First AFib since PM implant.

I had my first AFib and tachycardia since implant (4 weeks ago) tonight and it was different. I was surprised and frankly frightened .

I've had many episodes  of AFib, most without Tachy, but some with. I sit quietly, take Metropolol if it doesn't subside within an hour and a couple times required ER/hospitalization.

I felt this in my throat as a vibration, there was discomfort. HR 163. Kardio app verified the AFib. I took the medication within a few minutes. The whole thing was over in about an hour. 

Is it different with a PM?

Thank you!


New symptoms following pacemaker?

by Gemita - 2020-12-13 03:47:52

Dear Pharnowa,

I am very sorry to hear about your new symptoms.  When you go back to your clinic shortly they might check your settings and leads for any oversensing problems and also look for a significant event as the cause for your new symptoms.  If you are worried again before then, I would seek advice.

When I first got my pacemaker and during my healing period that took up to three months, I did experience worsening tachycardia and AFib + other arrhythmias and yes they definitely "felt" different with my pacemaker.  

At first I thought, “what have I done - have I made my arrhythmias worse by getting a pacemaker”?   But then I remembered that my pacemaker and heart had to adjust to each other;  settings and medication needed to be adjusted over a period of time;  that any trauma during implant could cause stress/worsening arrhythmias (the leads are after all attached to heart tissue).  (In your case, the implant procedure did not go smoothly unfortunately, did it)?   I also told myself that I was still healing from the procedure and will continue to do so for up to several months.  And it was exactly so.

Pharnowa, our pacemakers have some clever programmes set up to switch us to a different pacemaker pacing mode when we get a symptomatic episode of an arrhythmia like AF (when for example our heart rate reaches a certain high level, for a certain duration of time - whatever has been set up for you).   I wonder if this switch and change in pacing mode is what you felt?  

Mode switch is a pacing feature in many dual chamber pacemakers today where pacing/tracking in the right atrium is automatically switched to pacing in the right ventricle on detection of an atrial tachyarrhythmia.  This feature avoids tracking/sensing an atrial tachyarrhythmia like AFib and stops the chaos/the high heart rates in the right atrium from passing through the AV node and driving our ventricles too fast.  When the tachyarrhythmia ceases, Mode Switch switches pacing/tracking back to the right atrium.

This mode switch feature I most definitely feel and for me this can usually be felt initially in the epigastric region as a vibrating feeling, extending sometimes all the way up into my neck.  My level of discomfort will depend on my heart rate and arrhythmia present.  Any sudden increase in heart rate can cause worsening symptoms, particularly with an "irregularly irregular" rhythm like AFib, compared say to a "regular" rhythm like Supraventricular Tachycardia.  I am also "highly" symptomatic from right ventricular pacing for the duration of my arrhythmia, and I am more comfortable when my pacing returns to atrial pacing again.  So I have found that both the action of "Mode Switching" and the action of "ventricular pacing" can cause new, different symptoms during an episode of AFib.  I hope this helps to answer your question?

What to do about any worsening arrhythmias while you heal?  

I would first ask your nurse/EP to check your downloads for any new or significant arrhythmia episodes at a high heart rate, since he/she may decide to increase your medication temporarily to calm your arrhythmias.  After pacemaker implant I did in fact notice a new arrhythmia (Atrial Flutter) but of course it may have always been there in the background.

I believe things will settle for you as you heal but in view of your history with device migration and your other concerns, I would get someone to interrogate your device when you attend clinic shortly, to confirm what occurred, the arrhythmia type, duration of episode and heart rate, or check for any difficulties with pacing?   Any new arrhythmia or pacing problem can then be treated effectively if necessary.   (Write down your symptoms, time and date it happened and take with you to clinic, so they can correlate any arrhythmia with your symptoms).  

