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Sign of Mobitz 2 during sleep but no symptoms or any other disease of the heart
Hi,
I have recently went to my cardiologists for regular check-up for my high blood pressure (its normal, and the heart is physically healthy according to ultrasonography) and requested an ecg monitor since I felt extra beats, extrasystoles (that was only a 8 hours ecg monitor). The ECG monitor showed sinus arrests of 3, the longest lasting 3,4 seconds without visible p waves. Because of the arrests we did a stress test (biking while monitoring ECG) which came out negative and I was further adviced to have a 24 hours holter monitor check to make sure. The results for the 24h holter was frightening for me since there was one missing QRS complex with a prior p wave during sleep (PR intervals are normal, the ones prior and after the missed beat are the same length, the p wave came a bit early, around 15% early, but the beat after the missing one came in time). I have no symptoms, no sleeping apnea (I did check) and all results for my heart are normal, no ischemia only a few SVES and VES (under 1%), HR minimum was 49, and during the Mobitz 2 event it was 79 and the missed beat only took a second. Should I be worried or is it normal during sleep? Thank you!
I have recently went to my cardiologists for regular check-up for my high blood pressure (its normal, and the heart is physically healthy according to ultrasonography) and requested an ecg monitor since I felt extra beats, extrasystoles (that was only a 8 hours ecg monitor). The ECG monitor showed sinus arrests of 3, the longest lasting 3,4 seconds without visible p waves. Because of the arrests we did a stress test (biking while monitoring ECG) which came out negative and I was further adviced to have a 24 hours holter monitor check to make sure. The results for the 24h holter was frightening for me since there was one missing QRS complex with a prior p wave during sleep (PR intervals are normal, the ones prior and after the missed beat are the same length, the p wave came a bit early, around 15% early, but the beat after the missing one came in time). I have no symptoms, no sleeping apnea (I did check) and all results for my heart are normal, no ischemia only a few SVES and VES (under 1%), HR minimum was 49, and during the Mobitz 2 event it was 79 and the missed beat only took a second. Should I be worried or is it normal during sleep? Thank you!
COMMUNITY LEADER
Hopefully my post clarified some things as well.
Ventricles, sinus node, AV Node = influenced by nervous system.
Bundle of His= No nerves
EP study= just about any information you could conceivably desire.. Any information you read about EP studies not being able to diagnose any Sinus or Av nodal issues is wrong.
The problem with the EP study is this:
Why spend $50,000 and put you at risk for bleeding/infection etc; only to wind up putting in the same exact pacemaker regardless of the diagnosis? Its a waste... But not impossible.
Ventricles, sinus node, AV Node = influenced by nervous system.
Bundle of His= No nerves
EP study= just about any information you could conceivably desire.. Any information you read about EP studies not being able to diagnose any Sinus or Av nodal issues is wrong.
The problem with the EP study is this:
Why spend $50,000 and put you at risk for bleeding/infection etc; only to wind up putting in the same exact pacemaker regardless of the diagnosis? Its a waste... But not impossible.
1 Comments
I was not expecting someone as knowledgable to answer my question this thorougly as you are, I am deeply thankful to you now (hope this lead will help others as well). I was just rushing to my cardiologist again to clarify things for me when I started to read your response, and you managed to stop me from panicking again:)
I will definitely seek other cardiologists as well to have self-assurance that I am indeed not gonna collapse and die, but no need to rush it seems like:)
I have uploaded the other ECGs as well with the sinus arrests/pauses if you would like to have a look. (this is done by a les spunctual appliacation, P waves are hardly visible)
Im in the fortunate situation of living in a country with free health care and the EP study (if advised by a doctor) will not cost me anything, only the occasianal visits to the doctor during their private hours.
