Medtronic Settings for athletes with Sick Sinus tachy Brady?

Hi I am a 51 year old female who loves to run, lift weights, bike and do Pilates.  I am confused about the rate response setting and wondering if there are any other settings that might help someone who is very active? After the first day having my PM I felt great but didn't like that I would go to 110 just causally walking a hill so they said they could turn that of RR and they did.  Well today I don't feel as much energy and more tired and thinking I made a big mistake. I also started beta blockers so it is tough to know what caused me not feeling as great.  Prior to pm I always thought I only felt dizzy when hr below 40 so I figured I didn't need RR.  I guess I'm wondering is there a way to keep RR on but not have me at 110 around the neighborhood? I would typically be at 70-80 for that pre pm and felt fine.  My HR goes to 165ish on its own when running Pre-pm.  Any suggestions on this or settings for athletes in general that might help? Much appreciated! 


9 Comments

Medtronic rate response settings

by ar_vin - 2020-08-27 21:02:11

First, welcome to the club you never wanted to belong to!

There are many threads about Medtronic (and other PM) rate response settings; search and you'll find at least a dozen with a lot of valuable information from a lot of helpful members.

Here are two recent threads:

https://www.pacemakerclub.com/message/37472/hr-dropping-while-on-climbs

https://www.pacemakerclub.com/message/37482/long-term-effects-of-more-sensitive-rate-response-pm-settings

I can't speak to your specific case (brady/tachy); my reason for a PM originally was sinus bradycardia due a "sick sinus node" which was accompanied by chronotropic incompetence. Which means my heart rate stopped rising with exertion as it used to prior to my sick sinus syndrome diagnosis. Without rate response I had real trouble climbing hills or running.

I always have been physically very active so chronotropic incompetence was a real downer! Getting my PM settings adjusted at the PM clinic (based on a document from a member here) gave me my life back. I can pretty much do 95% of all that I did prior to my PM implant.

I urge you to first educate yourself about the following:

- your diagnosis

- your medications and their potential side effects

- the various settings for your PM (the documents are available on the Medtronic website)

Also, gather some data on your HR with various activities. I've found that a chest strap HR monitor (like the Polar H10 or the H9) works best. The wrist/armband optical sensors can be pretty unreliable.

Once you've done the above, make an appointmnet with your PM clinic and have the settings adjusted to suit your lifestyle.

Know that with a PM your heart rate is going to be very diferent than what it used to be. The good news is you'll adapt and your body will get used to being paced at the higher rate. Now, if you had another brand of PM you might have been able to get a more "natural" heart rate. The Medtronic PMs are simply designed to respond to movement so you don't have a choice there.

And come back and ask questions here......

Enjoy life with your PM - it's early days yet in your relationship ;).

 

 

 

 

 

Thanks!

by FitAF - 2020-08-27 23:38:50

Thanks for responding! Looks like I have some homework to do! I will figure out how to search the forums and what you suggested sounds like a good plan.  Do you happen to still have the information that was provided to you from another member that you said was really helpful to you? Thanks again 😀

I see you have Atrial Fibrillation

by Gemita - 2020-08-28 01:49:34

Hello FitAF,

Excellent post from ar_vin.  If you paste the links he gives into your browser you will find the member who has helped him and others, including myself, with regard to Medtronic settings.  It is a complex subject and I am just scratching the surface myself, so be thorough and patient with yourself as you learn, but the benefits to be gained from knowing your diagnosis, your pacemaker settings, the potential side effects of medication and how best to manage your condition are truly immense. 

Apart from learning about what is set up in your pacemaker, dealing with an arrhythmia like Atrial Fibrillation (AF) is also a complex area too.  It may be a common arrhythmia but the initial treatments for it (rate control and anti arrhythmic meds) are certainly not easy to tolerate and often cause additional symptoms, particularly if you try to exercise.  It will be trial and error and finding the right balance for you and your lifestyle that will be the key to success.

I have Sick Sinus problems (Tachy/Brady Syndrome), many arrhythmias including AF with both a slow and exceedingly fast ventricular response rate.  In the past I have experienced fainting episodes especially when my heart started pausing as I went in and out of an arrhythmia like AF.  My pacemaker has made such a difference to my quality of life by maintaining a steady, higher heart rate.  Even though my heart rhythm problems are still present, I tend to be less symptomatic, less likely to suffer from syncope and/or dizzy spells, breathlessness, chest pain, weakness.   I have even been able to reduce or stop some of my medication which has been a bonus too, but this would very much depend on your condition being treated and your lifestyle.  

I wish you a lot of luck and a happy journey ahead.  My best advice is find the right balance for youself in terms of level of exercise, since pushing too hard during an AF episode may not be helping.  Consider all your treatment options for AF, including your suitability for an ablation.  Make sure you are well hydrated at all times since dehydration/electrolyte imbalances can trigger arrhythmias fast.  Work with a good electrophysiologist who can help you manage AF.  

