Third Degree (complete) heart block

We’ve had this talk😉

by Lavender - 2022-07-20 16:27:49

FG,

I think your question is, "why should I agree to a pacemaker when nothing seems wrong?"  I know that you're struggling with being advised to get a pacemaker when all seems normal. I've answered you extensively on your first post but perhaps can add this:

I had zero symptoms. I was approved by a cardiologist for an elective gallbladder surgery. I hadn't had any big pains but an ultrasound showed lots of stones including one mega stone. 
 

As I was being brought out of anesthesia following surgery, I bucked. I had a complete heart block which nearly took my life. I ended up in the ICU wearing temp pacemaker patches as a just in case. Amazingly I was sent home saying no worries-it was wenckebach-mobitz. The cardiologist said she knew my heart would be ok on its own. 
 

Following that event, I had many tests -echos(2), ekgs(3 or 4) and a stress test. All were fine. I was dismissed from cardiac care. I was totally asymptomatic after all that even though my heart was down to 10 bpm when I was in the ICU. 
 

That was November 2019. In August 2020, I stood up at home and immediately collapsed in a faint-hitting a glass coffee table which broke. I wasn't hurt. I called emergency pcp number and was told it was probably just anxiety or a reaction to a steroid he gave me. He said go to bed in spite of my protest that I was NOT anxious. 
 

Thereafter, I went on to have fainting episodes for six months. I switched pcps. I saw six specialists who found nothing wrong. They were starting to dismiss me as having anxiety. Well, hell yeah!, I was fretful over dropping in the store, fearful to drive, fearful to be alone. 
 

Between fainting, I was absolutely fine medically. No symptoms but the fainting was totally unpredictable. 
 

Finally a thirty day monitor caught the rare arrhythmia-ventricular standstill-when I dropped on my livingroom floor with a thirty-three second pause. My guy got me revived and the ER confirmed the diagnosis with the monitor readout. CRT-P dual chamber installed two days later. 
 

Have you worn a longer term heart monitor yet?

I was angry that I wasn't sent for an electrophysiology cardiologist test early on. Would've saved me all the stress of six months of unexplained fainting. Some problems are hard to catch though. 
 

Have you had an EP test your electric system?

Maybe a heart monitor and an electrophysiology test would help confirm the need for a pacemaker. Maybe not, but it's nothing to play with if you've had complete heart block. 

Just anxious

by FG - 2022-07-20 19:44:09

Hello again thank you for your detailed response. That's just it they haven't ordered anything they haven't said anything other than oh you have third-degree heart block slam dunk pacemaker is next. That's what has me concerned, with anxiety, at this rapid progress to pacemaker with no real thorough explanations. I wrote an email to the EPs medical assistant and she responded courteously although  short, and said well maybe you can go get a second opinion because this MD feels quite calmly that this is in your best interest and he's confident that another competent physician will feel the same way. I am on the schedule for 8/23, that is set, but I still have time to seek more information and again I took your story with all details quite to heart. So I suppose I will ask around and get a second opinion and see if they agree. The first EP is considered one of the best in town by several people who don't know each other. So I will keep you informed. Thank you again for responding.

More info

by Lavender - 2022-07-20 20:10:12

When I had the complete heart block after the gallbladder surgery, they tried giving me atropine      and it did nothing.  You don't want to be in the position where you suffer the complete heart block and you rely on the escape rhythm only.

I read an interesting article on complete heart block:

This is about the block:  

The third-degree block is also known as complete heart block. As the name implies, no impulses from the SA node get conducted to the ventricles, and this leads to a complete atrioventricular dissociation. The SA node continues its activity at a set rhythm, but the ventricles activate through an escape rhythm that can be mediated by either the AV node (junctional escape), one of the fascicles (fascicular escape), or by ventricular myocytes themselves (ventricular escape rhythm).

The heart rate will typically be less than 45 to 50 beats/min, and most patients will be hemodynamically unstable. This rhythm is unresponsive to atropine and exercise...

The initial management of bradycardic patients that are symptomatic usually begins with the use of intravenous atropine as per the advanced cardiac life support recommendations. Unfortunately, atropine acts at the AV node and, as such, is rarely effective in raising the heart rate in patients with complete heart block. Subsequently, medical options for the treatment of symptomatic bradycardia include dopamine and epinephrine, but both may serve as a temporary supporting measure only and might also be unsuccessful in improving the patient's heart rate in third-degree AV block. Often patients in third-degree heart block will require pacing.

Some other excerpts:

The recommendation is that a pacemaker is placed in patients with a persistent third-degree AV block, although the term "persistent" is often a matter of clinician judgment.

