. PacerRep, So even though I have SSS I could still have the RR turned off, or would that be bad? I’m just trying to get my head together for when I see the EP Monday. Thanks.

Nurse is wrong

by PacerRep - 2012-09-08 08:09:46

RR doesnt drive the pacemaker, thats a ridiculous statement. It drives the Sensor rate, which is all rates above the programmed rate. EBfox is correct in what he said with the exceptiont that the device will track your own atrial rate with paced ventricular beats if it has to without the rate response.

Question for the E.P.

by PacerRep - 2012-09-09 01:09:54

Just say..."Doc - Am I Chronotropically (Ch-rone-a-trow-pick-a-lee) Incompetant?"

Scenario A
Doc- "yes you are"
You- Ahhh bummer....Now Turn on my rate response!!

Scenario B
Doc "no you are not"
You- Thats Great News Doc!!! Now turn off my rate response!

SSS

by PacerRep - 2012-09-09 01:09:57

Saying you have Sick Sinus Syndrome is kinda like telling somebody that you drive a car....O.K., What kind of Car? Make, Model, Year? What color is it?

SSS is a generic term that groups about 5 different heart problems into one. So Rate response in one person with SSS would be appropriate whereas in another it is not. It just depends on what kind of SSS you have. Really it comes down to the term Chronotropic Competance. If you are Chronotropically incompetant then you need RR if you are not, then you don't it's that simple. The first place to look is your daily heart rate trend on your printout, hopefully they checked that. If your heart rate curve is Flat--at your lower programmed rate all day...then unless your in a wheelchair 24/7 then you probably need rate response. If your heart rate is going up and down on its own, then you don't need it.

Really determining if somebody needs RR Should be one of the easiest things to do from a programming standpoint. (this does not include tuning the activity sensor)

PacerRep Thumbs Up

by ebfox - 2012-09-09 04:09:00

Hey TB,

Listen to PacerRep, it is good to have a pro on this site.

And if you are good with one drink a day, stick with it (I had not heard than men get 2- yay).

EB

Chronotropic Competance

by TickTock-UK - 2012-09-09 10:09:53

Does the Chronotropic Competance term apply for SSS only??

I have complete heart block paced 100% on Atrial only. 60 - 140 when I first had the PM fitted I was also paced on Ventricle, but for some reason this has now started to work on its own again, so now only Atrial pacing. I believe that the RR is still turned on, as I was not told that it was turned off at my last interrogation. I feel my PM is programed inadequately I feel increased fatigue, SOB during activity.

My heart rate is going up and down on exertion, only ever goes to 60BPM at rest when I go to bed.

Here in the UK they don’t give out much information or printouts and it up to us to ask any questions, that’s why it’s so nice on here with most questions answered straight away.

Has anyone got a list of questions that I can ask at my interrogation? BTW my next six month interrogation is a week next Thursday!!

Thx Len

RR is Off!

by tachybrady69 - 2012-09-10 02:09:24

I just got back from EP. He said I was sort of Chronotropically Incompetent. He turned if off though and had me run down and up a flight of stairs and then he did another Interrogation. My heart was working on its own to raise my heart rate. He said he would leave if off. He thinks as far as the arm throbbing goes when I first start to exercise) like walking) is because I am out of shape and just need to exercise. I am a commuter. I took a train and bus and walked and wasn't having left arm pain before the PM. I didn't think not being physically active for a few weeks would get me out of shape that fast. Anyway I want to thank you guys for your help and input, I won the battle of having the RR turned off and I didn't even have to ask him to. So let's see how it goes. He told me to buy a heart rate monitor so I can see right away how my own heart rate is responding. Actually I'm good with two drinks a day, but of course it isn't recommended, EB. lol!
TB

Heart rate

by tachybrady69 - 2012-09-10 07:09:00

I just went for a walk in my village. It is very hilly where I live. I walked 1 1/2 miles. I have a heart rate montior and I checked it after I walked up a hill. The most my heart rate got up on exertion was 81bpm. Isn't that kind of a low heart rate to be having after you just walked up an incline? Maybe I should have this in a new post. Oh I know what you mean by the 2 drink limit. Hmmm. I wonder if my heart rate would go up if I had a few beers!

Great News

by ebfox - 2012-09-10 07:09:45

Glad to hear it! I bet it makes a big difference in how you feel.

I am with you on the 2 drinks (hard to stop at 2 you know ;-)

How did you feel

by ebfox - 2012-09-10 11:09:36

It comes down to how you felt- did you feel like you struggled or went at your own pace? Did you feel winded or out of breath, or have chest pain?

Agree that 81 is not that high but if you felt OK, nothing to be concerned about. If you felt a little winded, it may be like the doctor said, you are a little out of shape. The fact that you walked a mile and a half is a pretty good indicator that you are not ready for the rest home yet-

I wonder if the throbing you describe is due to the complications you had early on- you may still be healing, it's only been 2 months-

EB

That's a Plan

by ebfox - 2012-09-11 01:09:55

Give it a week or so; try to walk some daily (even if you don't want to- don't over exert, but walk). I remember reading a study that basically said that hearts with SSS will respond to exercise. You can always go to the RR when you decide you need to, but the longer you let your own heart do it's thing, the better in my opinion-

Good luck, I am off to have my PM interogated-

EB

Not too bad at first

by tachybrady69 - 2012-09-11 11:09:48

To tell the truth I felt like I was struggling a little. I did end up stopping a few times to take a sip of water. I didn't have chest pains. I felt a little winded. What I felt was like it was more of an effort to walk than before I had the RR turned off. On the bright side though, my heart wasn't jumping out of my chest (well it was feeling like that before the RR was turned off) as soon as I would do anything to exert myself. My resting HR though it is set for 60 bpm always seemed to be in the mid 70's if I did the slightest little thing,like get up when the RR was on.. So you don't think a maximum HR or 81bpm after going up a hill is that bad? So would it get better the more I exercise and walk? Later in the evening I felt completely exhausted though and the back of my neck and spine is hurting. I felt like I must have pulled something on walking. I had walked the same distance three times last week and did not have a problem, except for the throbbing in arm. I had no throbbing yesterday when I walked, which tells me the RR was set too high and I guess my body was super sensitive, which is why my heart would start pounding right away, when the RR was on. Yes, I'm realizing I ma healing. Today I'm kind of afraid to go walking with my neck hurting the way it is. Can't understand what happened. I should probably go to the mall today and just walk on a flat surface. Part of me thinks that maybe the RR should be turned back on but with a lower response. I figured I'd leave it off for at least a week or so and see how it goes. again, maybe I just to give myself more time to heal and get back in shape.

Working at plan

by tachybrady69 - 2012-09-12 01:09:31


I just came back from walking around and around in Target. I didn't want to drive as far away as it takes to go to the mall. It was fla surface, not hilly, so that was good. Problem is I was walking at a fast pace and my heart never went above 60 bpm. That is disturbing. It did not budge. I checked it after each lap around the store. Stayed at 60 the whole time. I will keep doing the walks though and hopefully I will see some results. To tell you the truth though, I feel just like that nurse last week told me I would feel, like crap. I am not one to respond tp power of suggestion though, so I know it wasn't because she said it. I also felt a bit nauseous when I was walking. I wonder if that is because my heart rate never went up. Maybe my own heart works once in a while but not all the time! :(

EB;
So how was your Interrogation?

OK

by ebfox - 2012-09-12 09:09:44

Everything normal, I am not being paced very much (which is a good thing).

Stick with that plan for a week or two, I am pulling for you-

You know you're wired when...

Your old device becomes a paper weight for your desk.

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