Asymptomatic bradycardia: what to do now?

[Arlen__0]

  I am an active 51 yr. old female, total hysterectomy 11 mos ago, history of insomnia (fall asleep ok, awaken @ 3-4am, cannot return to sleep); history of clinical depression and migraines. Normal resting pulse = 60bpm.  Hospitalized 3 mos ago for sinus bradycardia (pulse 34bpm for several hours) with severe headache (not migraine), chest pain, fatigue, disorientation.  Echocardiogram, EKG, heart enzymes, brain CAT scan all normal, blood pressure in low normal range.  Reactive hypoglycemia was suggested, but endocrinology screening subsequently ruled hypoglycemia out. Follow-up stress test completely normal. No episodes for 2 months.
  2 Subsequent episodes in last 4 weeks with pulse between 41-58 (according to heart event monitor) followed by 1)fatigue, 2)dizziness and light-headedness, 3)disorientation, 4) headache, 5)  distension of neck veins, and 6) facial flushing and sensation of heat, all in that order.  Vein distension, flushing, headache and pounding sensation in heart persists several hours. Urinary and blood serotonin normal. 24-hr Holter monitor test normal. 30 day  Heart Event monitor normal, even during bradycardial episodes.  
  At my doctor's request, I have phased off 150 mg/day of trazodone, prescribed for the insomnia, but still having episodes.
    
    My cardiologist is puzzled but has not indicated this is serious.  My symptoms are incapacitating, however, when they occur, and I am concerned about another episode with pulse rate in low thirties and possibly losing consciousness.  I've also heard blood clot problems are possible when bradycardia occurs.  
  I have several questions:  Do I need to be seriously concerned about my situation?  Would a pacemaker seem a reasonable alternative to discuss with my cardiologist in this case?  My cardiologist specializes in atypical heart rhythms, but I am concerned about his assessment that this is not serious and he has not mentioned a pacemaker.  Should I be taking 1 aspirin a day to help prevent a problem with blood clots (I am using hormone replacement patches since my hysterectomy) ?  The more I learn on my own about bradycardia,the more concerned I get, but do not want to second-guess my physician.  On the other hand, if it is a serious situation, I don't want to ignore it, either. I live in Alaska, and have no close access to a medical school/research facilities.  
  What would seem to you to be a reasonable course to pursue?
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Dear Arleen
Certain abnormal heart rhythms predispose to blood clots, but not sinus bradycardia.
Regarding pacemaker placement, if you have a low heart rate (in the 30's and 40's) associated with symptoms at the time, pacemaker placement is indicated. You wrote, however, that your Holter monitor and event monitor were normal - if this means that you did not have any significant sinus bradycardia, then pacemaker placement is not indicated. A heart rate in the 50's (or even lower while sleeping) is not necessarily abnormal.
Incidentally, has anyone checked to see if you have thyroid disease?
I hope this is useful. Feel free to write back. I wish you the best of luck.
If you would like to set up an appointment with one of our cardiologists here at the Cleveland Clinic please feel free to call 1-800-CCF-CARE.
Information provided in the Heart Forum is intended for general medical informational purposes only. Actual diagnosis and treatment of any particular medical condition can only be made by your physician(s).