Pacemaker and AFib

Pacemaker implanted 7 weeks ago, have been in AFib several times, one lasting 32 hours.  12 days ago they " turned on" my pacemaker to assist with Afib, I have a new Medtronic that is to recognize when you are in AFib and take control and bring you out of it.  Within 24 hours I went into AFib for about 4 hours, I felt nothing, but?  Then it hit me again hard on Saturday, HR was over 120 felt some pain in R arm and chest area, so I went to the ER.  They observed hit me with Cardizem which brought rate down to 80's and admitted me.  Nine hours later, my pacemaker must have started trying to get me out of AFib and my heart rate shot up and down like crazy.  Much to the dismay of the EKG staff and my nurse as they were not familiar with this new pacemaker.  Within 40 minutes I was out of AFib, felt so much better, they observed me for another 24 hours and sent me home.  I had time to take a shower and set down to relax with my husband and I went right back into AFib, I was so disappointed.  I tried to tough it out did some breathing exercises, etc.  But again HR went over 110, felt some squeezing in my R arm and chest so back to ER I went.  They gave me NaCl .9%, hit me with Cardizem again, so my rate was staying in the 80 - 105 range and said there was no more they could do but call your Cardiologist in the AM.  So as I sit here waiting to hear back from my Dr.  I am still in AFib and very frustrated.  Originally my Dr. had suggested cardiac ablation but wanted to try Sotalol first, this has been increased 3 times and doesnt seem to be helping?  Has anyone else experienced this?  The last ER visit said I should learn to live with it, others do!  Well, I dont want too!  I feel horrible and cannot function, someone please give me some hope!!  Joyce


What to do about Atrial Fibrillation (AF) ?

by Gemita - 2021-07-06 11:45:24


To hear an ER doctor say “you should learn to live with it, others do” would make me angry too.  That statement is unhelpful, uncaring and serves no useful purpose.  There is a lot that can be done to help with AF, to help ease symptoms, to slow the heart rate, to protect you from an AF related stroke if you have risk factors.  Some treatments like an ablation may even give us a long period of remission or a temporary cure.  

I have had AF for years and I can honestly say that it is well controlled now, with minimum medication.  I have not had an ablation. I was offered Sotalol but declined, choosing Flecainide and Bisoprolol instead.  Sotalol is a dual action medication, both a beta blocker and an anti arrhythmic medication.  It can be powerful and make some of us feel even worse.  It looks to me as though it is not helping you at all, quite the opposite.  I wonder if it would be helpful to ask your doctors if you could stop Sotalol and just stay with Cardizem and your pacemaker to see whether a rate control medication (Cardizem), together with your pacemaker would be better able to keep your symptoms under control?  Sometimes medication for AF can make the episodes more frequent and the heart rate and blood pressure more volatile.  That is what I found.  

My blood pressure and heart rate when in AF can surge and fall very quickly too and this is why we feel so unstable Joyce.  Maybe you should explain to your ER doctor next time what happens to your blood pressure and heart rate and ask him/her how they would cope with such sudden changes.  Would they be prepared “to live with it”?  I doubt it very much.

So what to do?    My advice, stay calm and don’t go rushing into anything.  An ablation is usually the most effective treatment, especially if your AF is becoming more frequent, longer lasting and causing awful symptoms.  However medication, especially rate control medication like a beta blocker or a calcium channel blocker (like Cardizem), is safer to try first, rather than an anti arrhythmic medication like Sotalol or an ablation.  So the choice is yours.  Have you had a discussion with your EP (Electrophysiologist and/or Cardiologist)?  You sound very symptomatic when in AF and finding it difficult to tolerate, so it is important you have that meaningful conversation with your doctors.

Unfortunately a pacemaker is not a cure for AF, although it can be part of a treatment plan for your AF (it is for me and a successful one too).  There are pacemaker programmes and settings that can help us to feel less symptomatic when in AF and it sounds as though you have these set up for you on your pacemaker.  Unfortunately these programmes cannot always help to stop or reverse AF once it starts.  Only medication can help with symptoms and control the heart rate;  or an ablation can help to stop the AF and put you into remission for hopefully a long long time.

Remember a pacemaker can stop a fall in heart rate below the minimum set rate (base rate), but cannot prevent a fast heart rate from occurring.  Seven weeks ago your pacemaker was implanted.  My feeling is that up to three months would be a fair period to assess the success or failure of your pacemaker to make a difference.  It took me at least three months to get over the trauma of having leads attached to my heart.  My heart went crazy for the first three months, hitting me with every rhythm disturbance it could.  I thought I had made a big big mistake getting a pacemaker.  Today I am in a much better place.  I too have a Medtronic.  I am on a small dose of Bisoprolol, a beta blocker and am taking an anticoagulant for stroke protection and that is all.  My minimum heart rate is set at 70bpm day and night and my rhythm disturbances are so much better.  Today I had a pacemaker check and I was surprised to find that my AF is decreasing in duration and episodes.  My pacemaker has been a great success and I hope if you can be patient for a little while longer, it will be the same for you too Joyce.  Please feel free to private message me if you need further support.  Keep your spirits up and good luck.  You will get better with the right care and understanding.

Afib and pacemakers

by AgentX86 - 2021-07-06 15:52:49

Unfortunately, pacemakers are no magic bullet for AF.  Sometimes they can be set up to out-pace AF while the episode is beginning but according to my EP, it wasn't worth even trying (though I have Aflutter, no longer Afib).  The chances of success are low.  Unfortunately, it seems you're normal.

