Pacemaker Side Effects

[jeffswife]

My husband is a 53 year-old competitive athlete (30 years nat’l/world level running/cycling). Syncope episodes led to EP study, Holter, ILR that recorded periods of up to 5 missed beats. Cardiologist said Sinus/AV Node disease. Permanent pacemaker was implanted 9/2. Athletes are not good patients, after a week he was riding his bike. At two weeks, ran 3 miles easy. During next run, HR spiked to up to 226 for 20-30 seconds.  He took a week no exercise. Since then almost each time he has run (or ridden) he has had similar tachycardia episodes, up to 4 minutes per episode. He never had any prior abnormal HR. Stress tests did not cause episode they could monitor.  Ten weeks after implant, diagnosis of embolism from pacemaker site down arm, heparin, lovenox and indefinite coumadin. Resting HR went from 40s before embolism/treatment to 70s, with periods of arrhythmia (e.g. 60s-130s at night in bed) plus loud ringing in ears – none of which are coumadin side effects. Tachycardia continues with exercise (9 episodes in 3 hrs on bike yesterday). Cardiologist says supra-ventricular tachycardia or atrial fibrillation which pacemaker implant would not cause, wants him to take beta blockers – husband resists lifetime of meds, when would ablation be indicated? How would we get to a better diagnosis of true cause needed to decide right course of action? It is hard to narrow down with so many issues. Note: only abnormality prior testing had identified was mitral valve leakage (if pertinent).

[CCF-M.D.-MJM]

Hello,

This sounds very frustrating, especially for a competitive athlete.
The first step is to figure out exactly what the rhythm is -- an SVT ablation is sometimes much less invasive than a atrial fib ablation.  It would be very unlikely for a pacemaker to cause rhythms like this.  It is probably more related to the reason why he needed a pacemaker in the first place -- disease in the conduction system of the heart.

when would ablation be indicated?

Indications for ablation are 1. symptoms despite medical therapy, 2. desire to avoid medications (accepting that the ablation carries risk that the medications do not).


How would we get to a better diagnosis of true cause needed to decide right course of action?

It sounds like he has most of his symptoms when he is exercising.  I would put him on a treadmill and do an exercise stres test.  Other options are hotler, event monitor, home telemetry, and loop recorder.  If these studies are not helpful, an EP study may be useful.


It is hard to know what to do with the mitral valve leakage.  It depends on the degree of leakage and whether or not the atrium has started to dilate.

I think you should be direct with your doctor and ask him these same questions.  If he does not or cannot answer them to your satisfaction, seek a second opinion.

I hope this helps.  Thanks for posting.

[jeffswife]

Thank you CCF-M.D.-MJM for your answer.  We didn't think the pacemaker is causing the arrythmia/tachycardia but rather the implant surgery that stressed what as you said was an already known to be faulty conduction system. He had all of the testing you suggested before the pacemaker implant, identified nothing but the missed beats. He has had event monitor, exercise stress test and Holter monitor since tachycardia started, only the event monitor caught anything, need to pin the doc down on what it showed, plus request more testing because I agree "the first step is to figure out exactly what the rhythm is" in order to decide on treatment options. Husband really likes the doc, but he is an EP specialist - I assume second opinion with arrythmia specialist would add balance to the view. I also wondered if athlete's heart (larger, stronger) has any bearing.

[Stelladallas]

While our lifestyles are very different, there are some similar symptoms.  I initially started with AF, no luck with ablation, am now on medications but I also received a dual chamber pacemaker. Dx:  Sick sinus syndrome (either a fast pulse or an extremely slow pulse). I too have a mitral regurgitation which is not a focus of tx. but hopefully managed with some of the medication.  Good luck!  Stelladallas

[Eddie 14]

Side note.

Ask the pacemaker clinic, ep, or rep if the device has minute ventilation, or a motion driven rate response function.  If it is turned on, and is miscalibrated it could easily cause the pacer to jump his rate.  My hope is that your clinic has thought of this, but ask.  Basically your husband by jogging, moving etc, could be telling the pacer, hey... run me up!


Here is a bit more...


