Prostate Cancer and Pacemakers

I have had lone Afib since mid-2006, diagnosed with an old Holter monitor. Send data via telephone. I was put on metoprolol 50 mg and coumadin. Thus, when I needed meds for the Prostate Cancer (PCa) my oncologist looked for heart friendly ones. Note that I am now 83. When I took up biking again, in 2011, I noticed that hill climbing was problematic. My cardiologist agreed to cut the 50mg metoprolol to 25mg for the summer, when I was biking outside. That made a huge difference in climbing ability.

 I have had prostate cancer (PCa) since 2014. I did things like Focal Laser Ablations (FLAs) (Google it) and had MRIs to see what was going on. Finally had an Axumin scan and a full body bone scan. That found a few mets on left hip as well as prostate. I was put on 2 months of Androgen Deprivation Therapy (ADT) with Firmagon (Degarelix) an antagonist-more heart friendly, and abiraterone (Zytiga) and prednisone, and then some radiation and then ongoing ADT. Went from Firmagon-injection, to Orgovyx (Relugolix)-a pill. Continued abiraterone. A few months ago, I was taken off the Orgovyx and continued abiraterone. All these meds kept my PSA unmeasurable and my testosterone at  <7ng/dL.

As stated above, we looked for a heart friendly med, since I have been lone AFIB for years.

The downside of ADT is low T and associated loss of strength. My biking speed has dropped from 15+ mph to 10 or so. I finally succumbed and bought an Ebike.

On top of this I had a couple of syncopes. Gentle falls backward so no damage. Both followed by CT head scan since I have been on thinners since the lone AFIB. Lone AFIB became not so lone and almost continuous. My EP did a very thorough ablation and that fixed things for a while. I continued to complain of weakness and finally an echo stress test on a treadmill was ordered. I flunked due to chronotropic incompetence. EP said I was due for a pacemaker(PM). Pacemaker was inserted on Nov. 28, 2022, and now it is a matter of tweaking it for me. In a couple of weeks, I will have a bicycle stress test, with all kinds of technical folks around to tune the PM, including a rep from Boston Scientific(BS), For biking, the accelerometer is not all that useful, and the RightRate Minute Ventilation feature must be tweaked. My PM is a BS Accolade MRI L331.

I wanted an MRI resistant PM because many diagnoses of PCa are done using MRIs.

So, I think PCa and pacemakers can play well together.


9 Comments

Prostate cancer and pacemaker patients

by Gemita - 2022-12-26 17:47:35

Hello RMarkley,

Thank you for posting such a helpful message about prostate cancer and how pacemaker patients may be affected by treatments.

At my husband’s (now 84) last consultation with his urologist for stricture disease, he was found to have a very large prostate but this was not causing any obstruction or flow problems, so they are leaving well alone.   I recall the consultant mentioned that most men over 80 will probably have prostate cancer but that it is usually very slow growing and the patient is more likely to die from other causes like heart disease well before they succumb to their prostate cancer.  It wasn't particularly reassuring but I understood that treating prostate cancer when a patient has multiple health conditions can be extremely difficult and affect quality of life.

We share a common pest, Atrial Fibrillation (AF).  Fortunately mine has remained intermittent (since 2014) and has not really progressed, although I can still experience more frequent, longer lasting episodes.   I was offered an AV Node or regular pulmonary vein isolation ablation but I declined, choosing instead my pacemaker for syncope, pausing, sick sinus syndrome.  My husband also has a Medtronic pacemaker, single lead to right ventricle and also has AF.  We both take Bisoprolol as a rate control med although many here are on Metoprolol.  Yes beta blockers can slow us right down and make exercise extremely difficult.  It is all about finding the right dose and medication to suit.  Mind you, AF is probably the cause of my difficulties with exercise.  