The only real job of a pacemaker is to make the heart go faster, though that can mean faster than zero.  As you know, with AF, the problem isn't  a low heart rate.  However, this effect can be leveraged to eliminate the lowered heart rate effects of rate reduction drugs and antiarrhythmic drugs.  These drugs can then be increased to fignt AF.

Lowering the heart rate and stopping blood clotting are the critical aspects for dealing with AF.  AF, by itself, isn't dangerous.  High heart rates and clotting are. After having dealt with these two factors, makes AF no more than a PITA. 

As I mentioned above, a pacemaker can allow higher dosage of drugs (usually a beta blocker like Metoprolol - anything ending in '-lol') to take care of the high heart rates when in AF, while keeping the heart from going too slow when not in AF.  Anticoagulants, of course, are important to reduce the chances of a stroke but this is needed regardless of the need for a pacemaker.

If one isn't symptomatic, the rest isn't important.  If one is symptomatic, the rest can be very impotant for quality of life.  AF is a progressive "disease" as AF begets AF.  The more often and the longer you're in AF, the more often and longer you'll be in AF in the future, until you're in AF until the heart has to forced into a normal rhythm with a DCCV (electro-cardioversion).  This rarely last for any time, sometimes only minutes and others, rarely even years.  It's always worth a try but rarely succeeds for long.  There are really a handful of solutions, getting progressively more complicated and with higher risks (but with a potential of higher rewards).  Antiarrhythmic drugs can keep AF at bay, sometimes.  The problem is that as AF proceeds, usually higher doses and stronger drugs are needed to combat it.  All of these drugs are toxic and the higher you move up the chain, the more toxic they are. 

The second possible treatment is an ablation.  This is a minor surgical procedure, less involved than a pacemaker implant, where they go in through the veins, much the same way they did with your leads when they were implanted.  A catheter with a hot or very cold probe is used toband burn dams or maybe "fire breaks" are a better analog, in the heart muscle to break AF's electrical paths.  These procedures aren't always successful and often take two or three times to get all the paths blocked.  A highly traned surgeon is critical for this procedure.  The success rate  between "the best" and "also ran" is huge. The "ablationist" needs to do hundreds of these procedures a year and thousands during is career to be in the upper category.

There are a variety of these ablation procedures beyond the basic ablation, above  Each is more invasive and has higher risk. One variation, multiple small incisions are made in the chest to access the heart and burn the leasion are made from outside the heart (known as a min-maze). 

A way-more invasive treatment is know as the "Cox maze", where instead of cutting small holes in the chest to access the heart, they crack the chest open and do the job on the full heart.  Of course, this is very invasive and is never done unless open hesrt surgery is done for another reason (e.g. coronary bypass).

The final alternative, and almost always successful, is an A/V ablation, where the atria and ventricles are electrically separated and the atria allowed to fibrillate, while the pacemaker takes over the job of pacing the ventricals without help from the atria.  This has very serious and lasting consequences and is only conisdered as a last step, to be done after everything else fails and the symptoms of AF are still intollerable.

All of this takes a specialist to manage AF.  You're way past the care of a cardiologist now.  You really need the services of someone highly trained in electrical issues of the heart.  This sub-specialist if cardiology is "electrophysiology".  You need an electrophysiologis (EP) now. Your cardiologist may, or not, be still necessary but you need an EP, now,

Afib is tricky

by Theknotguy - 2021-07-06 18:54:32

What you are describing is similar to what I had at the first.  I went into afib with RVR shortly after I got my pacemaker.  For  lack of a better term my heart didn't like being ordered around by the pacemaker and decided to throw a temper tantrum.  Had  a trip to the ER and got Cardizem.  (Diltiazem) Which did help in the short term.  I think it was nine months before they got  my afib under some control.  What helped?
  People who have never had afib will say things like, "Learn to live with it."  Yeah, that really works.  It's like sticking your  finger into an electrical socket and wondering when you'll get shocked.  Not a good feeling.  
 What worked for me.:
 1) increased medication at first.  If sotalol isn't working (it didn't for me), go for another kind such as Metoprolol.  You'll have to  discuss with your EP as to what he thinks is best for you.   
 2) If you go into afib at home, ask your EP if you can increase medication at home and what are the upper limits.  I have a  standard set of medication I can take at home plus a time table.  So I can treat myself at home before yelling for help.  A lot  less expensive than going to the ER via ambulance.  Then when I do yell for help I know it's the real deal.  
 3) Ask EP if you can take over-the-counter magnesium and if he's heard about it.  It shouldn't hurt, but I'm not a doctor and don't know what may help or hurt.  It worked for me and I stopped having those knock-you-down afib sessions.  
 4) Ask your EP if a Medtronic manufacturer's rep would be helpful in your situation.  They have some resources the typical  pacemaker tech doesn't have.  
 5) Realize that even under the best of times, and with the best of results, this could take months or perhaps even a year to  figure out.  I think it was nine months for me.  And during that time what I told you last week wouldn't be true this week and  wouldn't be true next week.  
I think it was 90 days before they did any changes so you're ahead of the curve in that respect.   I know it's rough but hang in there.  


by AgentX86 - 2021-07-08 19:17:44

"People who have never had afib will say things like, "Learn to live with it."  Yeah, that really works.  It's like sticking your  finger into an electrical socket and wondering when you'll get shocked.  Not a good feeling."

Many people have Afib and never know it (until they stroke out).  I know people who are completely asymptomatic, who wouldn't remember that they had AF,  if they didn't have to take an anticoagulant and beta-blocker. 

However, for the rest of us, I'd break their nose and tell them to "learn to live with it".  ;-)

(all good advice)

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