Atrial Bigeminy

ventricular bigeminy

by Penguin - 2023-09-28 02:37:59

Hi Beni, 

I had ventricular bigeminy show up on a holter monitor and it coincided with a winded feeling.  I felt generally de-oxygenated with chest tightness - sometimes chest pain. Not sure if the two correlate, but it eased with settings changes. 

https://my.clevelandclinic.org/health/diseases/24576-bigeminy

I hadn't heard of atrial bigeminy either, but the link above explains that it's PACs.  I'm a bit perturbed that Kardia picked it up as A.Fib! Makes you wonder about accuracy. 

In terms of Qs for your cardiologist, I'd ask whether your PM has been set up to deal with AF - and if so are these the right settings and is there indeed any AF?  I'd also ask whether the fatigue is likely to be related to the PACs or your HF diagnosis? Sleep and lack of (caused by symptoms) seems to be a trigger for more symptoms for me. 

Atrial Bigeminy

by Gemita - 2023-09-28 05:40:47

Hello Benedeni,

Firstly I am so sorry to hear that you are still suffering from rhythm disturbances, disturbances that are frequently changing in nature just to keep us all guessing.  I have just had a quick look through your history and have seen a wide range of diagnoses for these uncomfortable palpitations, from PMT to possible AF and now to premature atrial contractions (PACs) that seem to be coming in rather fast at times.  I have these too so I do understand.

An increased burden of PACs has long been considered a benign finding.  However, strong evidence of their involvement in the occurrence of atrial fibrillation (AF) is being seen.  The question to be resolved is whether increased ectopic atrial rhythm is only a predictor of AF or whether it is a marker of atrial cardiomyopathy and associated problems?  I can do no better than attach the Frontier in Physiology link below to continue this discussion.  A rather concerning paper and challenges the belief that PACs are completely benign.  Further study, as always(!), is still needed:-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9638131/

From your last Holter monitor, you are clearly getting PACs and these are happening so frequently now that there is one PAC after each sinus beat, or normal heartbeat.  I see Penguin has kindly provided a link about bigeminy for both PVCs and PACs.  I have been advised my Medtronic pacemaker does not record or store PACs which is why a Holter monitor will be needed to confirm the extent of these disturbances.   My pacemaker however records and stores premature ventricular contraction % burden, so clearly they do not appear so concerned about our PACs.

A well set pacemaker can certainly help “control” the symptoms of any arrhythmia, even if it cannot stop the actual arrhythmia present, so it is well worth asking your doctor about any pacing algorithms which could help?  As a patient with many intermittent arrhythmias, I am always looking for better ways of improving my symptoms using pacing therapies since other treatments, like medication or an ablation are certainly not 100% effective and carry most definite risks. 

A number of triggers of atrial arrhythmias and specifically atrial fibrillation are well known and these most definitely include PACs, pauses after PACs, and increased vagal tone.  Many currently available devices have algorithms that may be activated in order to reduce the number of episodes of atrial arrhythmias by suppressing PAC activity or reducing the short–long sequence seen with PACs.  Algorithms aim to dynamically overdrive pace the atrium by pacing at a rate just above the intrinsic rate or ‘‘smooth’’ the atrial rate by pacing after atrial premature beats, thus preventing the short–long cycle lengths.   Rate smoothing algorithms can be difficult to adjust to suit us individually, but if we can get it right, it can make such a difference and improve our quality of life during these difficult arrhythmias.  I would perhaps start by asking whether your settings could be better optimised to treat your PACs?   

PACs from the Pulmonary veins can initiate AF, and beta blockers or calcium and sodium channel blockers can sometimes suppress these beats.  Careful mapping and elimination of these ectopic foci (during an EP Study/ablation) could potentially help too if meds/lifestyle changes are ineffective. 

Some members ask which is the best pacemaker for exercise.  I would like to ask my doctor which is the best pacemaker for arrhythmia control?   I wonder which manufacturer would come out on top?  I would particularly want to know what is the most advanced pacemaker device on the market, other than an ICD, that has the potential to help control an arrhythmia?  We need to continue to push our doctors for better “pacing” treatments for arrhythmias, otherwise we will never see real improvements in this area.