Remember though this should get better when you are fully healed and providing your pacemaker is working as it should.  The pacemaker, together with other treatment, should help stabilise arrhythmias or make them less noticeable, it shouldn't make your symptoms worse.  My pacemaker has most definitely helped me and I was a very difficult patient to treat.  Remember too Christmas can be a stressful, emotional time for many of us particularly so with COVID-19 restrictions preventing us from safely meeting our family in the comfort of our own homes.  I was due to meet family members in the park today, family I haven't seen since last Christmas, but sadly we have cancelled again due to heavy rain.  As I cancelled, I slid into AFib with the usual chest discomfort.  Oh for normal times !

As always, I wish you the very best Pharnowa

Thank you Gemita,!

by Pharnowa - 2020-12-13 09:52:02

As always, thank you for your thoughtful response!  I know I was very uninformed about PMs. I thought you got them and just lived. :)  

I have an interrogation this week to turn it down. We expect a significant snow storm, so not sure if I'll make it. I am keeping up with my daily walks and that helps. I also thought of you as I was so busy I may have not hydrated well as I know I should. You frequently remind us!

Be well!

Ah for some snow at this time of year !

by Gemita - 2020-12-13 11:58:53

Pharnowa, well most of us do get our pacemakers and just go live our lives, but throw in a crazy arrhythmia like AFib and it can really mess with even the most fine tuned pacemaker settings for the duration of the episode.  How can anything keep up with the changing nature of AFib.  

When I am in normal sinus rhythm, my pacemaker paces beautifully, calmly.  Hopefully one day they will devise a pacemaker that can control arrhythmias like AFib without resorting to medication and/or an ablation.  In the meantime, my pacemaker is doing a pretty good job at controlling my arrhythmias with, primarily, my higher heart rate setting. 

I hope you manage to get your interrogation this week, despite the threat of snow.  It is mild, wet and miserable here where I am in the UK, so not good for anything!


Arrhythmias, Mode Switching and All That

by Marybird - 2020-12-13 14:54:24

Hi Pharnowa, sorry to hear about your old "friend" (not!!) afib popping up in the middle of what seemed to be a good recovery. If you have an in-office pacemaker check and adjustment coming up, that will include a pacer history report, and I'd hope your afib session (lasting an hour) would show up on that. It wouldn't be a bad idea to mention it to the nurse, or whoever you see at the office in any case, but especially if it recurs. They might well want to adjust your meds.If they can get those right ( and sometimes it takes trial and error before that happens), things should be well for you, and your exercise program can only be a positive in this process. 

I might also suggest that in the event you're snowed out of your in office visit, you could see about sending them a manual remote monitor report- or do you have a remote monitor yet?  

Gemita, I really appreciate your explanation of the pacemaker's response to afib and other atrial tachycardias, including the automatic mode switching process. Sounds as though you've had all too many first hand incidents with all your tachycardias and your pacemaker's response to them.

I was clueless about the Mode Switching process on pacemakers, until I got a phone call from the cardiologist's office ( interestingly, not the EP, but the guy I'd seen before, in the same practice) informing me they'd gotten a "excessive mode switching" alert, and instructing me to increase my metoprolol from 50 to 100mg/day. The person I spoke to couldn't explain the mode switching bit, but when I looked it up I saw it was related to atrial tachycardias, and I saw explanations similar to what Gemita said. 

I wasn't entirely surprised by this turn of events, I have issues with atrial tachycardia, and I thought perhaps these might be occurring with increasing frequency. I wasn't sure, they don't last long ( a minute would be a long time, of the ones I feel, anyway). But there were times I just felt tired and a bit short of breath, but not aware of any palpitations, or perhaps I was just denying they were there, or thinking if they were significant the pacemaker would catch them and send an alert. Which I guess it did after all. 

While I can't feel anything I could identify as "mode switching", I think it's been my experience that the tachycardias I experience feel milder, somehow, than before the pacemaker. I can hear my heartbeat in my ears ( pulsatile tinnitis), so can sort of be aware of my heart rate when I pay attention to it, so with that, I may hear or feel a pause, ( I don't hear the heart rate during the tachycardias, but may feel them), followed by a strong, steady beat after a short tachy run and I wonder if that is the pacemaker kicking in. It's a comforting feeling. 