Thank you again! Hope to not have that PM soon:)
I will definitely seek other cardiologists as well to have self-assurance that I am indeed not gonna collapse and die, but no need to rush it seems like:)
I have uploaded the other ECGs as well with the sinus arrests/pauses if you would like to have a look. (this is done by a les spunctual appliacation, P waves are hardly visible)
Im in the fortunate situation of living in a country with free health care and the EP study (if advised by a doctor) will not cost me anything, only the occasianal visits to the doctor during their private hours.
Thank you again! Hope to not have that PM soon:)
COMMUNITY LEADER
Sorry it took this long to reply... I didn't see the post you made before.
At first glance the pauses seem like like arrests...
Similar story to the first one you posted. The preceding morphology is different. Looks like the last heartbeat is a bit deceptive. It comes in on time at first glance, however given it's morphology its likely ever so slightly off.
Basically thats probably a PAC with a really long recovery time/compensetory pause.
It's not entirely 'normal', but not quite at pacemaker implantation criteria. You probably have conduction disease that will become an issue at some point, fortunately it will likely be some time (5, 10.. Maybe 20 years?) before that time comes. It's certainly not to the extent where you need to be losing sleep over it.
Realistically speaking you're nust as likely to run into isues with your kidneys, liver, lungs, brain etc in that time. You could get into a car accident, or attacked by a dog. That's just life.. Short of locking yourself in a bunker with your own private medical staff theres not much you can do to protect yourself against that.
In the meanwhile just be vigilant about keeping in touch with a local physician and watching for symptoms such as fainting or shortness of breath.
At first glance the pauses seem like like arrests...
Similar story to the first one you posted. The preceding morphology is different. Looks like the last heartbeat is a bit deceptive. It comes in on time at first glance, however given it's morphology its likely ever so slightly off.
Basically thats probably a PAC with a really long recovery time/compensetory pause.
It's not entirely 'normal', but not quite at pacemaker implantation criteria. You probably have conduction disease that will become an issue at some point, fortunately it will likely be some time (5, 10.. Maybe 20 years?) before that time comes. It's certainly not to the extent where you need to be losing sleep over it.
Realistically speaking you're nust as likely to run into isues with your kidneys, liver, lungs, brain etc in that time. You could get into a car accident, or attacked by a dog. That's just life.. Short of locking yourself in a bunker with your own private medical staff theres not much you can do to protect yourself against that.
In the meanwhile just be vigilant about keeping in touch with a local physician and watching for symptoms such as fainting or shortness of breath.
4 Comments
Heck even if you locked yourself in a bunker you could still break your arm trying to grab a can of beans or something in the next 10 years!
Best strategy is truly to cross these bridges when the time comes.
Also; in terms of dropping dead... The bradycardia patients almost never experience sudden cardiac death.
Even if your atria just stopped working entirely with no symptoms or warning (an extremely obscure and farfetched scenario); you'd likely survive. Your AV junction or Ventricles would pick up the slack and sustain you for a few hours at least, likely up to 48-72hours.
In order for this to actually kill; You'd have to suddenly feel out of breath, dizzy, anxious and nauseous to an extent you never dreamed possible. Then you would have to ignore these frightening sensations and fail to call for help... For up to 3 days. If you're asking for advice on MedHelp it's unlikely you fall into the category of people that would try to ride something like that out.
Even if it happends at night, this type of event is something that would probably wake you up. You're body would start producing massive amounts of Adrenaline to compensate.. It would be like trying to sleep after being dropped out of an airplane or something.
Once an ambulance arrives they would just transcutaneously pace you, you'd get a pacemaker and that would be it.
In short: Even if your EKG said you needed a Pacemaker for this ASAP... You still wouldn't necessarily be at higher risk for Sudden Cardiac Death.
Best strategy is truly to cross these bridges when the time comes.
Also; in terms of dropping dead... The bradycardia patients almost never experience sudden cardiac death.
Even if your atria just stopped working entirely with no symptoms or warning (an extremely obscure and farfetched scenario); you'd likely survive. Your AV junction or Ventricles would pick up the slack and sustain you for a few hours at least, likely up to 48-72hours.
