What do you think?

Hello everyone. I am new to this club. I discovered it about a week ago and have been reading a lot here since. Let me tell you about my problem maybe you have some good advice and can help with some more information:
My mom has discovered about 3 month ago she has low HR and checked it almost daily since. It's about 43-56. On a checkup the cardiologist sent her to emergency because of low HR and the emergency guy wanted to put a PM. She did not agree to do it in a rush since she feels fine. And during the monitoring there overnight her HR was around 52.
Now she got admitted to another cardiology department to do more test and put a PM if necessary. Yesterday on the ECG in the morning she had HR 57 and in the afternoon was 60. The initial diagnostic is 2nd degree AV block type 1. She needs to get more tests these days so we don't have the complete picture yet.
As far as I read an AV block 2nd degree type 1 does not need a PM unless there are symptoms and is kind of depends on the doctor's oppinion. She has only the low HR which seems to be improving. Also forgot to mention we went to check for thyroid problems and she has a high PTH level (Hyperparathyroid, not very high which might be because of lack of vitamin D which she was prescribed and taking now for about 6 days). Also has a nodule on the thyroid but the lab work shows the thyroid levels are fine. I don't want her to put a PM if its not necessary or not now if she can wait for a while with this. A year ago she did not have any problems and her HR was about 63 when she went to the cardiologist for the regular checkup.
Can this AV block fix itself? She has no symptoms and if her HR is above 50 would not be dangerous for her and maybe the block could be reverted after the thyroid problems will be fixed, or maybe at least she can postpone putting the PM for a few months/years. Of course I don't want her to take chances either, but as far as I read the type 1 block does not usually turn into a type 2 or 3rd degree. Now, what do you think?
Sorry for the long post I would really need your help with this because you all know a lot about these issues.
Thank you

15 Comments

2nd degree heart block- no symptoms

by Selwyn - 2013-05-29 01:05:15

Indications for pacing:-

Asymptomatic type II second-degree AV block with a narrow QRS. When type II second-degree AV block occurs with a wide QRS, pacing becomes a class I recommendation. (Level of evidence: B.)

Asymptomatic type I second-degree AV block at intra- or infra-His levels found at electrophysiology study performed for other indications. (Level of evidence: B.)

Clearly a lot depends on the electrophysiology. This needs clarification. Once you have the further tests then an indication for a PM may be given based on the track records of other poor unfortunates that were not so lucky to have this level of evidence.

If you wish for further clarification send me a private email ( I am medically qualified- retired)
With best wishes,


Hi Selwyn

by IAN MC - 2013-05-29 01:05:16

I have often wondered about these published " indications for pacing" . It would seem to be incredibly straightforward that if the symptoms / ECG traces tick so many boxes then a PM is indicated ....but why is it that sometimes cardiologists don't always seem to agree whether a PM is indicated or not ?

Are they cast-iron indications or guidelines ? Are they universally accepted by all cardiologists and if not, why not

Sorry if this is a dumb question but I always remember my cardiologist saying " I THINK you need a pacemaker " with a rather uncertain look on his face. If the indications are so clear-cut why is it not a more definitive process than it seems to be to be ?

Ian

Ian

by Tracey_E - 2013-05-29 02:05:41

Ian, the cardiologist I had growing up (1970-1986) said "put it off as long as possible." The cardiologist I had in college, said "eh, let's wait and see how it goes." The one I had when I got out of school and up until I got my first one in 1994 said "some day you will need it, let me know when you want to do it." Then one day I mentioned my purple fingernails in passing. He said "get to the ER NOW, why the heck didn't you call me sooner?!" Why not? Because the mentality of the first one stuck with me so I was trying to tough it out. No one ever talked numbers with me and the internet wasn't around back then to look it up for myself. But it was always about how I felt, not what the numbers/guidelines said.

Qualified

by cropduster - 2013-05-29 07:05:23

Hi, firstly I am not medically qualified, I can only tell you my experiences.
I had many visits/tests at my doctors office where my HR was measured, BP taken, all was fine, infact my doc said it all pointed to me being in very good health.
It was only after wearing a monitor for 2 weeks that they picked up my heart pausing for 5 seconds.
I had a PM after that, which has not affected my quality of life at all.
I hope your Mother gets well soon, but if it were my Mother I would be persuading her to get the PM.

decisions

by Tracey_E - 2013-05-29 09:05:34

Electrical blocks do not normally go away or get better on their own, it's a breakdown in the electrical conduction so that's not something that can fix itself. Second degree either means she's in full block (no signal getting through) some of the time, or in partial block all of the time (some signal getting through), or some combination. We can go in and out of block.

