Tachy RHR after PSVT ablation-3weeks post procedure?

Hey all,

I had an RF ablation for PSVT about 3 weeks ago, was told it was a "success".  The first 4 hours my RHR was 60-80bpm which was great then at hour five it climbed to 110.  My RHR has remained above 100 often around 110 since the procedure.  I cannot take rhythm control meds due to a very low BP and orthostatic hypotension.  Also I am still having the higher PSVT with mild exertion (like standing over the stove for ten min which you can hardly call exertion).  Some of these are high enough to hit my PM upper limit of 140 and give me weinkebach.  I sent Kardia 6L ekgs, bp recordings, and symptoms to the EP.  Her assistant replied and said I didn't need to do anything and just come to my follow up in 4 weeks.  I know HR can be elevated post ablation but being tachy 24/7 seems like it would be considered too high.  Has anyone dealt with this?


15 Comments

Low dose beta blocker to help during healing ?

by Gemita - 2021-01-02 20:40:36

Hi Asully,

Haven’t had an ablation - yet - but have a multitude of atrial tachyarrhythmias including PSVT.  They are a real pest.  To be honest my EP isn’t too concerned when my RHR is in the range 100-110 bpm which is barely above normal heart rate (60-100 bpm range).  He only takes an interest when my heart rate is higher and sustained.  I can reach dizzy heights rapidly (200 bpm+) but they usually fall back just as quickly.  What to do about all this?  I take a daily rate control med - low dose cardio selective beta blocker Bisoprolol - to calm things down.  

I see like me you suffer from hypotension.  Had it all my life.  I find Bisoprolol at lowest dose does not drop my blood pressure too low and seems to calm my palpitations sufficiently to prevent a rapid ventricular response rate which is dangerous.  With orthostatic hypotension, get up very slowly from lying/sitting to standing and make sure you are always well hydrated.  Also I was helped by lower body muscle tensing prior to/while standing.  Ask your doctors for help to prevent orthostatic hypotension - there are a few helpful techniques to try before resorting to meds which didn't help me.

As you say your symptoms, I am sure, are fairly normal following an ablation, particularly while you are in the healing period which can take up to several months, or even longer.  Nonetheless, I think it might help to take a rate control med to help stabilize your heart rate while you are still healing and to give yourself a chance to recover your strength.  As mentioned, I take Bisoprolol daily or as an extra pill in the pocket when I most need it.  Alternatively I was offered Verapamil, a Calcium Channel Blocker.  I note your EP/technicians are not concerned about your heart rate at present?  I would still seriously consider taking a rate control med to try to calm everything down (with EP's blessing of course).  Sounds as though you might need some help?  If this continues and you start getting symptoms like breathlessness, chest discomfort, weakness, dizziness, I would ask to be seen earlier than 4 weeks.

Finally, maybe take a look at what you are eating and drinking too because it could be a factor.   Even small amounts of caffeine, chocolate and alcohol can send my heart rate up to dizzy heights and add Christmas to the mix with all the stress/excitement/lack of sleep associated with the festivities and you have a strong cocktail for a higher than average heart rate!

 

Ablation

by WazzA - 2021-01-03 06:26:22

Did your EP NOT tell you about the 3 month blanking period ? This is to enable your heart to settle down after being traumatised, it has suffered injury albeit on purpose & needs that time to recover.  

They didn’t “tell” me about a waiting period, but I was aware.

by asully - 2021-01-03 11:51:39

It is just from the studies I have read it should have only increased my HR about 10-20 bpm.  If I was not tachy 24/7, and having episodes or near syncope I would be less concerned.  Since I am 2 months post mitral valve replacement (redo sternotomy) I am a bit concerned about running hot all the time, and my heart failure specialist, and primary, have both indicated a similar concern.  We tried very low dose of digoxin (which typically doesn't affect bp) for the first 4 days post ablation but I couldn't sit without near syncope and dizziness, I was a mess low bp and my rate did not drop, so the HF doc had me discontinue it.  I would be open to trying more rate control meds but my docs have already given up hope that we will find one that won't take me to dangerously low blood pressure.  Thanks for the advice Gemita I have not tried that med yet maybe I will make a request and see how it goes I can't imagine getting up to 200 (mine is nowhere near that high), and luckily I have complete heart block and am 100 percent pacer dependent in my ventricles so I do not go in to vtach if I hit my upper rate limit.  I do however go into pacemaker mediated weinkebach, where my ventricles will beat at half the rate as my atria which causes all kinds on unpleasant symptoms.  My PSVT episodes tend to get right up at my upper rate limit but rarely over or only slightly over, I think when I hit that theshold my body doesn't try and push any higher so that's good.  I don't appear to be having any atrial flutter or a fib so that's also good, just ectopic beats and sinus tachycardia.