In order for this to actually kill; You'd have to suddenly feel out of breath, dizzy, anxious and nauseous to an extent you never dreamed possible. Then you would have to ignore these frightening sensations and fail to call for help... For up to 3 days. If you're asking for advice on MedHelp it's unlikely you fall into the category of people that would try to ride something like that out.
Even if it happends at night, this type of event is something that would probably wake you up. You're body would start producing massive amounts of Adrenaline to compensate.. It would be like trying to sleep after being dropped out of an airplane or something.
Once an ambulance arrives they would just transcutaneously pace you, you'd get a pacemaker and that would be it.
In short: Even if your EKG said you needed a Pacemaker for this ASAP... You still wouldn't necessarily be at higher risk for Sudden Cardiac Death.
thank you! :) im much less worried now. this is my refuge actually, that I'm gonna feel it, people around me will call an ambulance anyway or I will. I guess I can actually help myself then with reducing alcohol, quit smoking entirely and sleep well, do cardio-trainings, I'm not overweight tho and do sports 1-2 times a week. I'm wondering if an ablation could help (maybe not yet), but when the time comes? Well i have felt pretty bad dizzyness, weakness when I got this prognosis, but i had the holter on and showed nothing. Also, I was told I do not have apnea, but i believe its a wrong diagnoses, I do wake up to my own snoring, and if you look at the missed beat I thought is a Mobitz 2, there is muscle movement before it, maybe night tremor. And, well, a bit embarrassing to confess but I might have a reason for the arrests as well, lets call them arousals.
The point I want to make here that there is a great chance it is vagally stimulated.
Vagally stimulated is the #1 option if it happends more during sleep yes.
As for ablation; ablation cures fast heart rates. Pacemakers are the only intervention for slow hear rates.
Pacemaker technology isn't what it used to be. Recently the fda approved a wireless pacemaker thats rolling out into practice. Its the size of a small pill and has no leads. So yeah.. Not too,bad of a prognosis, especially not in the near future.
As for ablation; ablation cures fast heart rates. Pacemakers are the only intervention for slow hear rates.
Pacemaker technology isn't what it used to be. Recently the fda approved a wireless pacemaker thats rolling out into practice. Its the size of a small pill and has no leads. So yeah.. Not too,bad of a prognosis, especially not in the near future.
COMMUNITY LEADER
Wow I got an EKG and everything needed. Good stuff.
So the good news is, your Cardiologist sounds and looks like he meant exactly what he said.. Mobitz II SA block as opposed to Mobitz II AVB. 'Sinus Arrest' might TECHNICALLY be a poor choice of words to describe this. 'Sinus Pause' is likely more appropriate imo.
There are different ways of going about labeling these things however. You can make a diagnosis based of criteria or ECG findings (what was done here) OR you can choose a term that more closely aligns with the underlying mechanism "pause" in this case.
The AV Node is heavy influenced by sympathetic and parasymoathetic nervous stimulation.. HOWEVER, Mobitz II avb occurs in the Infranodal space anf the bundle of his.
This are is almost completely devoid of such fibers. In short, its entirely dependent on your heart rate. Meaning Mobitz II avb would get worse with exercise and would be worse during the day when your heart rate is higher.
This is very good news for you. Mobitz II AV Block is a sort of grim diagnosis and almodt always results in prompt PM implantation.
Your problem is definately sinus. However I think its kind of premature to diagnose the issue specifically as a Mobitz II SA as opposed to a Mobitz I.
Of course you always have concealed P Waves which could mask a progressive shortening. However more specifically we can take a look at the non Conducting P wave.
If you look closely, the P wave that DOES Not have a QRS has a slightly different SHAPE or morphology then all the other p waves!
It is likely that the explanation for this is that the P wave you see there is in fact an atrial escape beat originating from outside the node. Atrial escape beats are basically the same idea as atrial extrasystole/PAC but they occur LATE as a backup pacemaker.