Has she had a Holter to confirm how low she gets, or a stress test to see how she does on exertion? I would want both of those before making any decisions. If she walks up the stairs, is her rate still in the 50's? They call anything below 60 bradycardia so don't let that word bother you. Many people get by just fine with a resting rate in the 50's or even 40's. If she has no symptoms, it's 1st or 2nd degree, her resting rate is decent, then I would wait on the pm. If she starts getting dizzy, it dips lower than that or pauses, she doesn't have the energy to do the things she wants to, her rate does not go up with activity, then it's time to look into the pm.

When it's time to get it, it's nothing to fear. Most of us find the surgery is easier than expected and we come out of it feeling better than expected. Block is the easiest thing to fix with a pm because the sinus node (nature's pacemaker) works just fine, all the pm does is complete the broken circuit. Keep in mind as you read here that many people come here with problems, so it makes it look like problems are common. For every one person who posts here with a complication, there are hundreds out there feeling great and getting on with their lives.

Questions

by ebfox - 2013-05-29 09:05:48

I am not medically qualified either, but you are wise to educate yourself about this decision.

How does your Mother feel? Has she ever passed out or required medical transport due to low cardiac output? Has she worn a holter monitor for a month and did it show extended pauses? Is she taking any medications (such as beta blockers) that would make her heart rate even slower?

If her energy is low or if she has passed out, she probably needs a PM now. If not, your approach to fix the thyroid first is probably what I would want for my mother. Lots of people live good lives with heartrates in the 50s.

I don't know if AV block can "fix itself", however resolving the thyroid problem could/ should have a positive effect on her overall condition.

Good luck,

EB

Thank you all

by mk14 - 2013-05-29 10:05:07

Thank you all for your input and advice. So far my mom never had any problems. She feels fine and works full time. She will be 59 this summer. At the moment she is admitted to the hospital for some more tests. She had an effort test today and as far as she told me it all went great. Her sinus node is working fine and as far as I understand the block showed during the stress test. So apparently is not showing all the time. Today she also had a HR of 56. She also had an echo that shows her heart is fine. That's what I know so far. She will be put on a 24 hour holter monitor and maybe after that we will know more.

What I am thinking right now is that if it's a second degree AVB of type 1 which only shows some of the time, and if her HR is not an issue anymore, it would be a good idea to wait with the PM. I understand it's not a bad thing and it has a lot of benefits and I am all for it if she needs it. But as far as I saw a lot of your doctors waited with the implant until it was necessary. And as I said her thyroid problems might be what caused this. Would you put a PM with a HR of 56-60 and an intermitent AV block 2/1? Or just wait until the HR was constantly around 40 to do it?

I will keep you informed as soon as I find out more about this. Also, I appreciate any other thoughts or opinions or personal experiences you might have.

Quality of Life

by donb - 2013-05-29 10:05:19

Hello mk14! I can't add much to above postings other than your mom's history is like a replay of my past history with the same decision making problem. In my case age was an important factor as I was age 62 with the same symtoms. In my case it was low HR during sleeping & diagnosed as 1st to 2nd degree electrical heart block after passing out & going into ER. It finally boiled down to my cardiac nurse (wife) to make my decision. She was told, "Don will have to have a PM when he gets old". She responded, Don will not get old if he doesn't get a pacemaker". I had my PM Implant the next day & my Quality of Life has been great as now at age 81 am in good health & way too active. I have had implant problems with premature replacements mostly because of my skinny body. I was without of a PM for a couple months some time ago because of erosion problems, but my heart resorted to going back to your mom's present state. I have an appointment this June 17 for another replacement & site revison as this 81 year old abused his body doing bull work. Fact is, my pacemaker life has been great but doesn't make my mind tell me my actual age. I am gradually learning to ease off as most seniors normally do at my age. Thanks for posting, brings back memories !!
donb

No symptoms; no PM

by IAN MC - 2013-05-29 10:05:45

Hi mk14. Everything I read ,too, suggests that 2nd degree heart block, type 1, is usually considered to be fairly benign and only needs a PM if there are symptoms.

Apparently it can sometimes "fix itself" or can disappear if whatever has caused it is no longer there e.g. a heart attack can cause temporary block. Certain combinations of drugs may be the cause; remove them and the block may disappear....... but as with so many cardiac electrical problems the cause may never be identified.

I would play a cautious "waiting game" , get the thyroid problem sorted, and see what a Holter shows up just as the others have suggested. I think EB asks the important question " How does your mother feel ? "

as Tracey says... if she does end up with a PM it is nothing to fear.