I don't know any details about the pacer alert they got, I suspect it may have been from a routine 3 month remote check, from the timing, so I can't say for sure how long or exactly when the tachy was occuring. Though I'd guess it probably coincided from those few days I wasn't feeling well ( in hindsight, I was ignoring it at the time). I did find the increase in the metoprolol helped immensely in decreasing the tachycardia and improving my stamina overall. I still have some tachycardia, guess that will be a given, but mostly the incidents are mild and short-lived. I have had a couple doozies, though, along with spikes in high blood pressure ( the other monkey on my back), mostly coinciding with watching the news media about the current political events occurring in our country. I have to be careful and curtail that to almost nothing. Having a stroke won't help either me or the political atmosphere in the country.

I still have short incidents of tachycardia, but wonder if they are significant, or if they are kept more or less in check by the mode switching? I guess I still don't understand much about how this works, in my case where I'm generally atrial paced and the conduction system is good so the ventricles are generally paced at less than 1%. 

Also this alert incident got me on the ball to find out the details of exactly how often and when my pacemaker/monitor sends remote reports. I had no clue about this, figured it was just as likely the monitor just sat on the nightstand and collected dust, and stared at me at night with that little green eye ( actually an LED light indicating all is ok). I'd recently gotten a letter from a cardiac monitoring company stating that it would be "partnering with my doctor to monitor my cardiac device at home", with phone numbers and instructions to call with questions. So I did, and got the list of scheduled remote monitor checks. They're every 3 months, with the next one coming up Wednesday, Dec. 16th. I guess we will see then if the increased metoprolol has decreased my tachycardia as I think it has. 

Wish I could help you with your weather. I'm in SW Florida and the weather here is mild and sunny- typical for our winters. Wish I could send you both some. Though along with that winter comes the mobs of snowbirds getting away from the cold frozen north- along with covid-related shutdowns and restrictions. Things tend to get very crowded in the winters here. I saw a newscrawl yesterday saying that the Palm Beaches have been transformed into the "Hamptons South" from so many New Yorkers flocking there to escape the covid. I just hope they didn't bring it with them. 

Afib and pacemakers

by AgentX86 - 2020-12-13 18:28:07

Remember, pacemakers fix Bradycardia, not Afib.  For a few, the aformentioned mode switching, out-pacing, and similar algorithms help but it's certainly not universal.  It's so uncommon that my EP thought it was a waste of time.  These modes also aren't universal.  Some PM models support them, others don't.  They are programmable options so your EP has to explicitly turn them on.

Since metoprolol seems to have your tachycardia "under control", it's not an emergency that I'd go to the ER for.  AF is a PITA and tachycardia just makes it that much worse but it's not particularly dangerous at these levels, unless you also have something akin to Wolff-Parkinson-White syndrome.  Ask your EP if this is something worth a trip to the ER over and at what HR is critical for you.

AgentX86 and Marybird

by Gemita - 2020-12-13 20:56:10

AgentX86, I think with AF all options have to be on the table to fight this miserable arrhythmia and that includes a pacemaker.   My EP was also not confident a pacemaker would work for my AFib, although clearly my experience has been largely positive as far as experiencing fewer symptoms since pacemaker implant which after all is the goal of any treatment for AFib including an ablation.  No treatment for AFib can claim to be curative long term and an ablation comes with risks as you unfortunately well know.  For me the pacemaker works just as well as a number of anti arrhythmic meds have in the past and I certainly needed my pacemaker for bradycardia in any event.  Low dose beta blocker keeps my rapid heart rate during AFib under firm control mostly.

