2023 updates - best pacemakers for cycling?

nothing new

by Tracey_E - 2023-01-11 12:30:55

You've probably got the best one. St Jude/Abbott and Medtronic still only use accelerometers. Boston Scientific has one that uses minute ventilation, so it uses our breathing in addition to motion. CLS is generally considered the best choice. 

I don't use CLS but have heard that it takes someone skilled to get it programmed correctly, and that there is a period where the CLS has to learn you. 

Biking with a pacemaker

by Navpilot - 2023-01-11 12:44:46

DLBDATA,

Great question.  I just had my Medtronic CRT Pacemaker installed in Nov 2022 as I suffer from the same issues as you.  I am a road biker and have been riding in access of 11,000 miles per year for the last 8 years.  I look forward to riding again starting on Jan 16, 2023 after a two month layoff.  My concern is that Rate Responsive Pacing will not be responsive enough to adjust to the rapid changes in physical biking demands associated with hills and wind direction.  Is there anyone out there who has lessons learned on this issue or am I getting the "half backs out in front of the blockers."  Two years ago...I rode the 440 mile Natchez Trace while taking a Beta Blocker.  I really don't want to experience anything like that again.  Not fun.

Re: nothing new

by dlbdata - 2023-01-11 13:15:14

Tracey_E they had me using CLS for about 9 months, and several visits to adjust the settings.  But anything they did really didn't help. Often on a easy to moderate intensity ride my HR would behave fairly normally for say 30 minutes.  Then for no reason HR would go up to max pacing limit and just stay there, regardless what I was doing.  I could be coasting downhill for a minute and it would just stay there or maybe drop a little, but as soon as I started pedaling even easy it would flatline at the max again.  Sometimes it would feel OK when it was doing that, but other times it would feel really uncomfortable, I would feel fluttering. They had cranked the sensitivity down to the minimum, but it didn't seem to help either. A Biotronik tech was there one or twice also making recommendations. I've talked to a couple other cyclists in a Facebook Cardiac Athletes group, and they experienced similar issues and disabled CLS.  I was hoping maybe their was a better option.  Might have to start overand see if the new Pacemaker/EP doc has any ideas.

Re: Biking with a pacemaker

by dlbdata - 2023-01-11 13:26:16

Navpilot I'm stuck taking flecainide now as I developed paroxysmal AFib several months after getting the pacemaker and ablation. So it's like they gave me the pacemaker to help bring my HR up when exercising, but the flecainide does the opposite, suppressing my HR. And the problems with CLS, haven't helped.  I've mostly settled into more low/medium intensity endurance riding. I'm curious to find out with the CLS disabled is it just my natural HR ryhthm pacing me when I'm exercising, because I kind of feel the way I felt before getting the pacemaker.  The pacemaker has helped with regular daily activities though my base rate is programmed at 55bpm, before I was having serious problems sleeping at night.pulse in the 20's.

At the risk of sounding like a broken record....

by crustyg - 2023-01-11 13:53:07

...or a shill for the vendor (which I'm not), I have found the MV of BostonSci's family of PMs to work well for road cycling for SSS+CI.  It *MUST* be tuned for you (that can be a battle), and it has some weaknesses (which I think I know how to work around), but in my experience it's easy to understand and tune, and reproducible in results.

Some other contributors here have changed to BostonSci for road cycling and report good results.  Not all, and I think I know why.

Best wishes.

Re: At the risk of sounding like a broken record

by dlbdata - 2023-01-11 16:57:34

crustyg - Just from reading discussion on here I have seen some people mention the Boston Scientific worked well for them when exercising. When I discussed getting a pacemaker with the EP and told him I was a cyclist, he said he recommended the Biotronik because cyclists aren't moving around much, and that the CLS would work best. I had pericarditis/preicardial window surgery and lung injury ~ 3years ago, and my breathing still isn't right from that, so not sure how much of a factor that is in all this.

Would you mind sharing your theory about why the Boston Scientific doesn't work for some people?

Here goes

by crustyg - 2023-01-11 17:29:46

It's taken me a while (far too long) to understand this.  Minute Ventilation measures both breathing rate and breathing depth, multiplies them together and =>Minute Ventilation.  But because folk move around (flying being the biggest factor, where effective altitude in cruise is equivalent to about 9000 feet) you can't just calibrate MV at rest and go from there.  Flying, or going skiing, sight-seeing up a mountain would result in a significant and sustained increase in HR even at complete rest.