I really wish you all the best in getting your settings finely tuned for you and hope that your exercise capacity will improve from any adjustments.  I cannot help you with your settings, but we do have some members with Boston Scientific pacemakers who will be able to give good advice.  Please take care and I hope you will continue to do well and that your doctors will carefully monitor your bloods to make sure that your hormone levels are within a reasonable range for your well being, strength, quality of life and particularly heart health.    

pacemaker and syncope

by rmarkley - 2022-12-26 17:58:32

Hi Gemita, Your statement:  " I was offered an AV Node or regular pulmonary vein isolation ablation but I declined, choosing instead my pacemaker for syncope, pausing, sick sinus syndrome."

My EP and from what I have read indicate that pacemakers cannot stop syncope. I have had 2 syncopes, and would like that to be true. Here in Maine, a syncope costs you your drivers license for 6 months. (Not really unreasonable). I just got my license back. Both times, I ended up in a hospital with an IV for rehydration. Since then, I have forced fluids.

I don't understand your comment. References would be really helpful. I need education on this subject.

pacemaker and syncope

by Gemita - 2022-12-26 18:56:29

Hello RMarkley,

We can continue this conversation tomorrow if you wish since it is getting late over here in the UK, but I just wanted to respond briefly because this is such an important point you make.  I totally agree, certain causes of syncope may not always be helped by a pacemaker.

I had extensive monitoring (Reveal Linq implant monitor) for over 3 years and it is one of the best monitors out there I believe to detect syncope and correlate it to a particular event, so that any treatment offered is appropriate and likely to succeed.

I was found to have predominantly bradycardia induced arrhythmias.  I was also found to have frequent episodes of AF and other atrial tachyarrhythmias with a rapid ventricular response rate.  I also had long pauses at the end of my AF episodes as I returned to normal sinus rhythm.  I was found to have tachycardia and bradycardia syndrome (part of Sick Sinus Syndrome) and all these conditions have been helped immensely by my dual chamber pacemaker set at a higher lower rate limit of 70 bpm.

What hasn’t been helped completely, however, is my condition called swallow syncope (a vaso vagal problem) which is intermittently caused by my high pressure oesophageal motility problems.  This condition can also trigger my arrhythmias, but on the whole I am in a much better place now and at worst only get pre-syncope spells since my pacemaker implant.  Does that help a little?

syncope

by rmarkley - 2022-12-26 21:04:30

Hello Gemita

I had a Medtronics loop recorder implanted as part of my Afib ablation. It was implanted after my 2 syncope events, and never recorded anything unusual. It was removed when I had my pacemaker implanted.

Pacemakers can help some forms of syncope, but they do no appear to be very useful for vasovegal syncope. I do not know what type of syncopes I had, but my EP did not think my pacemaker would help. I, instead, try to keep well hydrated.

Long term monitoring is essential to answer your questions

by Gemita - 2022-12-27 05:26:38

RMarkley,

I note you had a Medtronic loop recorder implanted at the time of your AFib ablation in June 2022 but this was removed at the time of your pacemaker implant in November 2022.   What a missed opportunity to keep such a valuable recorder implanted to monitor your heart long term.  I believe you also had a ZIO-AT wearable patch monitor placed for 30 days after two syncope episodes occurred.  

With respect I believe the implant monitor should ideally have been left in place for its entire battery life (3-4 years) for patients with a history of syncope.  This is what my EP and other doctors recommended at the time of my pacemaker implant in 2018, because of the superior ability of the Reveal Linq monitor (superior to that of my pacemaker) to detect, store and diagnose the cause for syncopal events over a long period and to better monitor the results of any meds or other treatments we may be on. 

The Reveal Linq is safe in MRI environments when certain conditions have been met.  Shorter term monitoring may miss an important cause for an intermittent syncope episode occurring say every 6 months or even once a year.  Since they did not capture anything, I am assuming you did not experience a syncope event while wearing either the ZIO-AT patch for 30 days or during the period the implanted Medtronic Reveal Linq recorder was in place.  This is not at all unusual if syncope infrequently occurs.