In the meantime, you could look at your lifestyle to see where changes could be made:  try to relieve any stress, get more sleep, avoid caffeine, alcohol.  Continue to look for other triggers  and perhaps get some checks for electrolytes, sleep apnea, thyroid, high blood pressure, diabetes, changes in your heart block condition which might need settings adjustments.  As always I hope for the very best for you and since we are both battling PACs, you know where I am if you wish to chat.  Good luck Benedeni

Penguin

by benedeni - 2023-09-28 08:51:24

Thanks, Penguin.  That is a very good article from Cleveland Clinic.  I take a lot of stock in what they say.  The chest tightness you mention does go along with my other symptoms.  

About the Kardia device.  I Think what my doctor said was that the bigeminy fools the Kardia into thinking it's A-fib.  Sometimes it shows up as "Undetermined".  But the consistent thing is every time (or almost every time) I have these feelings and do a Kardia check it shows up as one or the other.  When I'm feeling pretty good it'll read Normal Sinus Rhythm.  So it seems reliable in that regard.  Plus the fact that my cardiologist thinks the Kardia is by far the best home device out there.

I will ask the questions you suggest at the next visit.  Seems like my most usual trigger for the pac's  is stress and exertion.  When either happens I immediately "feel it".

Again, thanks.

Gemita

by benedeni - 2023-09-28 10:06:46

And Thank You, Gemita.  I want to start with something you said near the end of your response.  You mentioned perhaps we should ask our cardiologist which is the best pacemaker for our ARRTHYMIAS especially for us older folk who can't exercise that much and enjoy sports like we used to.  I am definitely going to do that when time approaches for my next device.

The Frontier in Physiology report was hard for my mind to wrap around but after reading through it a couple of times I came away with a much clearer understanding of this atrial bigeminy thing.  Pac's are not always as harmless as presented to us and I am going to persue this issue with my doctor next visit as it seems very important to get a better handle on this.  I've had 2 mini and one quite major stroke (speech only affected, thank goodness) and my mother died from strokes so whatever I can do now to lessen the likelihood of following in her footsteps is front and center for me.

I could do better with the lifestyle changes as you suggest.  However, due to my esphageal spasm history, I no longer enjoy my glass of wine or Any alchoholic drink.  My blood pressure is an issue but as I mentioned, now it is almost too low.  I need to cut out the half cup of coffee I drink in the am.  Chocolate is a weakness but again I have to limit myself because of the esophagus.

Again thanks so much.  I hope both you and hubby are going through a Really good time and that it continues!

Exertion

by Penguin - 2023-09-28 13:33:26

When I was having a difficult time with high VP any exertion / activity made me feel weak and shaky.  

I've done a few exercise classes for people with cardiac issues (mainly people who've had heart attacks, but some people with heart failure) and most report that post exertion / exercise is when their symptoms affect them most. 

Keep pushing for answers

by Gemita - 2023-09-28 14:07:30

Hello Benedeni,

I had forgotten about your strokes.  You most definitely want to keep an eye on your rhythm disturbances.  Are you on anticoagulation by chance or anti platelets like Aspirin or Clopidogrel?

Yes that link was a bit heavy (apologies).  I have the .pdf version without all the references which is a bit easier to read, but these research papers are great for filling in the bits left out by our doctors. The odd PAC or PVC is absolutely no problem but when they come in quickly and in runs and go on for hours, they can most definitely cause symptoms.  In fact, symptom wise Atrial Bigeminy can be as difficult to tolerate as AF although I can tell the difference - the quivering heart in AF is quite distinctive.  The Kardia 6 lead is amazing.  

When I last attended clinic they found an internal ECG of a fast episode of AF and it was clear from that, that my PACs had triggered my AF, so I know it is happening and have evidence to prove it.  PACs on their own would not be recorded on a Pacemaker ECG or reported on as I have already said, but PACs seen with AF is most definitely reported.

I would have a long talk with your doctors if your symptoms don’t improve.  We have to keep pushing them for answers to make progress.

Hubby and I are doing okay, thank you.  Been to the eye clinic today.  Saw a lovely consultant and he has put me on long term antibiotics for recurrent eye infections (Doxycycline).  Had it before, but not for 3 months!