Exercise induced Hypertension

I have lately experiencing a sudden drop in blood pressure while brisk walking. I usually walk for 5 mi at a brisk pace (2.5-3 mph).  My tolerance this spring has been steadily decreasing, and I am fatigued the last 1/2 mi; lately though I have been unable to go more than a mile.  I am having sudden drops in HR, from >130 to 60, and subsequently am unable to increase my HR above 65-70. I have also extablished that my BP will drop to <95/60.  When this happens I feel dizzy, weak, nasea, tightness in chest, and SOB.  This only happens while walking, and not on ellipticle or treadmill, but I think it is time and not distance related.

I sent the data (captured from PM and HR monitor) to my EP doc, and he shared it with the company rep. The PM checked out fine on remote monitoring, and they had me come in to make a small change to an endurance setting; however, I am still experiencing these symptoms.  The engineer, and company engineers are stumped.

Background:  I am 68, T1D for 56 yrs (DXD age 12), Boston Scientific Accolade PM single lead installed 12/19 for SSS.  I am slightly hypotensive in AM, never drop lower than 115/70,, and  on 30 mg Lisinopril. Once the PM was tuned in I have no other issues Lower limit is 60, upper limit is 150, RR and MV (set to kick in at 120) are on.  Once my HR drops I am unable to get it back up some time, even if breathing hard to get the MV to kick in.

I just sent my most recent data to my EP doc and my cardiologist, and have not heard back. But I wanted to tap in to the knowledge base here.  My questions are:

1. Anyone else experience or know what could be causing this (I searche the internet and PubMed, but found nothing directly pertinent).

2. Which is causative?  A drop in BP or drop in HR?

3. How is it even possible for a paced heart to suddenly have a drop in BP?  And then not recover?

4. Could this be vaso-vagal autonomic neuropathy? I have had some episodes of orthostatic hypotension after sitting for long periods, but it passes quickly.

5. Echo a year ago was normal.  Ejection fraction >60%

Thanks in advance,

Mike

 


5 Comments

Exercise induced hypotension

by Gemita - 2021-06-20 14:46:51

Mike, I think you mean exercise induced hypotension not “hypertension” as you typed in your heading.  I see however you have long standing hypertension also just to keep us all on our toes.

My thoughts:

How is your diabetes control.  Are you getting hypos or hypers because that can really mess with heart rate and blood pressure?  Also why did your EP implant a single lead rather than dual lead pacemaker?  Do you by chance have a permanent arrhythmia like Atrial Fibrillation?

To try to answer your questions:

1) I can get similar symptoms with sudden heart rate and blood pressure drops but I do have some evidence of autonomic dysfunction (have had extensive testing) and I certainly have arrhythmias too and they will play havoc with both HR and BP, sending them from one extreme to another in no time at all which is why we can feel so unstable at times.  

2) Either a heart rate or blood pressure sudden drop can be causative and for me one quickly affects the other.

3) Unfortunately a pacemaker cannot control a fall in blood pressure as it can control a fall in heart rate (prevent it from falling below the set minimum), and a sudden fall in blood pressure can certainly cause the symptoms you describe.  I can still pass out even with my pacemaker, although it has been more pre-syncope symptoms rather than a full faint.

4) Autonomic involvement is quite possible especially since you have noticed some orthostatic hypotension but you should ask for Autonomic Testing at a specialist hospital once all other causes have been firmly ruled out including arrhythmias and suboptimal glucose control, although I see you have an insulin pump.  No doubt you still check your glucose levels frequently, especially when you get symptoms?

5.  Clearly your Ejection Fraction is good.  I presume you have no leaky valves, cardiomyopathy, ischaemia and the like, since I note you have stents in the RCA, so you have a history of heart disease.

If your manufacturer rep, EP are stumped, I would get some additional checks with your general doctor.  Blood tests and other investigations may be needed to look for other causes like infection, allergy and any adverse affects from meds, endocrine problems, dehydration, electrolytes, anaemia and so on.  Perhaps longer term monitoring to pick up an arrhythmia too would be helpful, as well as extra glucose testing and if all that fails to reveal a problem, you could ask for a referral to an autonomic testing clinic.

Mike I see you have a history of cervical spinal stenosis which may complicate the picture too. I think your issues might take some time to resolve and are perhaps more complex than just a matter of adjusting your pacemaker settings (which I see you have already tried).  I would seek a neurological opinion if your insurance will cover and they can perhaps arrange further testing to run simultaneously with any general investigations.  Good luck

When you hear hoofbeats, think horses not zebras

by crustyg - 2021-06-20 17:23:51

Hi Mike: please update your profile which still says Medtronic.

If you have autonomic neuropathy you're going to have BP problems all the time, not just when walking: you clearly state that it doesn't happen on X-trainer or treadmill.

Given your stated diagnosis SSS, it's almost certainly a sudden drop in HR =>causing reduced cardiac output =>drop in BP, especially if you're using big muscles that need a lot of blood.

So the Q becomes: why sudden drop in HR? Mostly likely some sort of atrial tachy (since you say single-lead PM, which for SSS must be an RA lead - unless your EP-docs have gone mad).  Your PM won't be able to sense vent activations *unless* you have retrograde AV conduction (which happens), so an atrial tachy makes sense.  PM's are notoriously bad at detecting short runs of tachy (for a start they are only set to record tachy events above a given rate - usally 10-20BPM above max-tracking rate) so they will miss a lot.

If you care to share your Accolade settings via IM I *may* be able to help untangle this with you: I think your PM is stopping pacing you because it's sensing electrical activations.

Alternatively it may be quicker all round to get either a 24hr tape (==Holter) or a Reveal implantation - these gadgets are designed to detect and record all activity, unlike a PM.

Exercise induced Hyportension

by Mike417 - 2021-06-21 10:06:37

Gemita,

Yes I did mean hypotension.

My last A1c, 2 months ago, was 6.2.  I am on a cgm, and pretty well controlled; very few hypos while exercise, and none when I have these episodes.  All blood work is in normal range, except for cholesterol.  At the time my PM was put in the surgeon said he had difficulty getting the second lead in, and decided for SSS I only need one lead.  I have switched to another practice.  BTW, all of my doc.s are at large university hospitals, and all have gray hair.

Crustyg,

You hit the nail on the head, if it were CAN/D, why is it only while walking?  I like the idea of it being Tachy, and I did not know the PM could not record these events.  I will contact my EP doc and ask for remote monitoring.  I have to dig out my Accolade settings and send them to you.  It will have to be after I return from a week long trip; we leave today.

I thought this group would have some ideas!!! Thank you!

Mike

And the answer is....none of the above

by Mike417 - 2021-07-02 14:11:36

I got in to see the EP PA the other day, and they did a few tests. The data I sent them helped with the diagnosis.  The critical test was to increase my pacing/HR and monitor; they found I was having device Wenckebach rate. My ventricle was dropping beats beginning at 120 bpm, and at 132 it was 2:1.

The solution is to put in the ventricle lead, or put it to the His Bundle to manage a more natural rate.

I should note that this EP clinic/doctor is not the instatution/doc that placed the device.

Mike

Glad you have a diagnosis

by Gemita - 2021-07-02 16:33:23

Mike, that is good news you don't have to see a neurologist and I am glad they saw the problem immediately.  Does that mean that you will be having a lead upgrade soon.  I hope so.  Anyway, sorry I sent you up every path, except the right one. I did wonder why they didn't persevere with the second lead.  Hopefully now it will soon be fixed

 

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