Exercise and Heart Block

I have had my PM since 9/2019.  I am 66 and prior to was in elite shape.  I could easily run 10 miles.  Now I struggle with 2. During the preceeding two years prior to 2019 I occassionally experienced EXTREME fatigue (once every three months) during intense exercise.  I discovered in stress tests that it was 2/1 heart block.  My EP said a PM would 'fix this'.  After the PM, I have regularly experienced 2/1 heart block during exericse (once or twice a month).  I regularly feel a 'soreness' in my left pectoroal muscle that seems to correspond to an overall fatigue.  I can still work out but NOT at my prior elite level (I am exhausted at the end).  One final thing.  The only positive thing from the PM (it did NOT fix my 2/1 block) is it displayed that I have AFIB.  Has ANYONE experienced the same thing and, if so, how did you deal with it?  My 'new' EP has me on MULTAQ which does not seem to be making much of a difference in my 2/1 heart block or AFIB.  It is frustrating to go thorugh the PM implant and see very little results (I pace 6% of the time  I very much appreciate any thoughts/insights.  I continue to see my docs who do not know why I present the way I do and suggest I am a 'unicorn' (which I DO NOT want to be)!  Blessings,  BW


2:1 Heart Block

by AgentX86 - 2021-01-20 23:30:15

If it really is a 2:1 block causing your problem (not Afib or whatever), it sounds like your upper tracking limit is set too low.  Basically, when your ventricles exceed this limit, the PM goes into skip mode so the ventricle "tracking" is lost.  It then drops to a 2:1 mode to keep from over-pacing the ventricles.  In other words, it's not a bug but a feechur.

This is done for a number of reasons and it's something you'll need to talk to/plead with/cajole your EP into having it raised enough to do your exercise.  It may be that he has good reason to leave it where it is (like keeping you on the green side).

I would look at atrial fibrillation (AF) as a cause for some of your symptoms

by Gemita - 2021-01-21 04:56:34

Hello Brad,

Their suggestion of you being a ‘unicorn’ or that what you are experiencing is in some way unusual, is hardly helpful.  I would be inclined to question whether your doctors really understand how both AF or powerful meds like Multaq can affect the body? !

I would respectfully ask for some additional monitoring to see how frequently your AF is occurring and whether Multaq is working for you?  Doesn't sound like it does. There are other treatments for AF, more effective than medication (like an ablation) that you could ask about. Unfortunately, a pacemaker cannot stop an arrhythmia like AF or a high heart rate from occurring.

As they may have mentioned, AF is an irregular heart rhythm which can occur at slow, normal or rapid heart rates.  I suffer from AF with sometimes rapid heart rates.  It causes the upper chambers of the heart to quiver (beat erratically) and so movement of blood to the rest of the body can be ineffective and cause symptoms like breathlessness, chest pain, extreme fatigue, dizziness, weakness, difficulty with exercise, particularly as our demand for energy increases.  I am not at all surprised you are having symptoms when you are in AF.  

In general, it is not a good idea to workout too vigorously with atrial fibrillation unless you have been carefully assessed for any underlying heart conditions.   Have they checked your heart function recently by echocardiogram?  If not, might be worth asking about. 

When in AF my heart can race with exercise so I have to be very careful.  My blood pressure can also increase or drop rapidly causing further symptoms.  AF is a pest and needs to be well managed with a range of treatments which might include anticoagulation (essential if you have AF stroke risk factors), rate control medication (essential if you have fast AF rates), anti arrhythmic medication like Multaq, or an ablation.  An ablation is the most effective treatment to try to stop AF but it is more invasive and you may need more than one procedure.  However if successful you would be able to reduce or even stop most of your meds in time, improving your quality of life and helping you to return to your normal exercise programme.

You may always have had AF without knowing and AF could well have caused symptoms similar to heart block.  I was told Atrial fibrillation can create a "diagnostic dilemma for identifying AV nodal disease or block", so I would go back and discuss your options for better control of your AF.  Get that under control and you might well sort out your problems.