Good control of AF is essential to prevent it progressing.  You could ask your doctors whether your pacemaker is running any additional programmes which might help reduce AF episodes. There maybe adjustments they could make to some of your settings in this area, making them "more" or "less" sensitive.  Mode switch comes to mind and this will be triggered when say an AF episode reaches a programmed upper heart rate limit and duration.  Too sensitive a setting may well trigger too many mode switches (= change in pacing mode) so as not to track your AF or allow your fast heart rates through your AV node to affect your ventricles which could be dangerous if prolonged.  However too sensitive a setting could cause too many mode switches and this can certainly cause symptoms for me.  I downloaded a copy of my pacemaker manual from the Medtronic website to read all about settings and what they do.  It is a long read but well worth it

See if you can get rid of that AFib

by crustyg - 2020-08-28 07:00:00

I too have SSS/CI and my EP doc said that in his opinion/experience it's only a matter of time before I get AFib.  Had two long episodes of AFlut, two ablations and OK so far.

From my (not exhaustive) reading of the literature there is some evidence that vigorous atrial pacing of folk like me may reduce the chances of going into AFib.  Which makes a lot of sense: our current thinking about the mechanism of atrial tachyarrhythmias in folk like me is that the massive vagal tone (very fit, normal sinus bradycardia, often low 40sBPM) in heart muscle that is exposed to natural hormones that tend to raise HR, little clumps of cells start firing off on their own and suddenly you're in AFlut/AFib.  Pace the atria back to something more realistic and the PM outpaces these clumps of cells => stay in normal rhythm.

So while I accept that for you having a HR of 110BPM whilst walking up a hill may feel odd, it's not that abnormal.  I had to really push my EP doc to allow me a maxHR of 160BPM, and as I always exercise with a chest strap I have a good idea of how much time my heart rate spends in any particular range.  When I review my overall HR over time, I'm still massively weighted to the left (which is good) even though I might ride for 2hr and be above 150BPM for 65% of that time.  It's a small proportion of the 168hrs in every week.  You would probably be the same (if not in AFib).  There is a small, but real risk of pacing you into high blood pressure but it's easy to keep an eye on this.  If you *do* become hypertensive from high pacing rates, avoid beta-blockers like the plague.  There are other, better choices for this.

If you can get rid of AFib before it becomes established then do so.  And then be willing to have your atria paced at something more normal in an attempt to keep in sinus rhythm.

Good info

by Theknotguy - 2020-08-28 09:47:03

I read your note and the notes from the other members.  Good information.  I'll add in my two cents worth and see if it's any help to you.  

I too, am active - in a different way - and also have afib.  My first serious afib attacks would put me in a recliner for three days at a time until the heart drugs and my heart would settle down.  Since then, thanks to my Medtronic pacemaker and some drugs my afib is somewhat tamed.  

While the pacemaker itself doesn't necessarily help with afib there are other things you can do.  First is the prescribed drugs your cardiologist or EP can prescribe.  My EP also suggested I take an over-the-counter daily dose of magnesium.  For me, the magnesium seemed to really help.  While I'm not advocating over-the-counter magnesium as a cure-all it is something you can discuss with your EP.  

My Medtronic pacemaker has two programs running on it for afib.  First is APP (Atrial Preference Pacing).  It watches my heartbeat and if I go into a certain kind of afib it will raise my heart rate.  Works about 10% of the time.   Not always helpful but it's there. Second is Minerva. (Don't know why it's called that.)   Minerva watches my heart bead and if I go into a certain kind of afib it will change my pacing and pace me out of afib.  Works about 80% of the time.  So that  would also be a question for your EP.  Does your pacemaker have the ability to run the programs?   Criticism of the pacemaker programs are, 1) they only treat   symptoms, 2) They may not be as effective as once thought.  It's still a question to ask.  Even with the two programs running, I can still go into an afib session.  My last pacemaker check two days ago said I had been in afib for three days and two hours.  Didn't know it as the only thing I felt was a little heavy breathing  as I went up two flights of stairs.  My EP didn't seem concerned and felt my situation was being taken care of adequately.  Past discussions with my EP were  that I had the kind of afib that doesn't respond well to ablation and it would be better not to damage my heart.  
 
 The hospital at which I volunteered had a 954 foot hallway.  I'd walk the hall way and be out of breath at the end.  Asked my EP and cardiologist what was going  on and they ran some tests.  Boiled down to settings on my pacemaker as I had gotten along fine with it for seven years.  A change in routine and a higher level  of exercise and my pacemaker couldn't keep up.  Two things, an adjustment to my rate response and a visit by the Medtronic pacemaker rep.  
 