In fact I would bet if you looked at your usual extrasystolic Atrial Depolarizations they are probably of the same shape as that nonconducted depolarization. This would be the most irritable focus, and hence the most likely to spontaneously depolarize as an escape.
So with that we have to ask why it didn't conduct? Well, the AV node is naturally designed to block impulses that occur at 'coupling intervals' that are too short. I.e. 2 atrial impulses that are too close to each other/heart rates that are too fast. This response is healthy and natural and occurs at longer intervals at night when the heavily Innervated 'core' of the node is under that more parasympathetic tone.
So, while it is possible that you have a Mobitz II SA, it is also possible you have a Mobitz I SA block with the progressively shortening P Waves being concealed. This is actually supported by the dropped p wave.
There is a coupling interval somewhere that is shorter than the preceeding couples sufficient to block. This blocked p scenario just makes more sense with a Mobitz I or with a 2nd degree AVB Wenkebach. At least IMO.
Like I said though, this is kind of a matter of semantics, and the only way to be 100% certain is an EP study. An EP study however would be a waste of time and money.. The treatment is the same regardless of whether its Mobitz I or II SA.. So most providers won't go throigh a study over something so trivial.
You also have some very discreet/Borderline "U" Waves. This is indicative of either Hypokalemia (LOW potassium) OR it could just be a normal variant. I wouldn't lose sleep.
Prognosis: You're too young for this! Unfortunately yes, that means at some point you'll probably need a pacemaker.
Personally I wouldn't be in too much of a rush to get one.. You're asymptomatic (not fainting short of breath etc) and these only happen at night time (not suprising).
You WILL however, at some point in your life become symptomatic. Maybe in 10 years or so you'll faint, or develop intermittent afib. At this point procrastination won't be an option.
With this knowledge it's really up to your provider whether they wanna be aggressive and just implant now (unlikely) OR just ride it out. The later option ofbjust coming back for routine follow-up every year, and keeping an open line of communication regarding your symptoms is the most prudent and likely course.
So the good news is, your Cardiologist sounds and looks like he meant exactly what he said.. Mobitz II SA block as opposed to Mobitz II AVB. 'Sinus Arrest' might TECHNICALLY be a poor choice of words to describe this. 'Sinus Pause' is likely more appropriate imo.
There are different ways of going about labeling these things however. You can make a diagnosis based of criteria or ECG findings (what was done here) OR you can choose a term that more closely aligns with the underlying mechanism "pause" in this case.
The AV Node is heavy influenced by sympathetic and parasymoathetic nervous stimulation.. HOWEVER, Mobitz II avb occurs in the Infranodal space anf the bundle of his.
This are is almost completely devoid of such fibers. In short, its entirely dependent on your heart rate. Meaning Mobitz II avb would get worse with exercise and would be worse during the day when your heart rate is higher.
This is very good news for you. Mobitz II AV Block is a sort of grim diagnosis and almodt always results in prompt PM implantation.
Your problem is definately sinus. However I think its kind of premature to diagnose the issue specifically as a Mobitz II SA as opposed to a Mobitz I.
Of course you always have concealed P Waves which could mask a progressive shortening. However more specifically we can take a look at the non Conducting P wave.
If you look closely, the P wave that DOES Not have a QRS has a slightly different SHAPE or morphology then all the other p waves!
It is likely that the explanation for this is that the P wave you see there is in fact an atrial escape beat originating from outside the node. Atrial escape beats are basically the same idea as atrial extrasystole/PAC but they occur LATE as a backup pacemaker.
In fact I would bet if you looked at your usual extrasystolic Atrial Depolarizations they are probably of the same shape as that nonconducted depolarization. This would be the most irritable focus, and hence the most likely to spontaneously depolarize as an escape.
So with that we have to ask why it didn't conduct? Well, the AV node is naturally designed to block impulses that occur at 'coupling intervals' that are too short. I.e. 2 atrial impulses that are too close to each other/heart rates that are too fast. This response is healthy and natural and occurs at longer intervals at night when the heavily Innervated 'core' of the node is under that more parasympathetic tone.