I agree with AgentX86 comments.  I experience something similar.  When I go into AF and my heart rate goes say above 160 bpm, my setting "Mode Switch" comes into operation.  This forces my pacemaker to stop tracking my AF in the atria, preventing the high, chaotic heart beats from passing through the AV Node to affect the ventricles.  But this switching can cause block symptoms and we can certainly feel it, so I would ask what your Mode Switch/upper tracking heart rate settings are. The problem is, is that Mode Switch and control of upper heart rate is there to protect us from any dangerous high heart rates getting through the AV node to affect the ventricles, the main pumping chambers of the heart, and I am not sure that they will be happy to raise the rate at which say any Mode Switch comes into operation for fear of AF causing worsening symptoms/increasing heart rates.  Personally, I believe it would be better to try to tackle any AF first to help correct your symptoms.  This would also help prevent any future potential AF related health problems (and there are many risks of uncontrolled AF).   The earlier AF is tackled, the better our chances of controlling or even curing it in the short to medium term.  I do wish you well.


Exercise and symptoms

by Selwyn - 2021-01-21 14:01:14

Personally, I would ask for an exercise monitoring test.

Whilst I do endorse what has been said to you by AgentX86 and Gemita, I am concerned that there is a lack of diagnosis. Your doctors should not be  vets. The resulting opinion of being a 'unicorn' is not stretching their diagnostic skills.

I would want to exclude angina if you have pectoral symptoms on exercise. You should ask them how they have excluded this. Angina of effort ( angina pectoris) is associated with fatigue on exercise.

Don't forget, about the side effects of your medication. This can affect your lungs etc.



Exercise and Heart Block

by bradwill13555 - 2021-01-22 21:54:32

Thank you all for your thoughtful (and informed) comments.  I am now on my 10th day of 'multaq'.  Interestingly, I 'feel' better than I have in about a year.  While I had one 'episode' of 'heart block', I watched (I wear a strap monitor and a watch) my heart rate bounce from 130 to 84 to 165 to 74 to 151 and back to 130 in about seven (7) seconds.  Of course the normal 'complete fatigue' accompanied this.  But, aside from this one instance, my workouts have clearly improved and the other 23.5 hours per day seem to 'feel' better.  Makes me think the AFIB is more central than previously thought.  Will continue to follow up (next week) with my EP (he is my 3rd...other two thought I should just 'accept' I am aging....).  This guy is at least trying to find answers.  Again, your kindness (and this group) is indeed a blessing.  Thank you.  BW

I have 2:1. Block

by PacedNRunning - 2021-01-23 02:20:28

Hi! I have exercise induced 2:1 block. It was vary hard to program my pacemaker for exercise took about 6 mos then another 3 mos to dial it in. There a quite a few things to tweak. First what is your upper rate limit? I had to raise mine to the max. I'm 49, runner, golfer etc. I experienced 2:1 block also after my implant and I was not happy. Felt just like you. What the heck did I get this for?  Ask about upper tracking limit. Make sure your AV delays are appropriate for exercise, meaning it gets shorter as your rate increases. Ask about TARP. If TARP is not calculated correctly you will experience 2:1 block prior to hitting your max. 
As far as feeling tired. It takes time to adjust to be being paced while exercising. You'll get use to that. I just ran less. Pre pacer I ran 50-60 mins each run. I cut back to 30 mins runs until I no longer felt tired after running. Then I increased it to 10 mins. Etc. The other reason you could feel tired it because your having block. Hemodynamically that eventually catches up to your body and makes you tired. So it's a domino effect of settings that can't meet your needs. Feel free to PM me with any questions. I like helping people get it tweaked for exercise because it's not easy. I did a ton of reading and learning to get where I am. I'm lucky in that my doctor allowed me to come in for adjustments whenever I wanted. So I would go in and say let's try this or that. Or what do you think about this or that. :). They can get it pretty darn good for you and feel back to normal. Or close to normal. :) 

I’m called a unicorn too

by PacedNRunning - 2021-01-23 02:22:49

I'm called a unicorn too. 😂. In the beginning they tried to limit my pacing to only with exercise but when that didn't work they paced me more. I felt great at 40-50% paced. 

Thank You

by bradwill13555 - 2021-01-24 22:05:17


Thank you!  We sound quite similar (including running and golf).

Will follow up with my EP regarding your suggestions.

One final question.  I am 'pacing' only 6% of the time according to my new EP.  When they put the thing in, the original doc told me I would 'only' pace when I went into 2:1 block (which it does not).  But you say you are pacing 40% to 50%.  I don't quite understand how the PM determines 'when' you 'need' to pace.  I keep thinking the PM responds to situations your heart/body/lifestyle create but it does not seem to be that way for me.

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