 Turns out there were some settings not available to the standard rate response and the Medtronic rep brought up some screens I'd never seen before and made  some changes not available to my regular pacemaker tech.  Another option available to you.  
 
 As ar_vin said in his note,  I'd keep some kind of record - including time and date- of activities and note what was good or bad regarding your rate response.    It really helps your EP and your pacemaker tech to narrow down where you're having problems and what settings to change.  Also note, it may take a while  before settings are what you would like and sometimes, the pacemaker just isn't going to deliver what you want.  As my EP said when I asked him one  question - "You're alive."  He was right, my other option was being dead and I liked that a lot less.  But still, it may take a while before you get things to  where you would like them.  

Hope this helps.  Hope the adjustment to your pacemaker goes well.

 

more thoughts

by Tracey_E - 2020-08-28 09:54:43

It will take some time to get used to the meds, to learn what is side effects and what is settings that need to be adjusted.

110 isn't what you're used to, but it's pretty normal for walking.  My rate was in the 40's most of my life so it took some time to get used to a normal rate. What was normal for the rest of the world felt like racing to me. Now I'm used to it and 40 would feel scary slow. 

Rate response can be finding a balance. There are different sensitivity settings. I choose to have mine very sensitive. It jumps right up at the gym, which I love. Downside is it also jumps right up when I walk across the room. That's annoying, but to me not annoying enough to turn it down because I love it when working out. They can try different settings before you decide what works best for you. 

RR settings

by Mike417 - 2020-08-28 12:37:42

There is some good knowledge in this forum.  You don't mention which MM PM you have, or your upper limit.  Your UL is what the pacemaker will help you acheive if you are 100% paced, otherwise your sinus node may take over at some point.

If you are a well toned athlete 110 going up hill may be high, but not much.  On the MM 110 is at an inflection point where the rate increase becomes linear.  The RR is a number not indicative of your HR, but rather the increase in HR.  The lower the number the slower your heart rate will increase after you go above 100.  What is counter intuitive is that the lower the number the steeper the curve (faster you increase), the higher the number the shallower the curve (slower rate of increase). So a RR setting of 125 may be right.- it sets a balance of how fast your HR increases for the amount of effort you exert.

I may have missed you saying that you go into afib, but if your HR goes up too high then there is crossover to the ventricle pacing and this will send you into afib.  They can test what that rate is.  For me when I hit 160 I would have afib, and the PM will compensate and lower your HR suddenly.

It took 9 months to get my PM working right for my 67 YO body, but the PM whould not kick in when hiking with a pack, which I do a lot.  So I had them swap it out for a BS Accolade.

Good luck,

Mike

Thank you everyone. It was a lot to absorb so took me some time to respond.

by FitAF - 2020-08-31 22:36:11

Gemita - thank you for all this information.  I see you mention programs for AF in my PM.  My PM is called Azure XT DR/ model W1DR01 and it says it has AT/AF detection so I do think it has those capabilities but I have no idea if they are turned on.  If those ARE turned on (which they probably should be), would that stop my high heart rate, say in the middle of a run/sprint? I typically get up to 158-168 by the end of my runs.  Can the PM tell the difference between AF and a run?  I think this is what you are getting at but I'm still learning and confused.

Crusty G - I didn't realize that pacing at a more normal rate instead of in Brady would help with the Afib. That is so good to know as I was resistant to have them move my limit from 50 to 60.   I have been at 35-42 for so long that I worried it would be too much of a jump but if that might help with the Afib, I'd be more inclined to do it.  When you say avoid beta blockers like the plague, why is that?  I am on a low dose of Metropolol and I'm not a fan of it so far (short of breath?, tired).

Theknotguy - So from reading the manual, it does appear to have some Afib settings and atrial preference.  I don't undertand them and I don't know if they are on.  

Tracey - I think you might be right.  I should probably put the Rate Response back on.  I have been at 35-42 for so long that I was afraid of the PM doing too much for me.  I was thinking that I only have symptoms when I'm lower than 40 but the truth is, I felt really good for that one day the Rate Response was on so I probably need it more than I thought.

Mike - I have the Medtronic Azure PM but I have no idea what the upper limit is. I think it is just set to keep me from going below 50 (45 at night).  Thanks for that explanation on the RR.  I do have Afib, but ironically, it happens mostly at rest.  I've been exercising pretty hard for decades and it has never been an issue until recently I have been slowing down (mile pace went from 8 1/2 min miles to 9:30).  I lift heavy weights, run, sprint, and I can reach a good HR on my own while running but I will go into Afib hours later while sitting on the couch.  So, I'm not sure how the Rate Response works with that.  

Ar_vin - thanks again for such a thorough explanation/answer!