A 2017 study concluded that patients with AV blocks are more prone to develop heart failure than those without an AV block, both acutely (over 6 months) and chronically (6 months to 4 years)

Patients with third-degree heart blocks are vulnerable to decreased perfusion related to symptomatic bradycardia and decreased cardiac output. Patients may experience syncope related falls and head injuries. Critically ill patients may be unable to protect their airway and may develop nausea, possibly aspirate, and may have delirium.

here's the full article-copy and paste

https://www.ncbi.nlm.nih.gov/books/NBK545199/

Good idea

by Lavender - 2022-07-20 20:38:53

"So I suppose I will ask around and get a second opinion and see if they agree. The first EP is considered one of the best in town"

I quote you. Good idea but you might not find anyone better than the best in town!🤓

Same situation

by dogtired - 2022-07-20 20:38:59

I too have a third degree block with a HR in the low 30s.  I'm asymptomatic and can bike swim and weight train.  I've seen 4 EPs and they all recommend a PM but NONE will say I'll deffinately notice any difference 2 think its more than likely I'll have more energy during excercise and ALL agree its NOT life threatening.  I asked 2 why its not a medical emergency they replied my pauses at 2.8 sec aren't long enough and my QRS complex is narrow.  They also mentioned since I've been stable (with 3 deg) for more than 2 yrs I'm unkiely to suddenly pass out. and in the end it was up to me.

I finally gave in and am scheduled for sept.  I agreed when I found an EP that could do Left Bundle Branch pacing which would replicate a normal heart beat better than the traditional RV pacing.

Did anyone else have heart rate responsive to exercise?

by FG - 2022-07-20 23:26:15

Thank you both for continuing to have a conversation about this.Since this began I've been taking my heart rate frequently. As I stated above its 38 to 40 upon awakening, and 40 to 44 during the day at my desk job. but here's what's interesting. Like Lavender, I've seen several articles that say junctional escape rhythm is not exercise or atropine responsive. Yet mine is very definitely exercise responsive. I have a narrow QRS. Within seconds of jogging, my heart rate rises. On a gentle to moderate jog I sustain 110 to 120, and when I ran extra hard this morning, getting kinda out of breath, I measured 140. I wonder what makes the difference and if it is significant or not. I certainly can't answer that question. And I haven't had enough discussion with the EP to ask him either. So it's on my list for the next visit. 

3rd degree block

by Tracey_E - 2022-07-21 10:10:59

Heart block doesn't need a lot of tests or specialists to confirm, once it shows up it's clear what it is. There is only one fix, a pacemaker. It's not going to go away on its own, it will only progress. There are no meds that will fix it. Sometimes it seems sudden and like the advice is given too quickly for a pacemaker, but it's really not that way at all from a medical perspective. 

A resting rate in the 40's at your age is reason enough to pace. You may feel fine, but it's still putting stress on your organs because they aren't getting the oxygen they need. It's also hard on the heart to be out of sync- the atria is beating faster than the ventricles so it's filling but not emptying as it should. Again, this isn't something you'd feel, but the damage is happening. 

Many of us find after we are paced that we aren't quite as asymptomatic as we thought we were. I had a lot more energy once I had a normal heart rate again. The surgery was easier than I expected, and after I felt better than I imagined I could. 

It is possible for the heart to go in and out of block, which would explain why your rate goes up on exertion. This is a good thing, but it doesn't necessarily mean a pacer isn't still warranted. You can ask for a stress test. That will tell them exactly what your heart is doing when you run. A holter will tell them how often you are in block. 

I'm sure it seems sudden and a pacer seems crazy when you feel good, but don't rule it out yet. Block does not go away, and it rarely stays the same. It usually progresses, so while pacing may not make you feel better now, it will keep you healthy. 

Tracey E from 2013

by FG - 2022-07-21 10:38:36

"I own a business, am a girl scout leader, hike or ski most vacations, do Crossfit 5 mornings a week.... my heart does not keep me from doing anything I want to do. I don't look or act like a heart patient. If we have to have a heart condition, this is the best one to have because it's an easy fix."

Thank all of you for this continuing discussion. I really am starting to feel better and more informed as you guys share your experiences. I think I'm already a member of the pacemaker group even pre-pacemaker…

Tracey do you still feel like you did when you wrote that nine years ago? All of you including Lavender who gave details of their experiences have helped me a great deal. I don't want to leave anyone out who has helped me so far.

yes!

by Tracey_E - 2022-07-21 12:27:56

Yep, I sure do! I'm still a Girl Scout leader, this past year was my 20th. My daughters graduated and now I've got two new troops. I'm leaving next week on a cross country road trip with my oldest and her husband, catching up with my youngest, and the 4 of us are hiking Utah's Big 5 plus some other more off the beaten path gems. I stopped Crossfit 6 months ago because of my back, but I'm running more and have been working with a running coach until I decide what I want to do next for weights and core. I've done 2 half marathons this year. 

The pacer has been a bit of an issue twice over the years.

- if I didn't have very old leads, I could have an mri to see what's going on with my back. Instead, I'm doing pt and being super cautious.  Newer pacers this is not an issue, you can have an mri. 

- in the last few months I've had a bit of swelling in my left arm, most likely due to so many years with leads in the veins on that side. None of my doctors seem inclined to do anything about it, and I probably wouldn't have even noticed it if my watch hadn't gotten tighter. So, something to keep an eye on but nothing I'm at all concerned about. 

The pacer has been nothing but a blessing for me.