Max BPM

Hi, Need some advice before I call the clinic in the morning.

Had a second aortic valve replacement in July, unfortunately had complete heart block after surgery and ended up needing a pacemaker.

I am a martial artist, competitive and instructor, tae kwon do and boxing etc as well as running, assault courses etc.

After all clear from surgeon I began training again last week but when running found I was hitting a wall and getting out of breath and dizzy.

Tried to train through it figuring i was just unfit again but no avail.

Strapped on my old heart monitor and found that I was hitting about 170 bpm and then heart rate was dropping back 90-80 and then settling at 70 for a maybe 30 secs before jumping up again, at which point I'd start running again but within second the same cycle starts again.

Pacemaker is Boston Scientific Ingenio.

I have reviewed the paperwork from my last pacemaker check up and there is a max bpm set to 165.

The spec for the Ingenio says max bpm 185

Prior to surgery I would often hit 200bpm in the ring

I cant afford to hit walls and get dizzy/out of breath when in the ring or abseiling or open water swimming.

Any and all advice appreciated.

Oh I am male and 42.

I have a assault course race on this saturday that i want this resolved by and the tkd british championships in november...


Thank you

12 Comments

thank you#

by JRTKD - 2014-09-14 06:09:10

Thank you.

So I may need to get them to change the pm to a different model then?

Can they re-use the leads (as I know they can't get them out easily)?

upper limit

by Tracey_E - 2014-09-14 06:09:55

What is happening to you is fairly common with those of us who are young and active with heart block. The pm will only pace you to your upper limit. It looks like they can bump it up a little more, but they won't be able to set it higher than 185.

It's always going to feel off when your atrial rate gets over 185, however there is something they can do which will help. There is a safety feature that puts us into an artificial block when we go into afib. It detects a high atrial rate and automatically drops the pacing to half (2:1 block) until your rate comes down. This is great if you are in afib, not so great if your rate is up due to exercise. They should be able to turn this off.

I can think of one other thing that may be going on. My rate will sometimes nosedive on its own for a few seconds during exercise, then bounce back up where it's supposed to be. The pm can be programmed around this, also, I think it's called rate drop response (or something like that, it's not rate response but sounds similar). Mine was diagnosed when I ran on a treadmill in the office. They turned off the afib thing and I was still having problems hitting a wall so I got on the treadmill trying to duplicate it when they were watching.

Hope that helps! The treadmill is a lot more efficient than trial and error, suggest it if they don't offer it. We're all different, and most offices don't have more than one or two active patients, so we can be a bit tricky. The good news is once we get past this initial period, most of us feel great and get back to what we were doing before.

change

by Tracey_E - 2014-09-14 07:09:56

99% of the pacers out there have a max of 180/185. There is only one I know of that goes higher, a Medtronic that goes to 220.

Yes, leads are interchangeable between brands but changing it out would be a last resort and odds are your insurance won't cover it because they won't consider it a necessity. Try the other things first. If your heart rate is no longer plummeting and you can get up to 185 vs 165, that should take care of most of the problems you're having. Also, many times our hearts beat differently after being paced so don't assume you'll need more than 185, you can't go by your old numbers.

My problems were similar to yours originally and we were able to work around it with programming for years. I eventually developed SVT, which is the hr shooting quickly up to 200 on its own within a few minutes of exerting. Similar effect but different cause and much more annoying to work around. I ended up going on a low dose beta blocker rather than switching to the pm that goes faster. I don't get over 160-170 now and I can still work out hard. We talked about switching to the Medtronic when I had my last replacement (I'm on #4 now) but my SJM rep is amazing and if I switched to another company, I'd have to switch to another rep. Programming around my other problems (the plummets, etc) is sometimes a challenge and he knows how to keep me feeling good so I made the choice to stay with a max of 185.

It's normal to take some time to get the settings right! The average pm recipient is older and sedentary with a laundry list of other problems, not young, healthy and active. They start with a good guess of what will work for us, then adjust as necessary. It's normal to take a few tries to get it right.

Upper tracking rate

by golden_snitch - 2014-09-15 03:09:22

Hi!

The parameter that's most important here is the "upper tracking rate". In your Boston Scientific Ingenio pacemaker the upper tracking rate indeed is 185bpm.
The Medtronic Adapta has 220bpm, my Biotronik Evia has 200bpm.

Like Tracey, I'm not sure that you can get this pacemaker replaced just because you can only go up to 185, instead of 200. If it were the case, that you were limited to 150-160, and are used to 200, then maybe, but 185 and 200 is just 15 beats per minute less. I guess you'll likely be told to try to adjust to this new maximum.