So, while it is possible that you have a Mobitz II SA, it is also possible you have a Mobitz I SA block with the progressively shortening P Waves being concealed. This is actually supported by the dropped p wave.
There is a coupling interval somewhere that is shorter than the preceeding couples sufficient to block. This blocked p scenario just makes more sense with a Mobitz I or with a 2nd degree AVB Wenkebach. At least IMO.
Like I said though, this is kind of a matter of semantics, and the only way to be 100% certain is an EP study. An EP study however would be a waste of time and money.. The treatment is the same regardless of whether its Mobitz I or II SA.. So most providers won't go throigh a study over something so trivial.
You also have some very discreet/Borderline "U" Waves. This is indicative of either Hypokalemia (LOW potassium) OR it could just be a normal variant. I wouldn't lose sleep.
Prognosis: You're too young for this! Unfortunately yes, that means at some point you'll probably need a pacemaker.
Personally I wouldn't be in too much of a rush to get one.. You're asymptomatic (not fainting short of breath etc) and these only happen at night time (not suprising).
You WILL however, at some point in your life become symptomatic. Maybe in 10 years or so you'll faint, or develop intermittent afib. At this point procrastination won't be an option.
With this knowledge it's really up to your provider whether they wanna be aggressive and just implant now (unlikely) OR just ride it out. The later option ofbjust coming back for routine follow-up every year, and keeping an open line of communication regarding your symptoms is the most prudent and likely course.
Thank you for your comment, actually my cardiologists referred to them as arrests, i will have a look on my ECG as soon as i can. I probably was sleeping then, but cannot be 100% sure about that, but i don’t really remember waking up during that night. Actually my cardiologists diagnosed my Mobitz 2 as an SA block, but its unlikely, because there is a P always, no escape rhythm or premature or missing p (it is really really rare, especially that the QRS is narrow - so its easy to misdiagnose). I don’t really have symptoms, only extrasystoles when tired or stressed, that also happened once during the stress test during which i was panicking, but the stress test was negative (no arrhythmias of any sort - Mobitz 2 actually don’t always show up during these tests), I felt a missed beat last night, but not quite sure if it was actually a missed beat or just slowed down my heart rate while focusing on it too much and not taking breaths. I am asymptomatic completely, however, my panic attacks and the reflux sometimes confuses me.
other useful information:
Age: 28
Weight: 85kg
Height: 182cm
No known heart diseases or symptoms
Got hit by electricity a month ago, but was hospitalized and under supervision for 8 hours without symptoms.
As far as i understand it cannot be caused by sleep apnea or the vagal nerve, but its more likely a problem with the bundle of His (maybe thanks to the electricity shock?) and requires a longer observation (probably a couple of days with holter) and ablation (PE study) cannot really tell if there is an issue. So if i start having symptoms I might require a PM soon?
I really deeply appreciate your answer, thank you!
other useful information:
Age: 28
Weight: 85kg
Height: 182cm
No known heart diseases or symptoms
Got hit by electricity a month ago, but was hospitalized and under supervision for 8 hours without symptoms.
As far as i understand it cannot be caused by sleep apnea or the vagal nerve, but its more likely a problem with the bundle of His (maybe thanks to the electricity shock?) and requires a longer observation (probably a couple of days with holter) and ablation (PE study) cannot really tell if there is an issue. So if i start having symptoms I might require a PM soon?
I really deeply appreciate your answer, thank you!
3 Comments
Also, I take lavestra (50mg of losartan) for high blood pressure, this might cause hiperkalemia, but unlikely. Maybe rheumatic fever?
And there is a little trembling before the mobitz 2, See here: https://drive.google.com/open?id=1wRNsaOEiXiUqHc29rIirRS71veHQrkyY
i wonder is this possible that there is a burried p wave at S? if you look closely
COMMUNITY LEADER
Before I can give any thoughts I would need some more information. I am a little confused regarding some points of the diagnosis you were given. If you wouldn't mind clearing some of it up; I'd have more to work with.
