How are settings determined?

This is probably answered somewhere in this forum, but I couldn't find it.

I'm a 68-year-old man with bradycardia (<38 bpm at rest) and chronotropic incompetence. My treadmill test showed a peak HR or 115 bpm. I lasted 11 minutes. 

I ride my road bike 3,000 miles a year, and hike 600 or so.

Anyway, I'm looking forward to getting a dual-lead Medtronic PM in a couple of weeks, and am wondering about settings. I assume I'll have a conversation with the doc about minimum and maximum rates, but don't have an opinion on what those numbers should be. Should I?  Are those rates an art or a science? Any thoughts on how I can determine how my new PM should be set up?

Thanks for any response.


Don't assume. Make sure you have a talk with your doctor

by Gotrhythm - 2019-06-30 17:20:38

One thing this pacemaker journey has taught me is that you must be proactive. Don't wait for them to bring up anything that's important to you.

They are pressed for time just like everyone else and are very likely to look at your chart, see that you're 68, and assume that a golf game on Saturdays is the most active you get.

I hope a cyclist will chime in here. I don't know much about it, but I am aware that some pacemakers are a better choice than others because of difference in accelerometers--the part that speeds your heartrate in response to exercise. The ones that depend on vibration don't work as well for cycling.

Anyway, you need to make sure you talk to your doctor about your lifestyle and the settings that will support it. Pacemakers come out of the box with certain standard settings--kind of one-size-fits-all.The settings can then be adjusted as needed.

Be aware that it may take several tries to get your settings right for you, and as your condition changes you might need adjustments to the settings.

Go prepared

by Theknotguy - 2019-06-30 19:06:17

As Gotrhythm said, make sure you go prepared to let the doctor know what kind of exercise you do.  If you can get a report from a FitBit or anything else that shows how active you are, it will be important.  As Gotrhythm said, you don't want the doctor to assume you just golf on the weekends.  

There is a certain adjustment period.  While the pacemakers come as one size fits all, the type of heart problem you have and how to address it can also affect how the pacemaker is tweaked to specifically fit you.  My EP didn't want to turn on everything at once so I had to wait three months, six months, then a year to get things changed.  He'd change the settings on one thing then sit back and see how I'd get along.  If they flip all the switches and you don't feel good, then they have nothing to change.  So it's better to make small adjustments and go from there.  Another thing, things may actually get better after you have your pacemaker and there may not be a need to activate some things.  That's why the EP's get paid the big bucks.  They have to figure things out for you.  

I'm six years out and have been undergoing tests for the last three months.   Question is if I have a new problem or if I need some additional tweaking to the pacemaker.  That's the reason for the tests.  The doc and I are working together to see what's going on.   Best scenario is I'll need another switch turned on with the pacemaker or I have to drop one of the non-heart related medicines.  The jury is still out and we're waiting on the verdict.  

You might also ask if your medical insurance will allow for heart rehab.  Another thing you have to do is to learn how to live with the pacemaker.  I do a lot of walking and hiking.  You'll hear about chronic incompetence.  That's where the heart rate doesn't come up fast enough to match the exercise level you're doing.  So I had to learn I couldn't just jump up and take off because the pacemaker wouldn't react as fast as my biologic heart rhythm.  That took some time in rehab on the treadmill with a heart monitor to show me how the pacemaker was reacting.  You may need to do the same thing.  

I do hope you have a smooth adjustment and everything goes well. 

Some thoughts

by KonaLawrence - 2019-07-01 03:12:09

Aloha Bugler,
I'm a 70 year old amature athlete.  I hike, walk and bike, but my primary sport is outrigger canoe paddling.  It's the "biggest" sport here in Hawaii.  When I got my brady diagnosis I did all the online research I could.  I also asked my doc what were my options.  He (Kaiser) said they do Medtronics mostly, but could arrange to do a Boston Scientific or St. Jude PM if I wanted it.  I aksed why they mostly do Medtronics and he said because I'm "rural" (on the Big Island) and there are way more Medtronics Techs here than any other manufacturer.  That was enough for me, I got a Medtronics.  I asked about the settings and was told they leave at factory default until the 1st checkup at 30 days.  Time for the incision to heal.  Then they discuss your lifestyle and adjust settings.  At 30 days I had my 1st "Interrogation"  (fancy name for a tech downloading the data from your PM).  There was a lot of talk between the Device Clinic Mgr (Nurse Practitioner) and the Medtronics Tech which I didn't understand.  I did understand the topic of base rate of 60 and max rate of 130. I told them I am very active and asked for a lower base rate and  higher max rate.  They told me they only make one change at an Iterrogation.  We agreed to drop the Base Rate to 55.  They said the next followup appointment is 6 months and they will readjust then if needed.  However, they would see me anytime I felt the settings weren't right for my lifestyle.  After that appointment I downloaded the manual for my PM from Medtronics.  I read most of the 200 pages.  Not only was my Max Rate a problem, but my Acclerometer parameters weren't right either.  Plus a number of other things.  I ended up with 8 adjustment appointments in the first 9 months.  They were very nice and accomodating, but I had to initiate everything.  They are very busy and most of their patients are just fine with the default factory settings.  Now I'm a happy camper.  I "captained" a 6-man crew in a race a week ago.  I use a Polar Heart Rate Monitor Wrist Watch.  My Heart Rate was in the 135-145 range for over an hour.  For me, that's great!  Good luck on your journey.  It will probably take a while, but eventually you will be better than ever.
Cheers, Lawrence



Be Open and Communicate

by Jman1976 - 2019-07-01 18:03:11

The replies above are all really good. I am 9 months post implant. My EP and I are still working on getting the settings correct or as close to correct as we can. I bring my workout logs from my exercise app, historical heart rate info, BP readings, etc. to the Dr visit. I also keep a "health journal" detailing how I feel physically. The journal helps to build a history and a means to convey that history to the Dr.

Fortunately, my EP is very good about listening to me and reading my notes. My last interrogation was in June '19. He made several adjustments based on my feedback. I'll let my body adjust for a few weeks and then go from there. As far as I know, there is no magic way to adjust the device to your body and it be good to go. I know we are close to right on mine, but not there yet. 


by bugler - 2019-07-03 11:20:16

Thanks for the wise counsel, all.

I was able to have a better-informed conversation with my doc, and I'm pretty sure my concerns have been heard and will be addressed.

Belated input from a cyclist

by crustyg - 2019-07-05 12:03:09

The Minute Ventilation (MV) (breathing rate * breathing depth) sensor input on the Guidant - now Boston Scientific - PMs was developed specifically for cyclists.  As the upper body stays fairly still on a road bike, there's little movement detected by the accelerometer, so without MV there's nothing for the PM software to use to determine that your heart rate needs to increase, which would give you inadequate heart output (blood pumping) to supply your leg muscles which are working hard => lactate production, and weak legs.

Your PM can definitely be tuned to optimise its performance for you.  Ideally you want a low heart rate when you are seated, resting, but responsive enough that if you walk upstairs you don't feel faint at the top of single flight.  When you walk briskly or run, the accelerometer will detect that and increase your HR - how much after what exercise is the tuning, and how quickly your HR comes down once you stop can also be adjusted.

Without some sort of breathing detection, you'll probably struggle to keep up your normal cycling rate and hill performance.  But life's a set of choices and mental adjustments to what you have now.  I know, as I'm struggling with it too.

You know you're wired when...

You have a little piece of high-tech in your chest.

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