Marybird, we are so alike with our arrhythmias and frequent mode switches.  My last count was 1,100 for the year and that was the figure for my significant atrial tachycardia episodes over and above a certain heart rate.  There were lots of brief in and out episodes too.  I have been diagnosed with multi focal atrial tachycardia also where there are lots of multiple ectopic foci within the atria.  I also have Flutter and SVT and runs of NSVT but nothing so bad to require taking out the sledgehammer just yet although I do get tempted sometimes!

Yes I too feel that my arrhythmias feel "milder" than before my pacemaker.  My symptoms are so improved overall which is incredible for someone with occasional dangerously high heart rates.  I would pass out with them prior to pacemaker so something is clearly working and it is not the low dose beta blocker!!

Your short episodes of tachycardia if rates are high and for a certain duration will certainly be held back by mode switching preventing these high rates getting through to your ventricles.  Unless you get something significant (high rate + long duration atrial tachy arrhythmia), your clinic probably won't contact you.  For brief in and out high heart rates, the rate histogram records these.  I have requested my data downloads to have a closer look at what is going on.  Number of mode switches roughly = number of AF events.  I am sure mode switch uses a lot of battery

Mode switch

by AgentX86 - 2020-12-13 21:43:54

It's great that the mode switch works for you but even your EP doesn't think it's a sure thing.  Mine certainy doesn't.  I wouldn't be a candidate anyway.  Since I'm always in flutter there would be no mode switching.'

Ablation can be pretty effective if done by the right EP.  There are only a handfull of really good ones in the world.  The average EP would be a hack.  Anything more than a PVI and they'd be lost, iffy at best.  Even with the best, it often takes a second ablation but that's usually enough (something like 70% the first and 90+% the second.

There isn't anyhing particularly dangerous about an ablation.  It's not much more, and in many ways less, dangerous than a heart cath or pacemaker implant.  They're all very similar.

Mine didn't work because they weren't for AF or, really, AFL, rather atypical AFL, which is in the left atrium.  You can't get there without going through (and I mean through) the septum.  It's a more complicated procedure than the typical AF/AFL ablation.  Even so, imajor complications are rare.  I'd highly recommend going this way over serious drugs for those with highly symptomatic AF or AFL.  Going through the the entire list of antiarrhythmics takes time, time for the AF to get worse. All of these drugs are toxic to one degree or another (the better they work, the more toxic they are). It's better to stomp it out immediately than wait.  I wish I'd done it before my Maze but it wasn't an option by then.

Except for the time they did a cardioversion while I was awake, the ablations were a piece of cake.  That was a second of excitement in the middle of a sea of boredom.  ;-)

For information on the mode switching Gemita is talking about:


Re: Snow.  Bah Humbug! I've had enough snow for a lifetime.  The year before we left Vermont, we had 36" (~1m) on St. Valentines day and 24" (~750mm) on St. Paddy's day.  Enough is enough, already.

It was sunny and 70F (20C) here today.  I hope it stays this way all the way to New Years.

Thank you all!

by Pharnowa - 2020-12-13 23:04:09

I feel better just knowing the difference in AFib after implantation can be explained. Something about my throat vibrating while my pulse accelerated was frightening. I acknowledge I'm a weenie.

AgentX86, 36in. is way above Pennsylvania totals. We are awaiting 12-18 and there is no bread to be found.

I look forward to enjoying easier shoveling now that I'm paced! :)

Thank you all again!




by AgentX86 - 2020-12-13 23:57:49

Looking forward to snow?  You are a sick puppy.

It wasn't all that unusual that we'd have snow on the side of the road piled higher than a car.  Once 10'.  It's quite disconcerting driving in a canyon where you simply can't see someone approaching and intersection from either side. 

It was also cold enough a couple of times that water mains 7' down would burst.  That's rather a mess when it's that cold.  Cold enough that even grave diggers are laid off.  The good news that when it was that cold it was a nice sunny day.  Anything above 10F and it was completely overcast.   Horrible, depressing place to exist during the Winter.  There's good reason snowbirds invade Southern states over the Winter. We just did it permanently.

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I have an ICD which is both a pacer/defib. I have no problems with mine and it has saved my life.