Are you sure it was a Mobitz Type II? Were you told whether it was a Mobitz II AV Block or a Mobitz II Sinus Block? You are sure it was Sinus Pause and not Sinus *ARREST*?
There is a type of 'Sinus Exit Block' (potential reason for a Sinus Pause) called "Mobitz II". This explanation however seems odd. A diagnosis as specific as "Mobitz II" to describe the Sinus Node would be EXTREMELY difficult to make without an EP study, even for the most experienced and brilliant Cardiologists in the world.
Sinus Pauses mean a missed P wave or 2, however the next p waves come in on time and the hearts rhythm remains regular. There's a pattern.
A sinus arrest could be 2 seconds one time.. Then 4 seconds another time.. The duration of pause and when the next p wave will come back is unpredictable. The distinction can be important.
'Mobitz II' more commonly refers to a type of AV heart block. During Mobitz II AVB there is a P Wave, with no preceeding QRS. A Mobitz II heart block would be something you would expect to see more during the day, not so much at night. Reasons for which I can explain later. First we have to get a better grasp on what exactly the problems are and when exactly you had them.
In a case such as this changing the variables just a littls bit can have a huge impact on your prognosis.
P.S. Your Age, Gender, and any and all potential Cardiac Symptoms you've had is helpful. The more medical history you provide the better as well. Everything from seasonal allergies, to joint pain.. Doesn't matter what it is. It's usually best to just put it all out there and let us sort it out.
Are you sure it was a Mobitz Type II? Were you told whether it was a Mobitz II AV Block or a Mobitz II Sinus Block? You are sure it was Sinus Pause and not Sinus *ARREST*?
There is a type of 'Sinus Exit Block' (potential reason for a Sinus Pause) called "Mobitz II". This explanation however seems odd. A diagnosis as specific as "Mobitz II" to describe the Sinus Node would be EXTREMELY difficult to make without an EP study, even for the most experienced and brilliant Cardiologists in the world.
Sinus Pauses mean a missed P wave or 2, however the next p waves come in on time and the hearts rhythm remains regular. There's a pattern.
A sinus arrest could be 2 seconds one time.. Then 4 seconds another time.. The duration of pause and when the next p wave will come back is unpredictable. The distinction can be important.
'Mobitz II' more commonly refers to a type of AV heart block. During Mobitz II AVB there is a P Wave, with no preceeding QRS. A Mobitz II heart block would be something you would expect to see more during the day, not so much at night. Reasons for which I can explain later. First we have to get a better grasp on what exactly the problems are and when exactly you had them.
In a case such as this changing the variables just a littls bit can have a huge impact on your prognosis.
P.S. Your Age, Gender, and any and all potential Cardiac Symptoms you've had is helpful. The more medical history you provide the better as well. Everything from seasonal allergies, to joint pain.. Doesn't matter what it is. It's usually best to just put it all out there and let us sort it out.
2 Comments
Sorry for making you repeat yourself. I reread your history a few times and it's good.
There's just a little bit of ambiguity regarding the precise nature of the events and when they occurred that needed that extra clarification.
There's just a little bit of ambiguity regarding the precise nature of the events and when they occurred that needed that extra clarification.
Also I see your description of the Mobitz II, it's just a bit unusual to occur during sleep. You're absolutely sure you were sleeping? Your description of the PR Intervals and recovery rhythm are on point.
I also see you describing the pauses as arrests, however these 2 terms get twisted easily as well. In terms of timing were these only detected on the ECG, or were they also picked up on the Holter or during the stress?
Did you experience any symptoms on the stress test? Did you experience any type of heart block at all?
I also see you describing the pauses as arrests, however these 2 terms get twisted easily as well. In terms of timing were these only detected on the ECG, or were they also picked up on the Holter or during the stress?
Did you experience any symptoms on the stress test? Did you experience any type of heart block at all?
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