Horse jumping

After lung surgery in December 2019 low level  arrhythmias were made worse. Now cardiologist is recommending pacemaker.  I have bradycardia and atrial tachycardia and bouts of atrial fibrillation.  I am asymptomatic other than feeling the abnormal beats and pauses , sort of freaky waiting for next heartbeat!    Dr believes that I am at high risk for trauma and bleed if I fall off my horses or horses fall with me as I am on Eliquis. So Dr goal is rather than wait til I have symptoms, do pacemaker now to avoid situa9where get dizzy or pass out and fall from horse.  I ride and compete with upper level jumping horses ,so alot of speed and movement involved. The issues I am struggling with are not getting clear answer as to when I might get symptoms, I do understand that may not be predictable. Also no straight answer for continuing my riding at same level without lead damage. Lots of repetitive movements, sometimes 1500 pound animals yanking that arm and need for full range of motion . I have read about leadless pacemaker but they are fairly new. 

Welcome input on strenuous activities and also the leadless possibility 

Thanks 

 


11 Comments

Horsing around

by AgentX86 - 2020-04-18 12:59:03

The issue isn't pacemaker leads, they'll be fine. OTOH, a pacemaker will do nothing for your Afib or SVT except, perhaps, allow higher doses of antiarrithyhmics to be used. The risk from stroke is still elevated. However, your horse jumping also puts you at risk of brain injury. Don't take anticoagulants and risk ischemic stroke or take them and continue jumping and risk hemorrhagic stroke. Hmmm.

What does your doctor say? I assume he knows that you engage in risky activity?

how long are the pauses?

by Tracey_E - 2020-04-18 20:31:25

If the pauses are long enough to be at risk of passing out, I would say that's a considerably higher on the list of things to worry about than damaging a lead. The leads are fine for strenuous activity. They are thin and flexible, designed to move with us. 

Not all things that lead to a pacer cause obvious symptoms. It's possible for the heart to pause long enough that it doesn't start up again or the first symptom could be passing out. Unless you have a crystal ball to let you know when it's going to happen, I would listen to the doctor and get the pacer now. Tiny pauses of 3-4 seconds are ok. Once they get over 5-6, it's time to get the pacer to kick in and prevent the pause. We've had two members that I can think of off the top of my head decide to wait until they knew for sure they needed it, then they passed out while driving. They found themselves recovering from both car accident and pacer surgery. Whether you ride horses or not, if your heart is pausing long enough to pass out, why risk it? Fix it and get on with your life. 

Horse risk

by NVjumper - 2020-04-18 21:01:15

Great  input, thank you. No one has said how long pauses are,will find out. Bradycardia when not active with occasional  rates in mid 30's that are brief alternating with 50's and low 60's. And not currently on any drugs  No crystal ball  here,unfortunately.  I was on Metoprolol  for 20 years for symptomatic  PVCxs which was stopped 6 months ago when HR dropped to 20 to mid 30's and I felt awful.  When DC with the SVT tried Metoprolol again but after 6 weeks was stopped because of bradycardia  again. 

Dr 's aware of riding dilemma,as am I. No good choice though Watchman may be a compromise. My passion in life is my horses  and I  sold my business, retired  to finally relax  from a high pressure business before all of this -lung cancer, horrible nerve issues postoperative with excruciating pain (thank goodness that is gone) lossof partial function in the arm on the side of surgery  and now the Eliquis,stroke,brain bleed possibilites and now throw in a pacemaker. 

