Got a new pacemaker

I had a generator change Oct 11. Before the change my resting heartrate was 73-74. Since the change it is 77-78. The pacemaker base rate, then and now, is 70.

I feel fine at rest. But I am puzzled, because I am pacemaker dependent--the sinus node working less than 1% of the time. Where are the new beats coming from?

When moving around, particularly if I'm standing any length of time, I don't feel so good. I feel weak, nauseated, dizzy, break into a cold sweat. My whole chest feels like it's being compressed. When I can check the pulse it's 136-139.

I do have PSVT, diagnosed a year and a half or two ago, but it never felt so severe as this. I'm on Diltiazem 120 mg. Sometimes I think it helps. Sometimes I don't.

I don't think the new pacemaker is faulty or "causing" the problem, but the timing sure makes me wonder what might be going on.


15 Comments

Sorry to hear this

by Lavender - 2022-11-30 18:39:18

I always enjoy reading your writings but this one made me look up PSVT to understand better. I am sure you're well educated on your own body but for those who like me want to know more:

From a Johns Hopkins site:

A normal heartbeat begins with an electrical impulse from the sinus node, a small area in the heart's right atrium (upper chamber). PSVT occurs because of a short circuit — an abnormal electrical pathway made of heart cells — that allows electricity to speed around in a circle and repeat the signal over and over. As a result, the chambers contract rapidly, which may impair heart function and cause symptoms such as lightheadedness or shortness of breath.

Have they suggested an ablation?

Also from Johns Hopkins:

How is PSVT treated?

Valsalva maneuver: In many patients, the tachycardia episode can be stopped by bearing down or rubbing the carotid artery.

Medications: Different types of medications are available, which vary in frequency, side effects, risks and efficacy. Because PSVT does not resolve on its own, medications would be taken for a lifetime.

Catheter ablation: This outpatient procedure is used to treat or cure many types of heart arrhythmia, including PSVT. Catheter ablation is a mature technique known to be safe and effective. Therefore, it is considered a first-line therapy for PSVT. It is often reasonable to go straight to catheter ablation rather than trying a medication first.

go back

by Tracey_E - 2022-11-30 20:37:53

The difference in heart rate is small enough I don't think they'll worry about it. But symptoms like that with a high rate is a reason to go to the ER. At the very least call your doctor's office and tell them what's happening. 

Maybe they turned rate response on with this one? That would artificially get your rate up when you move around. If you are only pacing ventricle, you don't need it. 

Definition

by AgentX86 - 2022-11-30 22:00:56

It seems that there isn't an agreed definition/difference between SVT, AFL, and AVNRT. Some say that SVT is the same as AFL (re-entrant circuit in the right atrium) perhaps with SVT having a atrial rate of 75-140bpm, where AFL is 200-400bpm. AFL then has an integral divider down to what the ventricles can handle (e.g. 300bpm with a 3:1 ration is 100bpm).  SVT wouldn't have the divisor because its rate is within the AV node's range. There are also differences in the P-wave but these can be hard to tease out.

Others just say that AFL is a type of SVT but Afib isn't. Still others group them, including AF,  in the SVT category.

Another source equates SVT and AVNRT. 

It's hard enough to understand this stuff but if the medical types can't agree on definitions, what chance do we have?

SVT

by Julros - 2022-12-01 01:39:26

SVT is a general term meaning a tachycardia is originating above the ventricles. In addition to atrial flutter, AVNRT, there is also Woffe-Parkinson-White syndrome, Lown–Ganong–Levine syndjrome,  and multifocal tachycardia. They are often identifiable on an EKG. The difference is in the electrical pathways. 

Gotrhythm, if these episodes are sustained, I would check with your doctor. You may need a medication adjustment. 

Yes please go back and get this sorted

by Gemita - 2022-12-01 04:54:24

Dear Gotrhythm,

It worries me to read about your symptoms of weakness, nausea, dizziness, breaking into a cold sweat, chest feeling like it is being compressed, since these are all concerning symptoms which should be assessed urgently if you haven’t already done so?  I am less worried about your resting heart rate (RHR) slight increase post new device since this can be normal with any stress and a device change can be a stressful event for some of us.  