Rate responsive pacemakers can be incorporated into either single chamber or dual chamber pacing systems. The normal heartbeat fluctuates during the course of 24 hours depending upon your activity. During sleep, the heart rate normally slows. During times of activity or stress, however, the heart rate normally speeds up to meet the increasing demands on the body. Individuals with the abnormality of the conduction system may be unable to properly speed up the heart rate during activity. This can result in fatigue, shortness of breath and/or activity intolerance. Rate responsive pacemakers have special sensors built into the pulse generator that can sense increasing activity by means of increased body movement (vibrations) and/or increased rate of breathing. The sensors will automatically increase or decrease your heart rate according to your body's needs. Your pacemaker physician can "fine tune" the sensor(s) to meet your individual needs according to your level of daily activity. Rate responsive pacing most closely mimics the normal heart beat

[PikaPika88]

The pacemaker tech told me that my pacemaker picks up 2 beats late.  Anyone knows what is this meant?  Anyone's pacemaker has played this trick before?  I really like to know but everyone said "don't know"!

Pika.

[jeffswife]

Thanks for the input. Eddie14, we will definitely ask about the motion driven rate response function. The intent of his setup is to have the pacemaker kick in only when his HR drops below 40 i.e. below his old normal HR (40s) to cover periods of missed beats and not pace any other time. Doc said upper limit didn't matter, hubby think it is 120, I'm sure we asked them to change it to 200 (since his racing HR can be up around 190), but that may have been for the ILR only. I'll check upper limit too and the rate it would pace if it did kick in. Hubby says he feels a mild electric-like shock at times when it does pace.

An additional thought I've picked up on this/other sites is response to alchohol. He does love his beer, 2+ per night. Might have been OK no HR effects before, but maybe not now. Think a week of no alchohol might be a good test.    

[axg9504]

I started having dizzy spells 3 years ago . My current advice is that I have a faulty conduction system and could benefit from a pacemaker. However I find that my bpm can be as high as 90 when my dizziness begins. It starts when I resume running after a rest period after I have run for about 10-15 mts. Sometimes I get over it, and can run a little more. My heart rate always dips after exercise sometimes to below 40. On one occasion it stayed there for hours (I'm no world class athlete, my normal bpm is around 80) I have no problems at rest. I was advised a PM but I'm not sure it's the answer . Jeffswife: what was your husband's heart rate like prior to his syncope before he had the PM implanted? Did he start out with tach and then slow down? Did they do a thorough study on a treadmill before implanting?

[jeffswife]

His resting HR was in the 40s, exercising ranged up to 190. When he stopped exercise HR dropped quickly back to resting or at least down to 60s after racing or hard/long workout. His fainting only occurred when not exercising, so likely his HR was in the 50s tops then dropped to zero. His tachycardia only started after pacemaker implant, still it quickly drops from maybe 220 to 120 when he stops running and the episode ends. He then starts running again, I believe if he didn't it would continue down to 60s. An episode today went from 224 to 80 for 15 secs then back to 120, then he started running again.  He did have every test there is before the implant, Internal Loop Recorder showed the missed beats.  He regrets getting the pacemaker in some ways, but needed it to avoid fainting while driving, working, etc. Good luck!

[axg9504]

Thanks! what's interesting to me is that jeff(i guess)'s bpm came down when he stopped running to his resting bpm. I've been told by some cardio's that it should not!! I start running at a v. moderate pace, my bpm goes up smoothly to 130-150(I'm 61). I have to stop after 8-10 mts to catch breath. When I resume running my bpm goes up to a lower level (120) for the same pace. Then I get to a point where when I resume running after a rest I get dizzy. I have never fainted. After this point my bpm goes down to 60 when I'm walking and maybe 90 when I start running. I have to quit because I get dizzy. I go home and my bpm comes down to 60-50-40. Once it stayed at 40 and below for 12 hours with symptoms (no fainting). Usually after 1/2 hr it goes back up to normal- 80. I have skipped beats too (Holter showed pauses of 2 seconds) and occasional PAC/PVC's. I did have an atrial ablation a few months ago but it did not fix anything.

[Prof. ATP]

I am not a physician, but I am an athlete with heart disease, so have studied a lot.  

Does your husband drink a lot of sports drinks like Gatorade, Powerade, or one of the more specialized products for competitive athletes?  It's possible that these have an effect on the heart's conduction system, because of their electrolyte content.  If this is the case, managing his electrolyte balance may help.

[axg9504]

How about diet drinks??

[Emmaj]

Hi Jeff's wife,

I also had sycope and a problem with svt with mitral valve prolapse. These symptoms appeared about 7 years before I actually needed surgery, that is, when the condition was not so very severe. I would study the symptoms of mitral valve prolapse/regurgitation and see if any others seem to fit your husband's situation... e.g., fatigue... I'm sure your husband has had an echo or two or five, but maybe he should question his docs about the possibility of his symptoms being related to that valve...

Best of luck!
Emma

[mary64]

A related discussion, Pacemaker was started.