I believe the intention is 2 fold re PM. First get safety net for bradycardia and second be able to use B blocker for SVT. Theory is  valid I am just freaked out about  doing procedure now with COVID 19 and small %of various complications including lead issues.   Glad to hear leads likely not real concern 

Just feeling overwhelmed at the moment and not in control. Will get through. Helps to have input 

Thanks

Horse jumping

by AgentX86 - 2020-04-18 22:32:29

I've waited to retire for several years to make sure we can live, not richly, but without worrying about where the mortgage was coming from (there is none).  I want to do what I've been wanting to do for years but never have had the time.  If after waiting a decade to do what I love doing, I ccouldn't, well, I understand your dillema.  I was planning to retire later this year but with KungFlu atound, I may have to put it off a little longer.  OTOH, I've been furloughed for five weeks so maybe I'll like it too much.  ;-)

I'm confused, you said you were on Eliquis (the best of the bunch for most) but above you say you're not on any drugs? A watchman may be a good alternative but it's not perfect either.  Some time after the procedure you'll have to have a TEE to make sure the LAA is really closed and the blood velocity is high enough to avoid clotting.  If that's OK, maybe you can be taken off the anticoagulant. I had my LAA clipped during CABG surgery and still have to take Eliquis. For the highest probability that the Watchman will be a success, make sure you find an EP who has done many of the procedures.  It's not a trivial task and has to be implanted correctly or it's a waste of time.

Yes, the stragy of a PM + beta blocker is reasonable, however you need a pacemaker in any case. I was in the same situation, hough antiarrhythmic drugs were the cause of the pauses so by the time I needed the PM, this strategy was no longer useful, so I had an AV/His ablation at the same time.

You can't go around with the risk of syncope hanging over your head.  In addition to riding and driving, think about everyday things you do, like climbing stairs.  A pacemaker is a must.  Being able to use a beta blocker or antiarhythmics comes along for the ride. 

The issue isn't the pacemaker.  There is nothing you're doing that wouldn't be possible to do with a pacemaker and you'd probably feel better, too.  The issue is the anticoagulants that you're going to need to take.  Do talk to your EP about the Watchman.  It might be a good alternative for you but make sure you understand all the issues.

three issues

by Tracey_E - 2020-04-19 11:28:04

The watchman may get you off the blood thinners and help reduce the risk of stroke from afib, but that has nothing to do with preventing pauses or being able to take enough beta blocker to stop the svt without your rate getting dangerously low. Three separate problems, two of which are fixed with a pacer. There's no rush, you could wait out covid, but imo it's a no brainer. 

Do your homework on the watchman. I have a friend who's a NP and paced, so better informed than the average patient. It was recommended for her and seemed like a good idea at first. She dug deeper and didn't like the potential risks of the surgery so opted not to do it. Actually, her words were quite vehement and colorful. She felt it is still too experimental.  

Have you had a holter monitor recently? That will tell you how low you get and how long pauses are. 

Multiple issues

by NVjumper - 2020-04-19 12:44:38

Yes,I do take meds,just not for SVT  currently.  For Watchman  would wait til arrrhtymia issues are good and then consider. As Tracy E and Agentx86 say, it has risks,not foolproof and from what I read may only partially mitigate stroke risk as  clots may still form. At some point will have to decide if it is an appropriate compromise that may allow me to stop Eliquis so can continue to participate in my sport. 

Also good point about driving,would be awful to have accident and even worse if other people injured

I initially saw Arrhymia specialist at Stanford  ( 5to 6 hr drive each way) as my surgery and workup were done there. The EP I saw was a great fit for me and explained things  well. He put in my ILR just before Bay Area went on lockdown. Then transferred care to local cardiologist who was highly recommended by my internist  but I am having trouble communicating with him for the level of detail I need. Have telehealth scheduled with him to review details of ILR that is leading to pace now decision  Yes you would think with ILR getting answers should be simple. The info I have is multiple brief atrial tachycardia,  1 recent Afib episode  , 1 episode of a mixed bag of PAC, PVC, short bursts of Bradycardia lowest was 34 ,intermingled with normal rates. Unfortunately the ILR has limits on what it can pick up, so all these were not picked up but recorded when triggered by me when I felt irregular beats but no symptoms. The ILR picked up what it recorded as pauses but device nurse said were slightly irregular RR  only. My resting HR has been low 50's for years even off Metoprolol. Now with the SVT is being called Brady-tachy 