I believe in previous messages, there was the possibility of receiving an upgrade to a CRT device?  A third lead could definitely trigger an increase in your symptoms while your heart is settling and healing from an additional lead fixation.  I certainly had post implant (mainly nocturnal) tachycardia immediately after dual chamber implant which continued for several months.  However if this was a straightforward device change only, then it is less clear what has triggered your worsening symptoms and I wouldn’t necessarily link these with the new device.  In view of your symptoms I would question a possible sudden change in your health as a cause which is why you need assessing properly.  Is Diltiazem a new med?  I wonder whether it is suiting you?  So many unanswered questions.

You specifically ask, “where are the new beats coming from”?  Perhaps I am reading more into this, but I am unclear from your post if your question really relates to (1), (2) or both?

1) the higher heart rate beats associated with an atrial arrhythmia like Paroxysmal Supraventricular Tachycardia?   The location (origins) of an atrial arrhythmia can be difficult to pinpoint and there can be multiple trigger sites across the upper heart chambers as in multi focal atrial tachycardia which is why they usually carry out mapping of our electrical disturbances during an electrophysiology study prior to any ablation.  With AF they focus mainly around the pulmonary vein area.  Of course if the paroxysmal arrhythmia is actually occurring at the time of the EP study, it will be easy for them to see the site of initiation and plan appropriate treatment.

2) On the other hand, are you referring too, to the slight increase in your resting heart rate (RHR) and wondering where these extra beats are coming from when your sinus node is only working at 1%?  I am almost 100% atrially paced too because of Sick Sinus Syndrome (SSS) (and let us not forget, pacemaker settings can change how much our hearts have to work on their own).  My RHR is also constantly changing due to things like autonomic function, stress, illness, effects of medication, effects of pacing, whether I am sleeping or awake.  My RHR can fluctuate between the set rate of 70 bpm either downwards to around 67 bpm or upwards to around 75-78 bpm and this can be so normal for me and does not spell a problem with pacing or my heart.  Remember too that ectopic beats may trigger these slight changes because in the presence of arrhythmia activity, we can expect anything.

Gotrhythm, although an EP study is invasive and not usually done unless they intend to ablate, it can be a first step towards getting some real answers as to the exact location of the problem(s) and whether you have any re-entry tachycardia?  This is what they were trying to establish with me.  But really, please go back and get an early assessment of your increased symptoms first, to make sure that you will remain safe.  As always I send my very best wishes to you and hope that your symptoms  improve quickly.

SVT

by AgentX86 - 2022-12-01 11:40:29

Those are, more or less, the definitions I'd use since "supra" does litterally mean "above" (though AVNRT isn't really above).  However, (some) cardiologists seem to disagree. They seem to want to separate re-entrant arrhythmias from other arrhythmias, so the three are separated into AF, AFL, and SVT(AVNRT).  We've seen this separation in this group, in fact. Lavender linked a Johns Hopkins article that stated the SVT is a re-entrant arrhythmia, as I noted (AFL is also re-entrant) but seems to be slower for some reason.  It's likely because AFL is usually concentrated around the pulmonary , thus a shorter path.  Mine was "atypical" and in the left atrium, which I thought I understood but I'm not so sure now.  Around the arota? Pulmonary vein?

Words mean things but who knows what's happening if the definition of the words isn't agreed upon (much like the rest of the world right now).

 

 

Medication for SVT

by Marybird - 2022-12-01 12:15:28

I'm an old hat when it comes to SVT, having had it on and off for many years. The type was never specified, until an EP I saw several years ago said he thought it was atrial tachycardia, and a couple visits to the ER for uncontrolled tachcardia showed A- flutter. My remote pacemaker reports show pwroxysmal  A-Fib episodes mostly short-lived, on occasion lasting several hours. So I guess I have a multi-talented heart.

The tachycardia is kept pretty well under control with fairly high doses of both metoprolol tartrate and diltiazem ER.  Over the years I have found this combination works better for me in controlling breakthrough tachycardias than either drug alone. I've personally found the beta blocker is much more effective than the diltiazem in controlling the tachycardia ( diltiazem alone doesn't do much for me), but the two drugs working in tandem seem to minimize the breakthrough, though it still occurs at times.

Just a thought, perhaps, if it seems to you and your doctors think medication is the way to go in treating your SVT, perhaps a low dose combination of two medications such as a beta blocker and a calcium channel blocker might be considered. 

