Pacemaker adjustments

I have a RR pacemaker by medtronic. I'm not on amy other meds. I had a very low heart rate ( 35-40) and symptoms- shortness of breath- before implantation. My issue is only my sinus node.
I'm thinking that maybe my lower limit needs to be adjusted up. I'm set at 55bpm now and wonder if I'm getting enough "juice" at this rate. Had it adjusted for the first time last week. They moved the upper limit from 130 to 150 which seems to work better as I was regularly hitting 130. Adjusted the time it takes to recover from 5 minutes to 2.5. I'm still hitting 150 when I run and don't feel like I'm at max so am thinking of having them move up again to around 160 ( I'm 61 but very active) .Make sense?
My main issue is at the lower end of range. My bottom is 55 and the midpoint was moved from 95-105. I am finding I am a little light headed at random times, Today I am pale after doing barre pilates. I have had a couple of light headed events at 75bpm. I'm wondering if I need to have the lower rate moved up or the slope of the pacemaker changed so that my HR goes up more quickly? Suggestions? Appreciate the help!

9 Comments

Depends

by Theknotguy - 2014-02-18 01:02:48

Depends. In addition to the PM, what other heart meds do you have?

For me, they can adjust the upper range all they want. It won't make any difference as I'm on two meds to keep my heart rate slow. The slow heart rate is to take care of a-fib. So, at the moment, no matter how hard I exercise, my heart rate barely goes above 120 bpm. I get angina and run out of air if I try to go faster.

The meds also mess around with my ramp up time, too. Sometimes it takes me 10 to 15 minutes to get everything up to speed. Once again, the meds kick in and it takes a while for the heart to speed up. Slow down time seems to be normal but it depends upon how much oxygen debt I have.

Depending upon the meds, that could explain the light head at 75 bpm. Your heart may be trying to transition to a faster speed and the meds are holding it back. Or, since you have a PM, you may hit a trigger point at 75bpm and you'll just have to get used to having a light head at that transition point.

Think about it for a second. You got a PM for a reason. So that means, even with the PM, not everything is going to go back to normal within a few days or weeks. Logically you think it will. Logically you think you'll just spring back. But the body doesn't work that way.

Another thing, they're having me exercise up to where I start angina. Then I'm supposed to back off and exercise at a level below angina. As my body gets adjusted to the rate just below angina, it pushes the angina level up. Two weeks ago, couldn't get above 115 bpm. This week, exercising at 120+ bpm. So you may have different speeds at which you get light headed and it may be due to how your body had adjusted.

Oh, and I'll get light headed at random times too. Usually it's just after I've initiated some movement. Welcome to the wonderful world of heart disease!

Hope things start getting better.

Theknotguy

Just guessing here

by KAG - 2014-02-18 02:02:41

since you didn't give many details on your condition. Sounds like you must have sinus node problems since your Rate Response is ON. My RR is Off so don't know about all those settings.

Unless there is a medical reason, I'd look at raising your upper limit higher. Sounds like you know what your upper rate was before the PM? For example if your upper rate used to be 160, I'd have them go to 165 or even 170 so your don't hit the upper limit.

You're on the right track. Keep after it until you get your device optimized for you.

Kathy

pacemaker adjustments

by jfasoneholder - 2014-02-18 02:02:52

Thanks for the input. I'm not on amy other meds. I had a very low heart rate ( 35-40) and symptoms- shortness of breath- before implantation. My issue is only my sinus node and yes my rate response is on. I'm thinking that maybe my lower limit needs to be adjusted up. I'm set at 55bpm now and wonder if I'm getting enough "juice" at this rate.

The real question is...

by donr - 2014-02-18 08:02:06

...What was your resting HR PRE-PM?

Supposing it was 65. W/your base rate now set at 50, you would be going below your intrinsic base rate & could well feel blah after exercise.

Let's look at what A TYPICAL HR will do under load (Load defined as O2 demand & resultant HR to meet that demand.)

You start out at base rate because you have been sitting & relaxing for 15 min. You start playing jackbunny down the road; The autonomic system determines that your muscles need more O2 so it sends a command to the SA Node to crank it up a notch or two. You keep running & the system continually sends the speed up msg to the SA node; the SA responds . This goes on till your body reaches equilibrium because you keep your speed steady & the Heart /lung combo system can provide the requisite O2 for the muscles. You reach your fractional Marathon distance & Throw out the Battleship anchor, which brings you to a screeching, instantaneous halt. You sit on a convenient folding chair, still breathing & pumping at an accelerated rate because the muscles still have to clear a bunch of lactic acid, clean up other waste products & send them to the kidneys. Meanwhile, the autonomic system is monitoring the shutdown procedure & sends continual commands to the SA node, which brings the heart down slowly. Finally, the command goes out that the job is done - all systems stand down; all squadrons "Splice the main Brace."

Now - what does an un-paced heart do????? Not all that because it has a crapped out control system. The SA Node doesn't work all the time; perhaps it not only has Brady, it has chronotropic incontenence & cannot respond to commands from the autonomic system to increase HR under load. Even worse, when the running is fin9ished & you plop into the folding chair, the SA just thumbs its nose at the world & returns to the base rate, leaving all those O2 starved cells knee deep in P&V (literally) W/ the trash lined up ready for pickup & the bloodsrtream garbage truck doesn't bother to come by. So the lungs are functioning correctly, bringing your bod young breath (you know, short pants). You agonize like mad till eventually everything is back to relaxed normal.

Now you have gone to Doc Cardio & he stuck a PM into you & jammed a couple harpoons in your heart walls.