This is getting really long but I am going to send cardiologist list of questions prior to appt. Plan to ask about pause lengths,  frequency,  is there risk if not paced that would lead to additional  issues arising-CHF cardiomyopathy, other conduction disturbances. I  need to know more exactly how PM will work,  at what HR will it kick in, how and when it gets checked ( a good reason to stay local if  cannot  be done remotely)  

He plans a Medtronic Azure dual lead. I believe it is conditional MRI compatible  (impt with my cancer follow ups)  and plan to see if I can go on website and see physician level details 

Welcome any questions any of you feel impt to ask during upcoming consult. If I had any symptoms or felt poorly this would be no brainers but I hike at altitude  4-8 miles daily, clean horse stalls,carry 50 lbs feed bags ,ride and jump horses, all without problems and with normal HR response  to activity-not bad at 67.  I feel great But does look like handwriting is on the wall. 

Thanks 

Horse jumping risk with cardiac pauses, anticoagulation, and pacemakers

by Selwyn - 2020-04-19 13:27:48

Hi NVJumper,

Any non-reversible cause of  heart pause of 3 seconds and more is a reason to have a PM. This is because there is a risk of sudden heart stoppage and not restarting. 

Leads are not a problem with any activity ( eg.  I swim a few miles every week, play table tennis for hours each week using my left arm, which is the side of PM implantation).

There is a risk of bleeding due to the trauma of a fall with anticoagulation. I would suggest you see the evidence re. Boston Scientific Watchman, as Tracy suggests:

https://www.acc.org/latest-in-cardiology/clinical-trials/2014/07/10/18/15/prevail

Of note is the complication rate of insertion, and the long term evaluation. 

If you are having problems with AF/SVT meds, consider ablation therapy. 

Unfortuantely, if you have pauses of any length>3secs,  you can get symptoms, WITHOUT WARNING, at any time. Such symptoms may be sudden loss of conciousness, or sudden death, even in your sleep. All quite painless! Having a PM stops this risk.

With regard to leadless pacing this is not without problems eg. 4% complication rate from the surgery, asynchrony between atrial and the paced ventricle, battery problems, removal etc. Why bother?

See https://www.myamericannurse.com/leadless-pacemakers-cardiac-pacing/

All activities in life have a risk. I am sure you are best placed to know what the risk of your show jumping actiivity is. It is a difficult decision.

 

Hope this answers your questions.

 

Thank you

by NVjumper - 2020-04-19 13:50:46

Thanks to all of for your time and  concern  I am glad I found this site. Maybe I read too much but did see Medtronic now has leadless capable of AV synchrony . Imagine that stats for this and finding Dr who is on good side of learning curve could be difficult vs regular pacemaker with so many done. Also lack of long term stats

Was wondering if ablation successful  for  SVT would that help lessen load on SA and thereby limit sick sinus progression and eliminate need for pacing

Seems like 1 question leads to another. 

Less confusion

by AgentX86 - 2020-04-19 14:32:32

Information is good.  We now have a better picture.  Some more comments:

Watchman:  In addition to the potential risk/reward of a Watchman, consider that 90% of the clotting occurs in the LAA.  That leaves 10% from elsewhere. Anticoagulants are effective no matter what the source.  A Watchman leaves the 10% gap.  The Watchman was originally designed for those who, for various reasons, couldn't take OACs.  For them, something is better than nothing.  Whether 90% is good enough for you is up to you.  IMO death isn't the worst outcome of a stroke so I'm on the conservative side, here.

ILA:  Yes, you've noticed that they can't see everything.  Pacemakers are much the same.  I think the issue is that single PVC/PACs, or whatever, are so frequent, even in a normal heart, that there is no point in recording them.  My pacemaker is incapable of measuring anything less than five in a row because it would fill up with useless data, missing something that might be important.  I had bgeminal PVCs (normal heartbeats with a PVC between each one).  My pacemaker couldn't record them but I caught a series and did a remote upload and even the device tech could see them clearly.  Miserable mystery solved.