A higher heart rate setting would probably help with your vagal AF

by Gemita - 2020-09-01 05:44:32

Hello again FitAF,  

Of course it is a lot to absorb and it is for me too.  Our bodies are so complex and so are our devices.  Just a tip, if you need any further help from anyone who has contributed to your post, you can always send a private message to them in case they do not return to your original post or pick up on your response.

I have read your responses to all of us.  What comes over time and time again is that “you tend to go into AF at rest” as your heart rate drops and you become nicely relaxed.  This is a clear indication that a higher lower heart rate setting say from 50 to 60 bpm or even higher from 60 to 70 bpm might just work better for you than your current lower heart rate setting to keep your AF under better control.  

My lower heart rate pre PM was always mid 40s bpm during the day (much too low to exert myself).  At rest it could fall to well under 30 bpm when I would immediately start noticing an increase in arrhythmias including AF.  When my heart rate was well up around 70 bpm, I rarely got arrhythmias.  My Electrophysiologist listening to my history said (as crustyg suggests) that for some types who have predominantly bradycardia induced AF (me) raising the lower heart rate limit and keeping it there day and night might just work and keep me free from my arrhythmias or at least control them better.   My pacemaker higher heart rate setting of 70 bpm at all times is a good treatment plan for me because the long pauses, skipped beats, falling heart rates were all definite triggers for my AF.  Ask for your lower heart rate limit to be increased and see whether this might help to keep you out of AF, particularly when you are “at rest”.

I am on a low dose beta blocker (Bisoprolol) to hold back high heart rates during arrhythmias but unfortunately beta blockers are not always the best med choices for us with “bradycardia induced arrhythmias” because they will actually cause bradycardia and worsen your symptoms if the dose is too high.  Even a low dose may be too high.  You might ask your doctors about an alternative med to Metoprolol for tachycardia, like a calcium channel blocker (Diltiazem or Verapamil).  Trialling different meds is necessary until you find one that suits.  I haven’t tried an alternative to Bisoprolol because it works so well for me at lowest possible dose but some folks think calcium channel blockers are better for vagal AF (bradycardia induced AF).  However sort your lower heart rate limit out first because it may be all that is needed to help you to control your AF.

Your question about AT/AF detection and what it does.  It is a detection algorithm NOT a prevention algorithm.  This means that the pacemaker technician is able to program the pacemaker to record/report on any heart rate above a set upper rate (say above 150 bpm or higher) and for a specific duration (say for a minimum number of heart beats like 20 beats). When this programmed event has been triggered, the event will be stored by the pacemaker and when we have our annual interrogation or sooner, if you are receiving regular monitoring, your doctor can assess how serious a problem you have and try to control this better with either medication, an ablation for AF or an adjustment in pacemaker settings/lifestyle changes.

And yes a pacemaker can tell the difference between an AF event causing a spike in heart rate to 168 bpm and a normal event like running causing a spike in heart rate.  Unfortunately though it may be difficult to establish whether exercise frequently induces your AF without getting regular exercise stress monitoring to see how your heart reacts as your heart rate climbs.   You may have both vagal and adrenergic forms of AF.  During exercise, my higher heart rates can certainly trigger AF just as much as when my heart rates fall during rest.

So AT/AF detection is for monitoring.  It won’t stop your fast heart rates during an arrhythmia like AF/tachycardia.  (No basic pacemaker can do this unless we have an ICD to shock the heart back into normal sinus rhythm during a lethal arrhythmia like ventricular fibrillation or other dangerous rhythm disturbances).  There are programs like APP (atrial preference pacing) and Minerva programs (see Theknotguy comments) that aim to specifically help prevent AF.  I have APP but I am not sure whether Minerva is on my pacemaker - probably not - but might be worth asking about.

What I was specifically referring to was "Mode Switch" which occurs when a high heart rate/arrhythmia is detected in the atria and reaches the trigger point set by the AT/AF detection algorithm.  If you have dual chamber pacing, this would then switch the mode of pacing from atrial pacing to ventricular pacing, so as not to track the chaos of AF in our atria.  It is complicated, but basically by switching to ventricular pacing, it aims to prevent the disturbances in the atria getting through our AV Node to affect our ventricles which could cause many more symptoms and be dangerous at prolonged high heart rates.  On cessation of our AF, the “Mode Switch” switches back to our programmed settings of APP (atrial preference pacing), if this is the pacing mode you have set up?  Mode switch can be finely tuned to make it either “more” or “less” sensitive and can make a huge difference to whether we go in or out of AF more quickly, so this area needs to be discussed.  I am currently studying this very carefully since I am not satisfied that the "Mode Switch" sensitivity setting set up for me is correct, since I am getting far too many mode switches with my in and out crazy AF.  But the good news is that a higher heart rate setting of 70 bpm night and day is really working well for me.  Good luck FitAF and stay well 

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