increasing AP-VP

I have had a Medtronic rate responsive PM for five years with excellent success. PM insertion was elective due to a Left Bundle Branch Block and occational lighth-headedness and two fainting spells; one serious and one minor. I have not taken much of an interest in my interrogation reports except for battery life which is 3 years . They tell me I am pacing100%.
After discovering this board, I started getting curious and in reviewing the print outs which I request , I noticed a reversal in the AP-VS, AP-VP percentages. In the last 4 years they have gone from AP-VS=70.9% and AP-VP=26.5%
to AP-VS<.01% and AP-VP=97.5%.
What is the significance of this pattern? Is my elecrtical system getting worse. Will see my cardio in 6 months.

22 Comments

Sounds like it

by donr - 2012-08-10 10:08:14

W/ the VP going up, it means that the bundle block is getting worse. Almost to a third degree block.

It sure would have been nice to see the other pair of combinations,

But - since these are combinations with "and" in the middle it is obvious that the VP has gone way up. Doesn't matter what it was, right now the Ventricles are paced almost always - along w/ the Atria.

Don

Donr--increasing AP-Vp

by zawodniak1 - 2012-08-10 11:08:52

Thank you,

What are the other pair of combinations you would like to see to further help interpret what could be going on..

My concern

by ElectricFrank - 2012-08-11 01:08:22

For bundle branch block or 3rd degree block without a sinus rhythm problem you should be having mainly
AS-VP as the predominant one. Your AP may be due to having Rate Response turned on unnecessarily. Look on the report for the Mode. It will be something like DDD or DDDR, but there are others. If there is an R on the end of the letters it means Rate Response is on.

With RR on the pacemaker calculates an atrial rate based on your activity. If your natural rate is less than the RR rate the pacer takes over and paces the atrium. Depending on settings this may propagate to ventricle pacing. The other issue is that it only takes a small increase in your activity to cross the threshold into large pacing increases.

frank

Other combinations

by donr - 2012-08-11 02:08:29

The two AS pairs:

AS-VS & AS-VP.

Meanwhile - Frank's answer may well be better than mine. You need to answer his question, also, about the RR function being on or off. You HINT that it is on by describing yourself as hosting a "...rate responsive PM..."

I focused on the fact that you started w/ a partial (apparently) bundle block. That's why the other two pairs are so important. Shoulda quit after asking for more info. Mea culpa.

Trust me - Frank will be back to see if you answer.

Don

Still Need ..

by donr - 2012-08-11 04:08:24

..to see the other two pairs of tracking data. Frank will want to see them also.

Don

here are the missing readings

by zawodniak1 - 2012-08-11 10:08:43

AS-VS<0.1%
AS-VP=2.4%
AP-VS<0.1%
AP-VP=97.5%

Does it appear that the LBBB has progressed to 3rd. degree.

Also, normally the print outs don't indicate any episodes.
This time it showed 2 ventricular high rate episodes.
07 minutes longest
05 minutes last
and
83528 PVC Singles
What is the significance of this data???

Electric Frank

by zawodniak1 - 2012-08-11 12:08:23

The Mode is DDDR
lower rate = 60ppm
upper tracking rate = 110ppm
upper sensor rate = 110ppm

detection rate = 150 bpm

Thank you Frank

by zawodniak1 - 2012-08-12 01:08:41

I am now making a list of questions to ask my Cardiologist in October after finally being educated on my interrogation reports.

Do you think raising my lower rate from 60 to 70 will my me feel a little more energized. I have an appointment to have this done by the Medtronic Tech in a few weeks but think I will hold off until I thoroughly review my last report with my cardiologist.

Good input on the rate response mode. I can walk for an hour at a brisk pace with no adverse effects and my heart rate is in the 90's---but I will explore this with him.

Thanks loads,
Rodger

Rate Response is ON

by ElectricFrank - 2012-08-12 02:08:26

The DDDR is definitely telling us that Rate Response is ON.

The "AP-VP=97.5% shows that the pacing cycle is being driven by atrial pacing most of the time. The VP would seem to show that your LBBB has progressed to a more complete block as often happens. That I wouldn't be concerned about as the pacer can easily handle it. I've been running that way since 2004.

My question is why they have RR turned on. Often as I experienced they just leave the factory settings turned on whether needed or not. After a bit of study I insisted that it be turned off (Mode=DDD). I was told I would be back in a week to have it turned ON. That was 8 yrs ago.

Another issue you may need to address. If you are at all active the Upper Tracking Rate should be increased. This sets the maximum HR that the pacer will pace your ventricles. As long as you had only a partial block this wouldn't have been a problem because your natural conduction would have handled the HR rates. Now that the block is complete you will find yourself with strange skipped beats and possible shortness of breath when climbing stairs etc. I would shoot for having it increased to at least 140.