Supposing it has been optimized by an alert, savvy Doc Cardio. Here's what happens. You start running; the Autonomic system calls for more steam; the PM, through its RR system, realizes that more is needed, but the SA engineer is sitting on his/her big fat butt sipping coffee (Chronotropic incompetence, remember?), so the PM sends its RR engineer in w/ a cattle prod, jabs the SA engineer in the butt & jacks up the rpm a bit. The RR engineer has a manual that tells it how to apply the prod & how often according to some algorithm in a notebook it carries. Now this is only an approximation of the real demand curve, but it's the best we have w/ current technology. The PM continues to monitor HR& continues telling the RR engineer to keep applying the prod. The HR reaches some rate & according to the manual, stops the prodding, except to keep the HR steady. You plop into that folding chair & the PM senses that you've stopped bouncing up & down, so it sends a message to the RR Engineer to change algorithms to the one called "Exercise Stand-down" (or some such nonsense.) So now there is a fixed rate at which the heart is allowed to slow down - HOPEFULLY, it is close to what the bod needs, or all that P&V & other garbage will be stacked at the cell doors, awaiting pick up.

So what can go wrong? eh?

1) Base Rate too low - cells are starved for O2 even before the starter fires the pistol, so you start out O2 deficient. The lungs work fine - just don't have a working delivery system, HENCE - SOB!!!!!

2) RR doesn't ramp up fast enough. Lungs still trying to make up for it, so you breathe harder than necessary for your running speed. You report a Medtronic PM - they have a dual slope capability in the RR algorithm, which gives Doc Cardio a lot of flexibility in adjusting it to make exercise comfortable.

3) Exercise Stand-down set for too short a period of time - You sit there & have young breath again, because the lungs are trying to make up for your slacker of a heart.

4) Base Rate too low - makes you SOB after you've had all your fun torturing your body.

Now - there are a couple more parameters that can be adjusted that have not been mentioned. IMNSHO, your UTR & USR, are set OK - you did not report any SOB at high output, or any sudden reduced HR at that time.. When you are anywhere south of the UTR, it has no influence over how you feel.

BUT - the AV delay, if adjusted too long or too short can cause SOB because the PM does not make sure that the Ventricles contract at the appropriate time. You claim no AV problems, so this shoud not come into play.

I stick my hand into my top hat & pull out little slips of paper that tell me that based on your reported symptoms, the Base Rate & your RR/Exercise functions are sub-optimum. An easy fix.

Don

Low rate setting can be increased

by Terry - 2014-02-19 03:02:59

There is no need to program the lower rate so low. I understand why they do that - ventricular pacing that bypasses the cardiac conduction system (Google that) can damage the heart over time. But the latest literature suggests that you can be paced as much as you want if the ventricles are activated in a normal, physiological manner. Be sure the lead is moved to the His bundle when you can, and in the mean time, monitor your ejection fraction to watch for possible problems. See PacemakerPatientAdvocacy.com.

All the best to you and yours,
Terry

DONR

by cindyredd - 2014-02-19 10:02:05

OMG DONR,

I love love your posts. Can you be my DR???
At least I can understand you.
And laugh. At the same time.

Best
Cynthia

I'm already your DR...

by donr - 2014-02-19 10:02:42

...because those are my first two initials!

All my life, I've lived w/ people thinking I'm an MD Because of that. Our #2 Daughter is an ER DOC & when we are out with her, & someone makes the mistake, I can always point to her & tell them "She's the Dr. I'm just a Dr's father." Always good for a laugh.

Cindy, you may be able to understand me, but what if I'm WRONG? You'd be laughing all the way to the morgue.

Cheers - & thanks for the kind words.

Don

My Experience

by Brain-watsit Dave - 2014-02-20 05:02:50

I have second degree AV block, I had the PM implantation just over a year ago aged 56. My resting heart rate was around 48 and dropping into the twenties overnight. A lot dizzy spells and tiredness but I never actually hit the floor. As a runner pre and post OP I was keen the upper limit was not too restrictive, so I dion't have the RR or an upper limit. My lower settings are 40 at night and 50 during the day, these seem OK. I managed to hit 176 bpm in one ten mile race post-OP with no ill-effect. It may be that your upper limit can be raised. Dave

Pacemaker Adjustment

by cindyredd - 2014-03-04 09:03:41

Still trying to understand the above. Pre PM , I was able to workout like a nut. I am three months out. Three adjustments.
The last Dr appt I got a 20 year old snotty medtronics guru who would not let me talk and see the settings are fine. However when I called medtronics I got a great gal that said my as settings should be lowered. I was at a 8 , now a 6, the lower she said the more xensitivey.

The issue is when I work out say doing the elipie for 45 min med pace.. When I go into cool down mode ,slow down my HR takes off to 168, and I go tachy, I almost passed out at the gym it happened twice the same day at the gym.

I. Went to the DR and not he says ,new talk, well uhmmmm its 168, for two min. But took 30 min to get below 100.
You will not die from it , well crap, thanks allot , I could not breath,walk ,talk,thought I was going to faint,great to hear I won't die.
Visit before was a totally other talk when the same thing happened , he said you may have afib,stay hydrated ,I do !!!
Blood thinners think on it, I took aspirin no daily.

Something still is not right ..
My hr is set now at 60 better ,70 was to fast, and mine does not have a 65.. Which I think would be perfect, however all my Dr says is hey you have the newest pm on the madket MRI safe , yippie.. I want to feel great. Not just OK..
The Brady is much better, but the fast hr is more prevelent since the implant.

Also when I stand up I am getting that pounding in my head again for a few min.at 70 I was not getting this but felt like a racehorse all day..

There must me a way to get this puppy tuned to perfection...

Any ideas in English lol

Best Cynthia

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