Best of luck

Ian

numbers

by Tracey_E - 2013-05-29 11:05:05

There is no one magic heart rate that determines when we should get the pm. I was born with av block and my heart rate never went above 44. Ever! Didn't matter what I did, I stayed in 3rd degree block so my ventricles never got the signal to beat. I got by fine with that until my 20's when I started getting dizzy and tired, then I got the pm. I didn't realize how tired I had gotten since it happened gradually. I felt fantastic after, more energy than I'd ever had.

If she feels good in the 50's, then just keep an eye on things. Intermittent 2/1 is good because it means she's not in block all the time, and when she is some of the signal is still getting through. If she gets into the 40's and still feels fine, then continue to keep an eye on things and wait. Or she may get to the 40's and get more tired, more dizzy, then it's time to meet her new titanium friend. It's a great sign that she did well on the stress test, that means she can get her rate up. A low rate resting may feel ok, but most of us don't spend our lives on the sofa so it's important to know how she does on exertion. Many people with 2nd degree block get by indefinitely. I hope your mom is one of them!

It is normal for those of us with av block to have a normal sinus node and for the heart to be structurally normal and healthy. AV block is simply an electrical short circuit, a disconnect between the SA (sinus node) and AV nodes. The animations on St Jude's website do a wonderful job of explaining how the heart beats, what av block is, how the pm helps.
http://health.sjm.com/arrhythmia-answers/videos-and-animations

My understanding is thyroid can cause a slow heart rate, but it doesn't cause a block. (but I could be wrong)

Guidelines

by Selwyn - 2013-05-30 01:05:41

Yes, guidelines are guidelines, not law. Level of evidence B is not level of evidence A, and so there is a balance of probability coming into play. Nothing is ever universally accepted in medicine. There are doctors that have tossed a coin and have had it come down heads 7 times in a row. What I am trying to say is that some medics have an entirely odd experience and this goes into the process of deciding what is the best treatment. I remember seeing a young man die having his tonsils taken out- ever since then I have been rather reluctant to recommend tonsillectomy in spite of guideline indications. Others may hold a different view if they personally have suffered the pain of tonsillitis. Cardiologists are not machines, their opinion is also based on personal experience. If they are prepared to break guidelines they should always be prepared to justify this to a patient, colleagues, and if necessary the coroner!

Hope this answers your question Ian. My advice is always get a reason from the doctor if guidelines seem not to be followed as in general what guidelines should represent is the probability of an outcome, though nothing is certain in medicine!

Evidence-based medicine

by IAN MC - 2013-05-30 02:05:34

Thank you, Selwyn, for your explanation; I suspected that it would be along those lines.

I guess in an ideal world all medical decisions would be rational and evidence-based but I do appreciate that Drs are human like the rest of us and past experiences and prejudices can affect their objectivity.

I'm not sure where this leaves us as patients though !

My GP actively attempts to discourage patients from any sort of surgical intervention . I quizzed him on this and it turns out that he, himself, is scared stiff of anaesthesia !

I also often wonder , if drug-prescribing is so logical and evidence-based, why then are there so many drugs listed in MIMS ?

This apart , I think it's great that you, a medic , happily contribute to this forum. I do hope that if ever you see advice being dispensed which is so medically unsound as to be potentially life-threatening that you will find time to let us know.

Best Wishes

Ian

Here is the latest

by mk14 - 2013-05-31 06:05:05

So, my mom seems to have intermittent AV block 2:1. The holter shows no pauses and the lowest HR at 36 during the night. The indication was for pacemaker, but she would like to put it off in hope that after resolving the other stuff with the thyroid maybe she will not need it anymore. I also plan on her having a sleep apneea monitor too see if that is not an issue (which might be).
So...again...What do you think? Would you put it off until the HR drops in the 40s or you feel dizzy or show any symptoms Now she feels perfectly fine. In fact even with a HR of 41-43 when she was first diagnosed she was feeling fine, no problems and working full time.
Thanks and looking forward to see your opinions and your experiences maybe.

Fix Thyroid

by ebfox - 2013-05-31 09:05:15

I think the sleep apnea monitor is wise.

I am with Tracey, get the thyroid sorted out then let's see where she is. If she passes out or has any other symptoms, that changes the game but for now you have a reasonable plan.

E. B,

when

by Tracey_E - 2013-05-31 11:05:36

36 at night is pretty low but if it's just the occasional dip rather than where she stays all night it's not urgent. Given everything else, my not-a-professional opinion is she should probably get it but there's no rush so if she wants to get the thyroid under control first, let her.

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