If this is too technical let me know and I'll try to say it different. I'll leave it to don to explain the PVC Singles.

frank

Resting Rate

by ElectricFrank - 2012-08-12 08:08:05

What is your resting HR? It might help to raise the lower rate.

On the first page Clinical Status section of the report there is are two long term histograms, on atrial and the other ventricle. These can give you an idea of how your HR is distributed over it's range.

frank

See What happens to answers...

by donr - 2012-08-12 08:08:46

...when you tell us everything!

Note that Frank changed his evaluation somewhat, based on the extra data you sent.

On to the residue he left for me to sweep up!

First - the Ventricular high rate episodes: Only two is not bad, but ask the medics about the length of time they exist. High rate is defined as somewhere in the 150 BPM range - but NOT in the V-Tach range, which is so high that the ventricles can turn into a quivering pile of uncoordinated muscle.

IF the episodes were as long as that, you should have sensed them.

On to PVC's. "83528 PVC Singles" - piker!!! I had 88452 of them on my 9 July download!

Let's put that BIG number in proper perspective. Mine were over a 5 month period. Divide my number by 5 & you get ABOUT 18,000 in a month - further, divide by 30 & you get 600 per day; divide by 24 & you get ABOUT 24 per hour. That is less than one PVC every 2 minutes! Not very many. You probably don't even sense that few. Consider that a heart beats 3.5 MILLION times in a month (which corresponds to a HR of 60 BPM) Now THAT's a whole lotta beating!

Now, what's a PVC. I copied the definition from the column on the left side of your screen.

"PVC: Premature Ventricular Contraction; occurs when the electrical signal that causes the muscle to contract comes too soon. The ventricle does not have enough time to fill before contracting. When PVC’s occur several times in a row and too close together, there is a danger of developing ventricular tachycardia or ventricular fibrillation. Although everyone has PVC’s, persons with damaged heart muscle have many more."

Sounds pretty terrible - it IS NOT at the rate you & I have them. You need bunches in a row to have potential for serious problems they mention. If you sense them, they can be scary, because it makes you feel like your heart skipped a beat. It didn't. I'll quote my Cardio, his nurse, & my EP: "They won't kill you." And, they haven't.

Any other questions, ask away. be glad to help.

Don

Don, Not bad for sweeping up the residue

by ElectricFrank - 2012-08-12 10:08:20

One additional comment about PVC's. They are probably the scariest of the arrhythmia's and also the most benign. The greatest risk from them is that they will scare the patient into passing out.

frank

Thou spaketh a bookful...

by donr - 2012-08-13 01:08:01

...Frank.

My whole trip through PTSD in 1977 leading to my PM in 2003 started w/ a single PVC! It occurred at 9:20 PM on 15 March 1977. I was drinking a can of Classic Coke while leaning against the drainboard in a shared kitchen in a BOQ at Aberdeen Proving Ground, MD. It must have been dramatic to remember all the details about the circumstances surrounding it.

I did not know what it was at the time & it really scared me. I had those suckers for all those yrs & never knew what they were - mainly because I never saw a cardio till 2002. Now I have them by the tens of thousands & think nothing of it till I see my periodic download.

Don

Frank---RESTING RATE

by zawodniak1 - 2012-08-13 04:08:05

The Atrial and Ventricular Long Term Histograms both show the majority of % of paced beats in the 60bpm to 70bpm rate area.

Do you think I would feel any difference if this was shifted to 70/80 bpm or God forbid 50/60bpm---Someone recently posted about having their PM lower limit adjusted to 50 from 60 and they felt better---surprising.

appreciate it!!

Resting Rate

by donr - 2012-08-13 06:08:28

The key question you need to answer so we can give an opinion is "What was your resting rate Pre-PM?"

We are all different in this area. In my experience, you want a lower rate set no more than about 5 BPM higher than your resting rate pre - PM. You get it much higher & you feel low level anxiety all the time - unless, of course, there is some reason to set it higher.

Don.

Resting heart rate 45,49,56,58

by zawodniak1 - 2012-08-13 07:08:58

From the somewhat sketchy records I have from before my PM insertion I come up with 45, 49, 56, 58 with the comment of "sinus bradycardia and left bundle branch block.". The low-level anxiety comment really strikes a cord as this may have been something I have been living with, with the PM without realizing. Definitely something I will mention to my cardio. Almost seems at this point trying a 55 or so might be a starting point rather than going above 60. But I keep thinking "If it ain't broke, don't try to fix it." and be careful to "not let perfection be the enemy of good enough:" But if they can easily change it back---Hey, nothing ventured nothing gained. What do you guys think?