Cardiologist:  I don't know if you're lumping all cardiologists in the same group but what you really need is an electrophysiologist, not a general cardiologist.  An EP is an electrician, where a cardiologist is a plumber.  You don't mention any physical problems (blockages, valves, etc,) with your heart, only electrical, so you need an EP.  We tend to use the term "cardiologist" for doctors who specialize in the physical aspects of the heart and  "electrophysiologist" (EP) for those wo specialize in electrical problems. They're both cardiologists but the EP has an additional two years of residency in electrophysiology.

Medtronic pacemakers:  I have one and they're not perfect.  Doctors tend to think anyone of a certain age is a couch potato.  Make sure you tell your doctor(s) what sorts of activity you do.  You indicate that you have but make sure it's drilled into his head.  The healhy heart has a pacer that's sensitive to the amount of CO2 in the blood stream.  The higher the CO2 content, the faster it paces.  You have Bradycardia so my also have "chronotropic incompetency" (inability to raise heart rate commensurate with physical demands).  To replace this function pacemakers use sensors to try to guess the oxygen demand.  Medtronic uses only an accelerometer to measure the body's movement.  The theory being that the more motion detected, the more oxygen needed.  That's OK for runners (or walker, like me) but doesn't work at all well for cyclists or swimmers.  The later groups don't have enough upper body motion to trigger the accelerometer and it gets difficult to match the sensitivity needed for these activities and normal life.  You may have the opposite problem.  The horse's motion may tell it to pace the heart (much) faster than needed.

Some pacemakers (only from Boston Scientific, I believe) use "minute ventilation" to measure the body's oxygen needs.  This more closely matches the oxygen needs (you breathe more because your body needs more oxygen) and more closely tracks the needed heart rate, no matter what the activity.  You might be better off with a Boston Scientific.   You should discuss this with your doctor.

Ablation

by AgentX86 - 2020-04-19 14:43:40

Ablation can solve the SVT problem, depending on the cause.  "SVT" is a general term that only means "atrial tachycardia" (literally, "above the ventricals").  it doesn't say anything about what's causing the tachycardia.  However, solving the tachycardia doesn't solve the Bradycardia problem.  You'll still need the pacemaker.  It _might_ get you off the anticoagulants, some time in the future.  You'd have to be SVT/Afib free for quite some time before it would be considered "fixed".  Ablations are rarely a lifetime fix.  The root cause of the arrhythmia hasn't gone away, it's only been fenced in.  Either the fence can break or another area can start up.  Since the underlying cause is still there, this is common.  Particularly if your asymptomatic, they may be reluctant to stop anticoagulation. 

If you do decide to go this way, get the best possible ablationist.  The skill of the catheter operator is paramount.  He should be doing hundreds a year and at least a thousand over his career.  There is a huge difference between the best and the also ran.

Wow

by NVjumper - 2020-04-19 15:22:30

Wow.  Was told ocal cardiologist has EP as subspecialty -will double  check  

Checking my pulse manually and Apple Watch, HRseems to have appropriate response to activity. Uphill fast walk gets 90 to low 100's if jog a bit or riding hard hits 125-145. Had treadmill stress test October  and reached target rate no problem.   Aware could be issue going forward. Certainly do not want needless pacing. Or under Riding has moderate upper body movements, more when jumping

I also have had periods of bigeminy but intermittent. Used to note these most after riding or running hard (when they seemed to be absent) but when cooling down more prevalent. But no significant symptoms -at least that I was aware of. 

That's one of my concerns about Watchman. Stanford EP stressed and was very clear that in his opinion ablation is for symptom relief or non tolerance of anticoagulants or if I wanted to take that risk.....

Will add to question list re if need pacing at activity how does that work 

 

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