Sinus Tachycardia or SVT ?

by Gemita - 2021-01-03 12:28:54

Asully,

Yes unfortunately for some there is a blanking period following an ablation as WazzA states.  Some lucky folks though never have any more problems.  For others their symptoms are worse following an ablation and they need more treatment or another ablation.  For some their doctors discover that the ablation has unmasked another arrhythmia previously not seen, so there is so much that can come out of an ablation Asully.  Reason why I am holding out for the moment, even though my doctors are prepared to do one.

You mentioned Digoxin.  I hated it too.  It is a heavy weight med for some.   Made me dizzy and extremely poorly.  I was also taking Flecainide as well as Bisoprolol.  I stopped Flecainide after my pacemaker and am now only on Bisoprolol which is extremely safe for me (since it mainly targets the heart not other organs, so side effects are reduced, especially at lower doses.  Start at 1.25 mg (lowest dose) and that may well be enough to hold down your heart rates to an acceptable level.  There are other more specific beta blockers for SVT, but I can only speak with confidence about Bisoprolol.  Hubby is also on it and has heart disease.  It has been extremely safe for him too.  

You mention sinus tachycardia as a cause for your higher heart rates, rather than your SVT which appears to have been treated successfully according to your doctors. Sinus Tachycardia can be difficult to treat but that is something that I would be asking my doctors about when you next see them.  You could ask whether the ablation might also have taken care of any ?inappropriate sinus tachycardia which might resolve after the blanking period or whether this would require additional treatment?  It is still very early days so hopefully your heart rate will steady

I think my PSVT was technically sinus tachy.

by asully - 2021-01-03 13:02:25

It was described at Paroxysms or supraventricular tachycardia showing a change in p wave morphology.  I have looked at the strips myself of the runs and it looks like sinus rhythm, it's just getting triggered early from my atria.  Maybe this isn't considered sinus tachycardia, please correct me if I am wrong and the change in p wave morphology means it is not?  The ectopic beats are mostly pacs with compensatory pauses, and a few pvcs.  I am still getting used to reading my strips again because they are different since they upgraded me to a crt-p.  Each time I get a new device I have to relearn what my baseline rhythm is.

Whoops sorry I just answered my own question.

by asully - 2021-01-03 13:20:12

I guess it was focal atrial tachycardia, originating from the posterior SVC/high right atrium junction.   However, I am still curious if it was still considered a "sinus" rhythm.  Time to crack open the textbooks lol.

That did not take long, this article has a good breakdown of different types of SVT in case y’all are interested:

by asully - 2021-01-03 13:26:00

https://www.ncbi.nlm.nih.gov/books/NBK507699/

How to tell the difference ?!

by Gemita - 2021-01-03 13:41:06

Hello Asully,  you seem to know your heart rhythms!  All I have learnt is that SVT is usually faster than Sinus Tachycardia, starts abruptly then stays at about the same rate until it ends whereas Sinus Tachycardia frequently changes rates, gradually speeding up or slowing down.  So to confirm, if the heart rate changes abruptly from a slow rate to a faster one and the fast rate is the same rate from beginning to end, we are looking at PSVT (paroxysmal supraventricular tachycardia).  That was what I was told.

We need long enough rhythm strips to fully assess rate changes or to catch the onset or offset of tachycardia though.  I will look at your link Asully.  I think we need to set up an ECG reading lab on this site!!

I have been diagnosed with episodes of MAT (multi focal atrial tachycardia), SVT, AFib and AFlutter + non sustained VT as well as atrial and ventricular ectopics, so my rhythm strips are often difficult to interpret.  My EP's technicians were even confused and wrongly reported my last significant event as atrial flutter but Medtronic technical services were consulted and they comfirmed evidence of MAT !

My pacemaker wasn’t catching my SVT.

by asully - 2021-01-03 14:50:39

It was below the threshold for an event recording except a handful of times so they thought I was only having brief runs (seconds to minutes) a few times a year.  Turns out I was probably having longer runs all along, we caught it in action one day when I just happened to be at my primary docs office and asked them to record it and send it off to the ep. We then confirmed it with a 30 day monitor (it was the new fancy biotel patch).  After my ablation I asked if she knew what rate my arrhythmia was generally showing up as and my EP said 120-140.  So it was in the low range but enough to be unpleasant especially with my low cardiac output.  I don't know much about reading ekgs or ecgs, I try and learn what I can, but unfortunately it is hard to find examples of paced individuals.  An ekg lab here would be great, or just a library of example images of strips showing different paced rhythms and ones showing various problems in a paced rhythm.  Most general practitioners and nurses can't figure out my readings because I am paced etc, they usually freak out when they first hook me up to a monitor.  It doesn't help that I am young and my pacemaker is generally not visable, so even if it's in my chart they somehow miss the fact that I am paced, I have become used to letting them know right when they hook me up so they don't panic.

