5 AT/AF Events since October ICD implant

AT or AF?

by AgentX86 - 2022-01-29 23:47:22

AT anf af at the same time? Tachycardia is usually, though not necessarily, a part of AF. It's one the two issues with AF (the other being blood clots).  Two minutes isn't usually a problem but it rarely stays that way. It's a progressive condition. You should find your CHADS2 score to see if you need anticoagulants.  Your doctor will certainly take this into consideration.

AF, by itself, isn't dangerous though it can easily  be a quality of life issue. The two side-effects, above, are the danger.  At two minutes, the tachycardia isn't a problem.  Blood clots may be.  Listen to your doctor.  He may prescribe drugs and will want to track it.  As I said, it's progressive.  Mine "went away" after a cardioversion for seven years, then came back with a vengence.

AF (atrial fibrillation) and AT (atrial tachycardia) episodes

by Gemita - 2022-01-30 02:32:48

Alexander, as AgentX86 states, the main concern would be the risk of an AF related stroke “if you have risk factors” and AF control/progression.   The duration (under 2 mins) and frequency of your AF/AT (5 episodes) since October would not particularly worry me or my doctors, but of course because of the “usually” progressive nature of AF, this may need to be controlled.  I say “usually” progressive nature of AF since this is by no means always the case.  My AF and other arrhythmias, for example, have indeed been reducing in both frequency and duration since I started treatment for some of my triggers (mainly vasovagal swallowing/gastric in nature).  

Also I suspect your doctors will not wish any high heart rates to continue since these potentially could trigger a defibrillator response which your doctors and you want to minimise, so for this reason they will wish to keep any high heart rates firmly in check with medication.

Should you be worried about any of this?  Worried no, concerned perhaps.  Five episodes of a tachy arrhythmia since October following an implant and the trauma of the procedure could well be normal for many of us, but I would certainly want to discuss any new arrhythmia finding with your doctors and to keep a close eye on “all” your arrhythmias in the future.   Good luck Alexander

AT/AF Alerts

by Marybird - 2022-01-30 19:59:10

Agent, in my limited understanding of these alerts ( trying to read the pacemaker manuals and information on the Abbott website) I'm under the impression that the alert comes from episodes of  "atrial high rate episodes" (AHREs) picked up by the pacemaker, but they don't distinguish between afib and atrial flutter, so the episodes are labeled "AT/AF" in the alerts. It's also my understanding ( and I could be wrong about that), that intracardiac electrograms can be generated by the pacemaker/ICD that capture these incidents, and these electrograms can be checked out by an EP or someone else with expertise in the subject, and like an EKG, they can determine what the rhythm actually is. That's a question I'm saving for my next encounter with the pacing tech in the cardiac clinic I go to, to clarify if this is indeed how they figured my AHREs were actually incidents of afib ( as they told me), or could they possibly be a-flutter or atrial tachycardia?

In my case, remote pacemaker reports are read and interpreted by a monitoring company contracted by my cardiologist, so I'm thinking that there are people there ( supposedly an EP or two and pacemaker techs) who look at and interpret the electrograms of the AHRE incidents, so they can see the rhythms and they send a completed written report to the cardiologist. I'd guess they saw afib on my electrograms, and that's what they reported.

As for patient notification of those AT/AF alerts, it sounds as though Alexander, you get electronic notification of those directly  at the time of a remote monitoring event? I know your doctor would get those alerts, but I never figured they might send the alerts directly to the patient as well. I know there are a number of alert reporting options that can be selected by the EP/clinic at the time the remote monitoring is set up.

As far as whether or not you'd be notified by your cardiologist of AT/AF alerts really depends, I think, on whether or not there are clinical decisions or actions needing to be taken as a result of those alerts. I can give you examples of this from my own experiences with remote monitor alerts and notifications.

