How do the doctors decide your pacemaker setting?

Just wondering how the doctors decide what your lower and higher heartbeats should be set at.  The doctor that put my pacemaker in only saw me during my hospital stay, as I was on vacation when I had to have my pacemaker implanted.  The electrophysiologist that I saw before going on vacation did not think my symptoms were heart related, he was pretty sure it was due to vasovagal syncope. I had only seen him this one time. The cardiologist I was referred to has not changed my settings.   My low is 50 and high is set at 140.. I feel during exercise 50 is a little to low.  I don't see my cardiologist for a year.   Just wanted a little input, before I call.  I was diagnosed with Mobitz 2 type 2 AV heart block.  I have had my pacemaker almost 7 months and have had it integrated once, and 2 remote transmissions.  I have a Medtronic Azure MRI model W1DR01.  Thanks for any input.  


Good question

by heckboy - 2020-02-12 17:46:41

I think my original settings were done after a conversation explaining my PM programming. I went back a lot over the few few months asking for tweaks until I get I'd gotten the best combination. So if you're not feeling great, get a tune up! Maybe all you need a tweak to your rate response (or something).

Good Question

by Ms Rutledge - 2020-02-12 20:42:16

Thanks for the input.  When I mentioned this during the integration was told your pacemaker is working just like it should.   Now just to convince the drs to tweak it.  

Pacemaker working "as it should"

by AgentX86 - 2020-02-12 23:01:15

The above only means the pacemaker is operating normally.  It says nothing about how well it's suited for you.  The best plan is to study your pacemaker (or pacemakers in general) and during an interrogation tell them what you want changed.  If it's not out of the ordinary, they'll work with you.  You can get small changes to your minimum rate (50 to 60), for instance, without a problem.  The upper limit may require signoff from an EP.  There are also settings for the sensitivity, delay, and slope of the rate response.  These are easily negotiated but you really have to understand your situation and the pacemaker settings so that you know what to ask for and what they can do (immediately and with EP's signoff).  For best results, it's a two-way street.

If you can, charm your EP into giving you a proper tuning session

by crustyg - 2020-02-13 11:54:34

What folk want out of their PMs depends a *lot* on their lifestyles.  Rate Response tuning can be complex, so you and your EP doc or tech have to talk about your objectives before you begin.  The dancers want instant response from the RR - dancing goes from stationary to full demand in less than a second, so your HR needs to respond ASAP.  Runners are usually well served by the accelerometer in the PM, but without perhaps quite the instant response of the dancers.  Road cyclists want something that drives up HR with little upper body movement.  At least, *in theory*, if your natural pacemaker (the SA node) is still working perfectly and your dual chamber PM is set up correctly, as you exercise your SA node activations are sensed by your PM and a corresponding impulse sent to your ventricles, bypassing the AV-block problem, so you shouldn't need RR.  But it sounds as though you do ("I feel during exercise 50 is a little to (sic) low").  With a working SA node, your Type II block should be allowing a lot more than 50bpm from your ventricles.  Or perhaps your SA node *isn't* working correctly now.

Against all of that is the need to have the lowest HR without you feeling dizzy, allows you to fall asleep easily and which doesn't drive up your BP (known side effect of pacing large, athletic hearts used to very low HRs).  Overpacing the heart over a long period causes damage to the heart muscle.

With all that in mind, during a tuning session your EP tech makes an adjustment, and you try it out.  Waltz down the corridor, step on the treadmill, start pedalling on the exercise bike and see the effect.  Too much, turn the sensitivity down, too little, increase it a bit - and try again.  A smart tech and your input can get this done in 30-60min.  And you're set for the next few years, or your interrogations show over/under-pacing, or you add in a new activity.

You will probably need to use maximum charm to get a high enough HR - commonly we're started at 50 or 60/130, but that's not nearly enough for a really active person of our age.  Getting your EP doc to sign off on 150 or 160bpm as a maxHR takes some effort.  50bpm may be too low for you, depends a lot on your heart muscle condition, heart size, A/V synchrony, valve efficiency and all that guff.  Plenty of folk here found that 60bpm was too low for them, 70 much better - and the converse.  If you've been used to 38bpm for a long time, feeling your heart beat at 60bpm when trying to sleep can be very odd.

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by ROBO Pop - 2020-02-13 17:52:12

I agree, odd, but you should adjust to a higher heart rate in a few weeks and not even be aware. Mine was adjusted from 60 to 70 to 75 and finally 80. It was a little unsettling at first and I was jittery, but I adapted and it's my new normal plus solved a problem. Not to mention a lot of my pesky arrhythmias are gone.

One thing you should do is write a journal and make sure you also document your lifestyle plus any annoyances you experience to share with the Cardiologist or Electrophysiologist so they can better adjust the settings for your needs.

One final thought. Not all device technicians are created equal. Try to ensure the one who adjusts your device is the best available. Much of their knowledge comes from experience. If he/she keeps telling you your device is working as it should, run. That just means it's operating as set up but not necessarily as you need

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