PSVT

by AgentX86 - 2021-01-03 15:07:21

SVT is a catchall term for any atrial tachycardia (literally, "tachycardia above the ventricles"). It could be AF, AFL, ST, or pretty much anything from the atria.  PSVT simply means  proximal SVT,  or an atrial tachycardia that comes and goes on its own, each episode may last minutes to days. The opposite of proximal is persistent, which lasts longer than a week and may or may not stop on its own. "Permanent" isn't an official term but is used to indicate that it can't be stopped.

Proximal can easily degenerate into persistent if not treated, usually by ablation (by then it may be too late).

 

Pacemaker data

by Gemita - 2021-01-03 16:10:02

Asully,Yes that is the problem with the pacemaker, it only stores data that it is set up to retain, that is, the set conditions have to be specifically met for a tachyarrhythmia to be recorded.  A tachyarrhythmia has to reach a certain heart rate and for a certain length of time for it to be recorded or flagged as a significant event.  Often shorter episodes or lower heart rate episodes will be completely ignored so the true arrhythmia burden may not be fully appreciated.  I keep diary notes of dates of my most significant episodes to discuss with my pacemaker team.  They are sometimes surprised that from diary notes of my symptoms alone, I was able to tell them what arrhythmia I was in at the time.  I hate being symptomatic but it has its benefits!

I will have a think about how we could set up an ECG learning experience on PM Club.  I would think those with copies of any recent ECG reports, including from Kardia 6 lead monitors, could start us off by posting some of their rhythm strips in the gallery for perhaps a periodic discussion on the possible underlying rhythm present for each posting.  It doesn't matter if we get it wrong - we would be learning.  We could open it up to anyone who could make a meaningful contribution.  We have to start somewhere and I know so many here want to try to understand what their ECGs mean, including me.  We could go to You Tube but we wouldn't get the same feedback.  Of course I realise paced rhythms will be difficult to interpret. I will have a think about it and consult other members for their views.  Anyway, lovely chatting with you Asully and please let me know how you go with a rate control medication.

Hi AgentX86 yes my EP is never really interested when I ask him which atrial tachyarrhythmia was recorded - he just says it could be any one of them because of the unpredictable nature of my arrhythmias and their often in and out nature.  I think too he realises that now I no longer have my loop implant monitor, he would need an external event monitor to confirm with confidence what rhythm disturbances I am getting.  I do understand the difference between paroxysmal, persistent and permanent arrhythmias.  Fortunately mine have been paroxysmal for many years and I hope they remain this way, although I accept the natural course is for them to progress by which time treatment becomes more difficult

 

PSVT

by AgentX86 - 2021-01-03 21:21:56

Hi Gemita, my comments weren't pointed at you. I was only trying to covey that these are very generic terms and don't specifically identify a cause.  Of course the cause may or may not be important but these are scary sounding terms that, by themselves, don't convey much information.

Point taken AgentX86

by Gemita - 2021-01-04 04:14:10

But how difficult it is to interpret with confidence the specific rhythm disturbance we might be in.  If professionals can't always get it right, even with a surface 12 lead ECG, what hope is there for us?  And 12 lead monitors can report incorrectly too - happened to me at the start of my arrhythmia journey, with frequent PVC complexes becoming "PACs, with right bundle branch block" when accurately read by my EP!!  Just cannot understand all of this

Profssionals not getting it right

by AgentX86 - 2021-01-04 22:42:11

If an EP or cardiologist can't read an EKG, they should find another line of work.  OTOH, I had an ER cardiologist who couldn't even identify AFL (maybe that's why he got the crappy ER duty). My EP wasn't impressed and showed me the telling sawtooth on lead 3 of the EKG.

EKGs are just a snapshot.  If the problem is intermittent an EKG probably won't show it, which is why we have Holters and event monitors. Sure, we can't be expected to be able to identify all of these problems but that's why we pay EPs.  However, once the diagnosis is made it should be possible to train an interested lay person to identify it on an EKG.  Kardia Mobiles are quite useful tools, even in semi-trained hands.

Just catching up on this thread.

by asully - 2021-01-13 22:25:36

In my practice learning to read ekgs, spending time using it while walking around the hospitals after procedures and cross checking my skills with the nurses Aflutter and AFib are pretty easy to learn to spot.  Like you said Agentx the sawtooth pattern is a giveaway for aflutter.  Unfortunately SVT isn't afib or flutter, most of the time they look like a tachy sinus rhythm but you do see a change in the shape of the p wave or sometimes I get "extra waves" not sure what those are, might be just background noise although they seem to consistently happen during SVT episodes.  At present I am tachy 115 bpm RHR after laying down for at least 4 hours.  I have had a couple nights this week where I finally dropped to mid 90s after extended bed rest (I am hopping that's a good sign).  Follow up with ep on the 22nd so I guess I will know more then.  I also just found out last week my TSH (thyroid stimulating hormone) is suppressed, I may be hyperthyroid, waiting on referral to endocrinologist, hyperthyroidism is known for causing SVT.  So I will be interested to find out more and see if that's a contributing factor.  If any of you want to take a crack at reading my 6L kardias I have plenty to share lol.

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