Resting HR, Again

by donr - 2012-08-13 08:08:28

With a diagnosis of "Sinus Bradycardia," Your resting HR Pre PM cannot be 45 or 49 - too low! UNLESS you are a real jock w/ a low natural resting rate. Second - w/ the 56, 58 HR coming at a session where the cardio gives the same diagnosis, he/she obviously sees something else that tells him that your natural resting rate is above those two numbers, also.

You asked above if raising your lower rate from 60 to 70 would make you feel better. What's wrong w/ trying it at 65? That's an allowable setting on the PM, & appears to be at or just above what your natural rate might be from the data you have given us. You have the rest of your life to find the right setting, so you may as well creep up on it, as opposed to jumping around & getting confusing results as to how you feel.

Obviously you do not have detailed med records from well before you encountered the need for a PM due to Brady. Makes it kinda difficult to accurately fix where to set the lower rate. (I knew mine from years of annual physicals in Uncle Sam's Army.)

There is a slim chance that you are a natural 55, but that would be unusual short of being a well conditioned jock. That's why they keep setting PM's at 80 for people as an initial setting - seems to be the default.

You need to have a discussion w/ your CArdio about how HE determined your base rate for the PM setting. Then ask if you can try the 55 - or the 65 - whatever you might feel comfortable with.

Good luck w/ him.

Don

more on my resting heart rate

by zawodniak1 - 2012-08-13 10:08:35

Don,
Just to clarify, the HR's I provided were from EKG's over a period of years before the PM. Are you inferring that HR 's with bradycardia are lower than what my true resting HR was at the time.-----thanks for your patience..

What is your resting HR?

by donr - 2012-08-13 11:08:54

Hmmmmm! Generally, w/ Brady, your HR is lower than it would normally be. That's the definition of Bradycardia. If you read a lot of posts & comments, you will find that 40's & 30's are where most Brady HR's reside for people whose normal resting rate is in the low 70's.

It's that lower than normal HR that makes you feel so fatigued all the time.

Do you know when the Brady began? Your situation is confusing & somewhat indeterminant. That's why I suggested that you ask your Cardio HOW he decided where to put your base rate for your PM.

If, indeed, your true resting HR is down in the 40's or low 50's, having a base rate of 60 would be significantly higher than normal & it could well make you feel borderline anxious all the time.

Don

Effects of Lower Limit

by ElectricFrank - 2012-08-14 01:08:50

The sinus bradycardia is more information as to why Rate Response would be turned on. So far I had only been going on the LBBB and inferring a progression to a full block.

So here's my take on the effect of the various settings. As your effective resting rate is lowered you you will have more tendency to feel low energy after a time of low HR. For me this happens if I sit in my recliner watching TV for a while and my HR settles out around 57 or so. I've learned to handle it by getting up and moving around actively for just long enough to drive my HR up into the 65-70 range. At that point my energy is back. Same thing after a nap or getting up in the morning.

As far as overall energy that would be dependent on having a fast enough rate when active. Since RR is actually controlling your sinus rate (AP-VP) then maybe what you need is the RR settings tweeked. The names of them vary with pacer make, but what you are looking for is the one that changes slope of the curve that controls HR with activity. That would move the center of the histogram up. Mine shows a peak in the 70-80 interval. If you are performing daily activities with an average HR that is on the low side for you it put a chronic drag on energy yet not cause light headedness.

As for the borderline anxious effect of a high lower limit that is an individual thing. It has no effect on me at all. I've come back to bed after a pit stop and have my pacer start its self test where it drives my HR up to 85 and then 100. I've been asleep before it finishes. Same with office checks, where I feel it, but so what.

Hope this helps,

frank

Electric Frank--RR Question

by zawodniak1 - 2012-08-20 03:08:16

I am learning more each day as I read the board. After five years, I finally learned how to trigger my RR mode. I firmly tapped near the PM and she went from 60 to 90+ in less than 30 sec. then slowly settled back down to the 60's. My RR is set at 110. What happens to the PM once it increases my HR to 110 if my activity rate is increasing the demand on my heart beyound this point. Does the PM not do anything beyound 110 and just let my ticker do it's own thing---what happens???
Thanks a bunch,
Rodger

Donr--increasing AP-Vp

by zawodniak1 - 2012-08-21 05:08:37

Donr,


Thanx for jumping in. I will stay tuned.. This PM technology is in study in and of itself. For every answer, two or three crop up.
Rog

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