Looking at your prostate cancer meds, I am wondering if they may “rarely” be causing acute arrhythmia disturbances/events like long QT and non sustained torsade de pointes or other non sustained ventricular arrhythmias or are causing/have caused severe electrolyte imbalances which of course cannot be corrected or helped with a simple pacemaker alone.   

I believe it is important for you to have long term monitoring to get to the bottom of your intermittent syncope events, particularly “if these continue”, since management of your symptoms will depend/rely on getting a proper diagnosis.  In your shoes I might be asking for my implanted monitor back since it was only in place from June to November. By the way my husband has collapsed due to severe electrolyte imbalances which were corrected with IV fluids and magnesium/potassium supplements.  May be you need more careful monitoring in all areas with your continuing cancer treatments?

Keeping any arrhythmia under control will make such a difference to your capacity to exercise.  When I am in an arrhythmia like AF, my heart is clearly unable to effectively pump blood around my body due to the irregularity of rhythm and volatile blood pressure and heart rates AF can cause.  I struggle to exercise in the presence of an arrhythmia like AF or for that matter, even during prolonged ectopic beats.  

Good luck with your settings adjustments and I sincerely hope they help.   You sound very determined to do well and I am sure you will succeed.  Keeping hydrated is an excellent plan for us all 

exercise with Afib and electrolytes

by rmarkley - 2022-12-27 10:49:22

Gemita

Your depth of knowledge indicates that you have medical training?

I had the Zio-AT attached 5 days after my first syncope-on Jan. 15,2022. I used 2 30 day Zio attachments, with Zio-AT ending on Feb. 17, 2022. My second syncope was on May 20, 2022. The Zio's detected nothing of interest. No AFIB. Some SVE/PACs and some VE/PVCs. My continuous AFIB really started after my second syncope.

Whenever I exercise, I always drink a electrolyte. I used to use Gatorade, but changed to Nuun to control the amount of sugar I was ingesting. My potassium and magnesium are monitored by my PCa oncologist and are OK.

I rode my ebike all summer while in AFIB, including some metric century rides. Part of the reason my power was lower than previous years was due to the PCa meds reducing my testosterone level to <7. The only PCa med I am on now is the abiraterone-250mg and prednisone 5 mg. To relax my bladder neck somI can pee more easily, I take Flomax 0.4mg and cialis 5mg once daily. The Flomax tends to mess with blood pressure.

We will see if the EP and his troops can get my PM working so I have a higher energy level-keep my heart rate up while biking-in 130 or so range.

I am not a doctor but I enjoy caring for others

by Gemita - 2022-12-27 19:46:00

Oh what a compliment, thank you.  No, no medical background here at all, just personal experience living with complex health issues and having to learn quickly how best to effectively manage them. I sometimes read research papers so that is where my knowledge comes from and of course being a member of this Club helps me to become an effective communicator with my doctors.

I think you are doing amazingly well with your current meds and with the treatments you have received so far. I cannot imagine cycling while in AF but perhaps your heart rate is slower.  You seem to be well in control and no doubt you will explain to your EP just where you want to go with exercise. I wouldn’t try to change too much too quickly and just like with our meds, it will be trial and error until you find the right settings to suit your needs. 

I see you have bumped up your post asking for advice on settings.  Good move and hope you receive the help in time for your appointment.

biking with Afib

by rmarkley - 2022-12-27 21:24:52

Gemita

My afib pulse rate was in the 80 -90 bpm range. I just felt a bit weak, is all.

80 -90 bpm range

by AgentX86 - 2022-12-27 23:19:37

Mine too.  Sucks eggs.  My flutter is 240-300bpm but the ventricular rate was also around 90.  I knew when I was in flutter because my rate instantly went from 50ish to 90ish. It took a while before my doctors believed me when I told them when I'd gone into AFL. They kept looking at the EKG.  I didn't need no steenkin' EKG.

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I wouldn't be alive if it wasn't for pacemakers. I've had mine for 35+ years. I was fainting all of the time and had flat-lined also. I feel very blessed to live in this time of technology.