At the moment, you do not need the pacemaker's rate response feature, because you have a complete block with no sinus node issues. But if you should ever need the rate response, your Boston Scientific device is better than the Medtronic with the higher max. tracking rate. Your device has two sensors for rate response, Medtronic has only one.

But if you can convince your cardio to replace the pacemaker, then ask for a Medtronic Adapta with an UTR of 220.

Inga

Thank you

by JRTKD - 2014-09-15 03:09:30

Thank you.

If they adjust the upper tracking rate to 185 and I am still banging on its doors they will surely have to change it.

Pretty sure my cardiac surgeon would back me on it, as long as the medtronic one is available on the nhs.

One of my questions today will be why they didnt choose it in the first place.

I had special leads (apparently) put in, definitely sure they would work with another pm? (leads are ingevity mri)

I am speaking to the clinic this morning.

will let you know. fingers crossed.

What is rate response?

Pacemaker choice

by golden_snitch - 2014-09-15 03:09:41

Hi!

Did you talk to your cardio before the surgery about what kinds of sports you'd like to be able to continue after the pacemaker implant? Did you tell him how high you need your heart rate to go up? Often heard from other patients that they did not discuss this issue before the surgery, and then ended up with the wrong pacemaker. Even if you talked it through, he probably thought that 185bpm should be enough. And to be honest, 185 is really not that bad. If he had given you a pacemaker that can do only 150bpm, then I'd say, oh my God! But 185bpm allows the great majority of pacer patients to continue their activities. I could also imagine that NHS probably did not give your cardio that many options.

Rate response is a feature mostly patients with sinus node issues need. A fully functioning sinus node adjusts your heart rate to your level of activity. In patients with a sick sinus node, it is unable to do so, so their heart rate doesn't go up when exercising (called "chronotopic imcompetence"). In this case, a sensor in the pacemaker can be activated. It senses when you get physically active and adjusts the heart rate accordingly. But heart block patients usually do not need the rate response feature. Their sinus node works well, so it dictates the perfect pace.

Good luck!

Inga

good news!

by Tracey_E - 2014-09-15 04:09:31

Sounds like they are very responsive! Good luck with your new settings. Let us know how it goes.

thanks again

by JRTKD - 2014-09-15 04:09:38

I don't need rate response nor can I imagine that I would in the future.

There was no real discussion about the pacemaker options, they knew I was a competitive martial artist and the pm was implanted sub pectoral. I was recovering from a bout of pyrexia and wasn't particularly capable of decision making anyway.

You are right and worse case scenario I could live with 185 as long as it doesnt drop when it is reached and it happily bumps along there.

I will push for the adapta though.....

result

by JRTKD - 2014-09-15 12:09:39

Called them this morning, they told me to come straight in, which I did.

There were a couple of modes that were active and were acting to bring my rate down when it hit max bpm at 165.

The technician has switched those off and upped the max tracking rate to 185bpm and some other thing to 210bpm

185 is the default maximum on the Ingenio although she has contacted the rep as she understands there is an overide to this.

I have a further appointment in december where they can look to unlock it if I am still struggling.

What she has said is that I can go above 185 up to 210 but the bottom chamber may miss beats above 185, and I shouldnt really be operating above that for extended periods anyway. She said I shouldn't notice the missed beats.

If not they would look to change the pm for a more suitable one for my way of life, commenting it's not often they get to see patients whose heart rate can get to over 170.

Sounds good!

by golden_snitch - 2014-09-16 04:09:32

Glad to hear they responded that quickly, and are apparently willing to work this out for you.

Maybe you have a Wenckebach-behaviour (2:1 block) setting like I have in my Biotronik Evia: I won't go into 2:1 block until the atrial rate hits 214. And I go into mode switch to DDIR mode at 200.

Hope you are already doing better!

Inga

Yay!!

by Tracey_E - 2014-09-16 10:09:42

What an improvement! So glad to hear your first run went well.

went running

by JRTKD - 2014-09-16 10:09:51

went for a run, other than being terribly unfit (2miles in 23 mins) heart bumped along 165-177 with a couple of spikes to 188 and 192 for a couple of sprints.

:) pretty happy with that.

Now to get that time down.......

You know you're wired when...

Your pacemaker interferes with your electronic scale.

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My cardiologist is brilliant and after lots of trial and error got me running. I finished this years London Marathon in 3hrs 38 minutes.