I was notified a total of three times by my cardiologist's office about pacemaker monitor alerts. The first two times, one for a "excess mode switching" alert ( associated with tachycardia), the second time either that or possibly an AT/AF alert (not sure which) they called me with instructions to increase the dosage of metoprolol I take for heart rate control.  The third time was to inform me of multiple alerts they had gotten for afib events lasting over 1, and 2 hours. At that time they called me to come into the office, see the cardiologist, who handed me a diagnosis of afib and a prescription of Eliquis. These are all actionable events, hence the notifications from the cardiologist. I was informed later that my earlier alerts were actually from "short runs of afib", which is why they increased the metoprolol.

So now I take rate control drugs for Afib, and Eliquis as an anticoagulant to help prevent strokes. I probably still have some of those AT/AF incidents and those are reported to the cardiologist. But they've pretty well done what needed to be done about the afib, so unless they think a medication change is indicated, I wouldn't expect at this point to be contacted by the cardiologist's office to tell me about any additional incidents- they wouldn't be actionable at this point.

It may well be that if you weren't contacted by your cardiologist/EP about your AT/AF alerts, it's because they believe the information is not actionable at this point. If the alerts represent a new event, a change in your status, healthwise, and something needed to be done, they would notify you. In any case, if you aren't sure what's happening, or you have any questions, it'd be a good discussion to have with your cardiologist.

I hope this makes sense.

Marybird

by Gemita - 2022-01-31 06:43:32

Mary, what a helpful post from you for Alexander.  From my experience with my Medtronic pacemaker, what you say in para.1 is largely correct.   As a matter of fact, my EP tends to place all my atrial tachy arrhythmias under one umbrella when discussing monitoring findings with me.  He is always more concerned with the “speed, duration and my symptoms” during an arrhythmia rather than the "actual arrhythmia identified", which as you will see below, can be difficult to accurately assess.

As we may know, before an arrhythmia is recorded and stored, certain conditions have to be met.  This will depend on the pacemaker “parameters” set up by the EP to record an arrhythmia, but it usually has to be of a certain duration and speed before it is recorded.  So perhaps a good question for our EPs might be at what rate and duration will my arrhythmia(s) be recorded and stored on ECG and what happens to those that fall below this threshold - will they be totally rejected or will they be counted in logs elsewhere like “total number of high atrial tachy arrhythmia episodes”, “total number of mode switches", etc.?  

To help appreciate how complex a firm diagnosis from a paced rhythm can sometimes be, I quote from my last in hospital report when two of my EP technicians were unable to confirm to me the arrhythmia which had occurred. They had to send the tracing to Medtronic Technical Services for analysis.  My technicians initial diagnosis was: 1:1 SVT but after Medtronic Technical Services looked at the AEGM they reported Multi Focal Atrial Tachycardia, and I quote from their report:

"During episode 3,576, the patient appears to have had a multiple focal atrial activation (sinus and other atrial onset) due to different kinds of morphologies.  This is an AEGM and as such the signal representation is sensitive to how much slack you have with the tip/tissue interface.  To be more conclusive the rhythm should be verified with a surface ECG.

The reason why MAT (multifocal atrial tachycardia) would be plausible is that at times the sinus beats are present with a similar morphology and rate and at other times a completely different morphology is present (narrow high amplitude versus longer low amplitude).  This explains the different kinds of amplitudes".

Well Mary, you can appreciate how complex this can all get and that in some cases, only a surface (external) ECG at the time of the arrhythmia can really sort this out.

thank you all - some additional information

by Alexander - 2022-01-31 22:16:16

Hi Everyone,

Sorry I have been recovering from Covid then a general malaise. I've been really worn down as of late. 

Here's some additional information -

General Summary

Programming evaluation revealed a normally functioning device. His presenting rhythm was intermittent AP/VP. He has been paced 9.1 % in the atrium and 18 % in the ventricle. All measured data was stable and WNL. Acute lead issues: none. Chronic lead issues: none. The battery remains good with an estimated longevity of 7.9 years. There were 5 AT/AF events recorded. Episodes appear to be AT/AF. Longest on 01/04/2022 for a duration of 01 minute and 56 seconds.

Pacing parameters are programmed to DDI 50 bpm.

Tachy therapies begin at 187 bpm.

The patient is not anticoagulated.