Pacemaker Blues

10/1/07 EP Study, Medtronic Dual Chamber PM in DDD mode implanted for 2nd Degree AV Block, RBBB w Bifascicular Block. Unable to elicit any SVT or dangerous Vent. Arrythmia.   H/O IST, HTN, IBS.  On Tenormin 50mg BID for HTN,PAC/PVC IST post implant.
Having trouble for the last week w daily uncomfortable heart sensations when PM activates(occurs most often after meals w bloating, upper body exercise/or just reaching for something, walking/stairs).  I have caught episodes with event monitor.  Both reg Cardiologist and EP have seen tracings and tell me I am feeling "Fusion Beats" explained as PM and ventricle kicking in simultaneously, then add PAC's into the mix (sometimes 3-4 in a row) and I feel dreadful: breathless, uncomfrtable heart sensation, no energy.  Just want to sit/lie still as it rarely happens when I'm not moving.   Technician is working hard to make me feel better by increasing AV delay, turned rate down to 50, etc, etc,  Docs say I may have to learn to live w it.   I hope not, I feel awful when I'm blocking down and PM is gearing up.  Perhaps a second opinion?
Questions- Is it common that block kicks in when activity increases?  Never had cardiac cath should I ? (no ChestPain and cholesterol good, Echo is WNL), Any other ideas for tweaking the PM in hopes of feeling better.   Thanks, I'm a little discouraged and co-workers (nurses) beginning to think I'm a malingerer...beginning to wonder myself as there are days I leave early because of the way I feel.  I live in Fla and am envious of those 90 yo joggers I see daily.  Thankyou.

[Michael J. McWilliams, M.D.]

Is it common that block kicks in when activity increases?

For certain types of block it is common that block increases with faster heart rates.  For Type II second degree AV block, it would be expected that block would increase with faster rates.

Never had cardiac cath should I ? (no ChestPain and cholesterol good, Echo is WNL),

If your symptoms correlate with pacing, then I would not recommend a cath.  Some people are very sensitive to paced beats and it sounds like you are too.


Any other ideas for tweaking the PM in hopes of feeling better.  

It is tricky issue.  Many people with IST are very sensitive heart sensations as you are finding out.  IST is often an overlap syndrome with IBS and sometimes even fibromyalgia.  This is a conversation that I have with IST patients when they tell me that they want a pacemaker.  Some people don't feel better with a pacemaker, they feel worse.

The only pacemaker tricks that I can think of are to maximize the AV delay to encourage intrinsic conduction if possible.  I don't know of any magic bullet to fix your problems though.  If you truly have second degree AV block and need a pacemaker, there is no good way to minimize pacing.

I hope this answers your questions.  thanks for posting.

[worriwart]

Thankyou.  I do indeed have documented block which obviously has progressed since 1st dx in 2003.  Indeed I have unfortunately always been hyperaware of cardiac issues.  Since my AV delay has been maxed to the max, it seems it will be up to me to learn some coping measures. It was suggested to decrease the atenolol by the nurse, but perhaps it's better to stay with the current dose as it keeps my rate down and does help with decreasing the documented PAC's & occ PVC.  They even  tried turning off the PM and had me "walk the halls" at a fast pace....of course my rate dipped to 45, I didn't feel that uncomfortable pacing sensation (turned off) but I didn't like the s-l-o-w feeling either.  I'm difficult to please, Ha Ha.  You probably can't answer anything else here, but I'll ask anyway, my colleagues are questioning if there might be a newer, better med to try....Is there in your opinion?  Sincerely, Worriwart.