PM alerts

Soooo..... guess I spoke to soon when I was telling everyone how incredible I finally felt.... maybe ill enjoy some crow soup; ) my wonderful merlin at home transmitter has beem sending alerts to my EP everyday. Last week they attempted to adjust some settings and basically turnedcmy alerts off for the time being. I had a pacemaker inserted in late September bor sever bradycardia. My basic settings are 60/120. Withbalerts of anything > 150. Monday I recieved another call stating theyb were putting me on matoprolol 50mg bid. Which would be fine and dandy if my b/p were high; however that tends to be on the low side, especially now. They proceeded to load that to 25mg bid. My alerts read that iegms show a tach. I continue to have these episodes daily at least 10 that I am aware of. Today that had me come in for a hoter monitor so they can assess these episodes better as I only have a single lead. There is talk about possibly adding another lead. I will find more information after my holter results. My ep is also considering reopening me up to move my lead as it pulls up and is very sensitive. Any food for thought I'd appreciated..... thanks in advance

5 Comments

Sorry about your trouble

by Theknotguy - 2013-12-20 06:12:57

Sorry you're having so much trouble. You sound very similar to my situation. I've got a-fib plus the pacemaker.

My a-fib is three different kinds. One kind is just a flutter. The other kind makes my heart go faster and faster. The third kind tried to kill me.

They give me Metoprolol to slow down my heart so I don't go into a-fib. The pacemaker keeps my heart beating fast enough so I don't pass out. They can't control the rhythm so they control the rate.

They had to adjust my Metoprolol from 50mg up to 100mg. The other problem is my heart, when slowed down, continues to go slower and slower. So they've got two choices, slow my heart and it stops. Keep it at speed and my a-fib will kill me.

Based upon what you are saying I feel (in my non-medical opinion) you are going through a similar situation to me. The Holter Monitor will give them a clearer picture of what is going on. Sorry you have to go through the long time of being on the monitor.

I've got two leads and am getting along fine. Problem is how much Metoprolol you need. I was kinda OK at 50mg. Am getting along fine at 100mg. Can go up to 150mg if I get an a-fib session. So there's a little leeway there before I have to punch the button and go to the ER. I'm also on Cardizem.

Hang in there. Hopefully it will get better in the near future.

Theknotguy

Theknotguy

by Tick-tock - 2013-12-20 07:12:17

Thank you! I only have one lead- wish they would have went with a dual chamber right away. My EP wanted to do a single lead due to my age, so my heart would be as natural as possible.... Well apparently I don't like nature :) also, thanks for being able to read my jibber jabber.. Siri likes to switch my words around =)

Atrial tachy?

by golden_snitch - 2013-12-21 03:12:55

Hi!

I do not get the relationship between an atrial tachycardia, and a single-lead pacemaker. The pacemaker should NOT be the problem. So, if it's atrial tach I'd not go for a dual-chamber implant, because it wouldn't change anything. If the atrial or ventricular lead is inhibited by atrial tachycardia, the same thing will happen in a dual-chamber device; pacemakers cannot do anything about tachycardias. So, if any procedure, I'd have the tach ablated. But can try drugs first, of course. Many atrial tachys can be ablated easily, though, so that would be a cure. This doesn't apply to Afib, but what you have with the rates >150, sounds a lot like an atrial tachy (SVT) or atrial flutter, and that can be ablated.

Best wishes
Inga

asfasf

by boxxed - 2013-12-21 10:12:07

Snitch, it's not a matter of needing an atrial lead to improve pacing functionality. It's moreso what the device can see and giving clinically relevant information to the doc so the doctor can figure out the best approaches to treatment.

Single chamber devices can sometimes be notoriously difficult to diagnose rhythms with. This becomes increasing problematic when it's a defib and inappropriate shocks are coming into play. Is it fast rates from AFib or is it a true ventricular event?

Those reports are seeing your ventricular rates. That's the only thing it sees. it can only see the results of what your top chamber is doing. But not the top chamber itself. The analogy I use is that I'm your best friend, you've recently had a really a bad breakup and have been in tears, and I'm trying to figure out how you're coping by and if you're improving by only observing how many used tissues are in the waste basket when you're not at home and if there is more or less as time goes on.

Is it a 1:1 rhythm, is it atrial tach, is it atrial flutter, is it atrial fib, or is it NSVT/VT? Some RVR (rapid ventricular response) from Atrial Fib can regularize and not be classically "irregularly irregular" with sudden bursts of speed and pauses.

They are not sure what's going on in the atrium. Is it fast and organized and discrete signals in the atrial channel? May be AFlutter. Is it organized and discrete signals but with an atrial rate of 150-200? Could be Atach. Is it chaotic and disorganized with atrial rates of 300+? Probably AF. How long are you in these atrial rhythms? Can't tell because the device is only recording when the ventricular response goes > 150. You could be in AF for 20 minutes with dozens of fast events recorded. You could be in AF for 4 months straight with no ventricular rates > 150 seen and recorded.

Boxxed

by golden_snitch - 2013-12-21 11:12:05

I do understand what you are trying to say. However, we do not even know, yet, if Sgates has a single-chamber pacemaker with an atrial or ventricular lead. It sounds a bit like it's an atrial arrhythmia, and that what sensed this is an atrial pacemaker lead: "My alerts read that iegms show a tach." Don't know, but "a tach" is usually the abbreviation for "atrial tachycardia". So, if Sgates has indeed a single-chamber pacemaker with an atrial lead, then we are talking about adding a ventricular lead, and that doesn't make any difference, if you have an atrial tachy.

If a pacemaker picks up an atrial tachy, you always need to confirm with a holter - no matter, if you have a single- or dual-chamber device. Pacemakers do pick up a lot of artefacts, so you can never just trust the pacemaker report, without doing a holter. A pacemaker is not there to help diagnose arrhythmias; a pacemaker is there to treat bradycardia. It's nice that it can pick up arrhythmias, too, but as I said before, unless it records an ECG of these, you cannot be sure that what it picked up really was an arrhythmia.

If you give someone with a simple sinus bradycardia a dual-chamber device, you not only risk that the person ends up being paced in the ventricles, although there is no need to - happens often because loads of cardios never optimize settings -, but you also increase the risk of lead-related complications (thrombosis for instance). Especially young patients who might need a few lead replacements in the future, you should start with what is really needed. And in someone with sinus brady, that's an atrial lead, and not a ventricular. In someone with heart block, however, a dual-chamber device might be better to provide synchroneous pacing and avoid pacemaker syndrome.

Now, with regards to single-chamber ICDs: Yes, that problem with Afib etc. used to be a real problem. However, there are new leads on the market now that can sense the atria very well, although they are placed in the ventricle. See, for instance, the Biotronik Linoxsmart S DX ICD lead.

Again, I don't think we are talking about adding an atrial lead in this case.

Inga

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