PM for bradycardia, now developed atrial tachycardia!!!

atrial tachycardia

by AgentX86 - 2021-01-31 13:46:34

First, "supra ventricular tachycardia" (literally "above the ventricles") is just a fancy name for "atrial tachycardia". It's really a symptom rather than a diagnosis. It could mean a lot of things.

Beta blockers are the standard treatment for such things and Bradycardia would contraindicate beta blockers. You may be a candidate for a ablation.

Tachy/Brady Syndrome

by Gemita - 2021-01-31 14:49:33

Hello Heartfelt,

Yes, I have a similar condition.  I have both tachycardia and bradycardia, known as tachy/brady syndrome - part of the Sick Sinus Syndrome disorder.  It was first diagnosed in 2014.  I got my dual chamber pacemaker in 2018.

I also have atrial tachyarrhythmias (supra ventricular tachycardia, multi focal atrial tachycardia, atrial fibrillation and atrial flutter), so I do know what you are facing.  I also have hypotension (low blood pressure), so although my pacemaker prevents my heart rate from falling below its set rate of 70 bpm, it cannot prevent my blood pressure from falling and that can be a real problem as you are discovering.  The trick is to take the smallest dose of beta blocker you can to prevent your SVT or AT from going too fast, without reducing your blood pressure too much.  I am on low dose Bisoprolol which is proving very helpful and I am able to maintain a reasonable blood pressure control without coming over faint from falling blood pressure.  If you find your blood pressure falls too low on a low dose beta blocker, then as AgentX86 mentions, you may be a candidate for an ablation which can be extremely effective at stopping a fast arrhythmia like SVT.

Unfortunately when we start to have electrical problems, it can be quite usual to go from one extreme to another - I started with tachycardia and went to bradycardia.  Now I am the proud owner of multiple, fast and slow arrhythmias.  My pacemaker/beta blocker are both providing some stability, although I may need a bit of extra help in the future by way of an ablation, or two.  Good luck and I hope you can get your tachycardia under control since a consistently high heart rate can be dangerous.

Atrial Tachycardia

by Marybird - 2021-01-31 15:55:50

As Gemita mentioned, if your bradycardia is due to a dysfunctioning cardiac sinus node ( also called sick sinus syndrome), it wouldn't be that surprising that you also developed tachycardia over time. I also have SSS, with tachy-brady, though I had had the tachycardia for a number of years before the bradycardia developed.

I was also told by the EP I was referred to I had atrial tachycardia ( as opposed to other types of tachycardia originating in the atria, such as atrial fibrillation, or atrial flutter, or other type of supraventicular tachycardia due to errant electrical pathways involving the AV node). I can tell you the treatment options he discussed with me for the tachycardia.

I had been taking metoprolol ( beta blocker) for a long time, and when I had adequate doses of the stuff it did a good job at controlling the tachycardia, but we thought the bradycardia I developed several years ago might be at least partly caused by the metoprolol. The EP suggested that perhaps a calcium channel blocker such as diltiazem might be more effective at controlling my AT, and perhaps might not lower the heart rate as much, so I tried a low dose of diltiazem for about 6 weeks before we determined that at least for me, it didn't do an adequate job of tachy control, and I still had significant bradycardia ( one or the other, couldn't seem to hit a happy medium). I had the pacemaker implanted, and ended up on a low dose of both diltiazem ( 180mg/day) and metoprolol ( 50mg/day) and that seemed to help at least for a while. I have since had to increase both the metoprolol and diltiazem to control the tachycardia and the blood pressure, but I keep thinking that the combination of diltiazem and metoprolol work better together than either one alone in controlling the tachycardia.

But that's me, I also have high blood pressure that can be difficult to control, so I have no problems taking beta blockers, even the diltiazem in high enough doses to control the tachycardia. It'd be another issue with low blood pressure, I'd think.

The other options the EP mentioned to me, for consideration over time, depending on how severe/symptomatic the AT got, were of course increasing doses of both the metoprolol and diltiazem, if those were unsatisfactory he mentioned taking antiarrhythmics such as flecanaide, propofanol, or his personal favorite, (I think), dofetilide. He had also discouraged ablation for me at the time, mostly due, I think, to the paroxysmal, start and stop nature of the tachycardia. He explained that AT can be very difficult to ablate as it often is very difficult to induce in the EP lab, it can be hard to maintain the tachycardia and thus difficult to track, and find the culprit sites causing the tachy. My tachy was well controlled with medication and being off and on like it was, he recommended the medication and pacemaker. But he did say later on that ablation for me would be an option if the tachycardia was frequent enough that it could be induced in the EP lab. So ablation for AT can be an option for some people.

Those were the options I was presented with in the event my AT got worse over time. My own preferences are to never have an ablation, and to continue with the heart rate controlling drugs I take now, ie, metoprolol and diltiazem, especially since these also serve to keep my high blood pressure under control. I'd like to avoid taking the antiarrhythmics I mentioned, if possible, as I am leery of the side effects of these drugs, and they don't do much for blood pressure, so I'd STILL be taking the other drugs to control that. But again, that's me, lots of people take antiarrythmics and do fine with them, so that's a discussion between you and your doctor.

Everybody's different, though, and your best bets are to discuss treatment options with your EP. What you and the doc decide will depend on how frequent and how symptomatic your AT is, your medical history, other medical issues, and your own preferences. It's sometimes a matter of trial and error, finding a combination of drugs and their dosage to see what works best. You will get there!

SVT

by AgentX86 - 2021-01-31 21:20:28

Atrial fibrillatoin and atrial flutter are SVTs but not all SVTs are AF or AFL. AF is pretty easy to spot.  You'll be able to feel (at least palpate) an irregular heartbeat.  AFL can only be diagnosed on an EKG.  Otherwise it looks like any other.  It's a very regular atrial tachycardia with atrial rates in the 240 to 300bpm, or even higher.

You're right to want to avoid antiarrhythmics if at all possible.  BTDT.  Antiarrhythmics are all toxic, to one degree or another.  The better the antiarrhytmic the more toxic.  Beta blockers aren't antiarrhythmics but reduce tachycardias, which is important.  Your point about assymptomatic SVTs is right on.  If one is asymptomatic, just treat the tachycardia (with a beta blocker or calcium channel blocker) and an anticoagulant to limit the stroke risk and be done with it.  Antiarrhythmics aren't needed at all.  Symptomatic STVs need to be addressed to the degree that they reduce the qquality of life.

Atrial ahrythmias are progressive so it's best to nip symptomatic SVTs in the bud or paroxysmal will turn into persistant and possibly permanent.  Ablation is the only real solution, though antiarrhythmics help.  Ablations aren't always successful but the surgery is simple (for the patient) and can be done with only local anesthetic but twilight sedation is the norm.  If you go this way, get the best.  There is a huge difference in the skills from EP to EP.  You'd want someone who does at least a hundred a year and a total more than a thousand.  Your EP may not be "the best" so will tend to avoid it.

Atrial Tachycardia?

by Marybird - 2021-02-04 10:08:41

Well, seems my last couple remote pacemaker reports have shown a small amount of a-fib, so I guess that makes attention to the tachycardia a bit more pressing, and it explains the increases in the metoprolol the cardiologist has prescribed. They tell me they are watching the reports ( they will get alerts too if the a-fib/ tachy reaches above the preset thresholds) and are hoping the metoprolol will squelch the afib enough to make an anticoagulant unnecessary. They will increase the metoprolol as necessary, and go from there as indicated. Metoprolol has always worked well for me, I guess it just seems it's requiring higher doses now as apparently they don't want even breakthrough afib.