Best of luck in solving, or at least mitigating your SVT issues.

Thanks to you all

by Gotrhythm - 2022-12-02 12:38:37

Thanks for all the replies.

Tracey, I too have questioned RR. I've always had and needed it. With old pacemaker we had finally gotten it tuned just right--which was an RR that was the fastest possible. Could it be that my heart is responding much better to this pacemaker, causing the RR to overshoot the programmed rise?

Could the same thing be causing the elevation in resting heart rate?

It wouldn't be the first time my heart has responded in its own eccentric way to being paced.

To those who expressed concern about the dizziness, nausea, etc. I too am bothered by them but so far, the symptoms have gone away within a minute or two of sitting down. Really too fast to even get to the monitor in my bedroom and send a tranmission. I haven't seen the point of going to the ER. We all know that arriving at the ER with no data and no symptoms will only result in a bill.

As always I am so grateful for this group. Having knowledgeable, sympathetic people to sort through questions with is the working definition of support.

transmission

by Tracey_E - 2022-12-02 18:18:41

You can send it after the episode and just tell them what time to look for.

Not copy paste.

by PacedNRunning - 2022-12-06 05:31:46

I have been told that settings are not copy paste. So may need some adjustments there for the RR. Second, the device has to learn you so it may take a couple of weeks to adjust. I was bummed when I found out settings aren't copy and paste. Hopefully it won't take long to get it back to the old device way 

One More question

by PacedNRunning - 2022-12-06 05:39:11

I saw in a previous post. You hit ERI back in June but they didn't replace it until OCT and your dependent? I ask because I've seen others unable to schedule their replacement until it hits ERI. I have 11 mos remaining and my EP told me he will not allow it to get to ERI since I'm dependent. I haven't found anyone that has their replaced before ERI as a routine change. Can you explain how the end process goes? I've had mine since August 2018. 

PacedNRunning

by Tracey_E - 2022-12-06 10:15:53

Insurance won't usually pay for it before ERI. At ERI (elective replacement) you still have about 3 months of full function and insurance will rarely replace it before this. Perhaps you are thinking of EOL/EOS? That's the stage after ERI when it has limited function. There are two stages at the end. 

Those estimates are just that- estimates. I've had it say 6-12 months for almost two years, I've had it say 6-12 months but 2 months later was in ERI (I'm on #5, also dependent). It's just a guess. Usually they will check more often at the end. It gets more accurate as it gets closer to the end and they will always figure in a cushion. 

I've always had my replacement during ERI but before EOS.

Thanks Tracey

by PacedNRunning - 2022-12-07 01:29:16

Thank you for that information! I see my EP in 3 weeks. I wanted to clarify with him because via email he said they routinely replace before ERI. I think he must have misspoke. It is nerve wracking waiting to the end. I just know how miserable it feels without the PM

names

by Tracey_E - 2022-12-09 08:52:07

Some of them call it something else, just clarify that they'll replace while it's still fully functional. And know for your own peace of mind that that is a 3 month window. The first replacement is the most stressful, then you realize it's nowhere near as complicated as you expect 

ERI

by Gotrhythm - 2022-12-12 15:18:49

I was scheduled for replacement before EOS.  Unfortunately, I caught a cold--can't remember the fancy name for it, but the exact virus was identified--the cold caused an asthma flare and I had to be hospitalized 24 hours before the pacemaker replacement. My surgeon decided to postpone the replacement surgery.

That caused about a month delay and the pacemaker was EOS by the time it and I said our final goodbyes. Can't recommend  EOS to anyone, but I'm happy to reassure you all, that even at EOS, the pacemaker doesn't keel over dead as it were. RR was still functioning, and it maintained a resting HR of 65. (My "normal" pacemaker enhanced rate is 70.)

Since I wrote the original post, my resting HR has come down to 75, but I still think the RR is too sensitive. I'm theorizing PacedNRunning is right on both counts. RR isn't exactly what it was, and my heart and pacemaker are taking some time to get used to one another.

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I'm 35 and got my pacemaker a little over a year ago. It definitely is not a burden to me. In fact, I have more energy (which my husband enjoys), can do more things with my kids and have weight because of having the energy.