So, MV as it feeds into Rate Response is the difference between a long-term MV baseline and a short-term MV average.  Only this *difference* feeds into MV => RR.  Current firmware for BostonSci MV locks (stops updating) the long-term baseline only when HR is above 90BPM (leave aside the crazy Endurance setting which is completely wrong).

Seems good?  Well, no.  Imagine, you have SSS+CI.  Your resting HR is 50BPM. You start to exercise, and eventually your breathing increases (muscles demand oxygen etc.), and as long as you're below 90BPM the long-term MV baseline is slowly increasing.  Not much, but enough.  What gets your HR >90BPM: answer, the RR in your PM.  BUT, the only thing driving RR is MV, as your upper body doesn't move much on a road bike.  If you set off slowly (as your HR is low) your HR increases slowly - in fact your actual breathing (rate+depth) increases quite quickly as your muscles aren't getting the oxygenated blood that they need, as your HR is too low.  See the problem?  Any road cyclist setting off quite slowly or in a peloton is going to raise the long-term MV baseline quite a lot before HR finally reaches 90BPM and NOW long-term baseline is locked and any extra MV produces a larger and larger feed into RR => HR finally starts to clock up to 120+ but may not go much higher due to the small difference between long-term baseline (now much higher than usual long-term MV baseline when at home) and short-term MV average.

Solution - in two parts: a) don't try to ease into the cycling, make a bit of an effort and go for it as much as feels sensible (and yes, I do know how unpleasant it is to push such big muscles into the red while HR catches up), b) set MV sensitivity high, so that even small increases in delta-MV produce large increases in HR and then set a sensible Vent Threshold where the HR response to the MV feed is sharply reduced - perhaps only 65% or 70% of initial gradient.  So nearly max MV sensitivity to get HR above the magic 90BPM and then a much shallower rate of HR increase as MV continues to rise.

Net result: cyclist sets off, fairly energetically, MV responds quite quickly, HR goes from 50BPM to 95BPM or so (locks long-term MV baseline) and quickly reaches vent threshold (typically 120BPM) and now HR climbs to 130BPM or so whilst cycling in a peloton, and drops to 100-120BPM at other times (long-term MV baseline still locked) and when the big hills are reached, MV drives HR up to maxHR (perhaps 155-165BPM) - and all is well.

For those for whom BostonSci MV seems not to produce a proper RR when road cycling, I suspect that a) they set off much too slowly for far too long, b) their MV sensitivity is set much too low and the Vent Threshold isn't set to reduce MV feed into RR once they've working a bit harder.  For anyone with a reduced lung capacity use a higher MV sensitivity and a lower Vent Response above Vent Threshold.  You don't need the lungs of a professional athlete for MV to work correctly.  In any case MV isn't measuring real lung ventilation (as you would in a lung-function test lab - FEV1/FVC etc.), it measures the change in chest impedance during the breathing cycle and does some very clever filtering to remove the changes in chest impedance from blood flow, heart beats etc.  The absolute change in chest impedance  == depth of breath, and the rate of change of chest impedance == breathing rate.

The EP-techs that I see mentioned that they have heard good things about CLS for road cyclists with SSS+CI, *but* it's become clear (to me) that CLS can be very tricky to tune.  IMHO, MV is simpler to understand and is more reliable, producing reproducible results.

Make sense?

Re: Here goes

by dlbdata - 2023-01-11 18:29:33

crustyg - thanks for that very detailed explanation. I think I get it.  It sure would be nice to have an EP actually monitor us while we are exercising and see how things are working (or not). CLS tricky...sometimes seemed like OK lets try changing this and see what happens. Then go home try it and come back again, repeat. Not real easy to do if the doc isn't local.

I guess I'll have to see if the new pacemaker doc has any ideas to tune what I've got now.  Hoping somebody on here with a Biotronik had something to share that worked for them.  Thanks for all the info you shared.

Anti arrhythmic med Flecainide

by Gemita - 2023-01-11 21:52:40

dlbdata:  I am glad you are receiving helpful feedback.  I just wanted to say, remember too that in the presence of an arrhythmia like AFib and while on anti arrhythmic or rate control medication, you can expect additional difficulties getting those settings adjusted to suit you.  Also, you have had a lot going on and your past medical history of pericarditis/pericardial window procedure is bound to have taken its toll.  

I think you are doing incredibly well to be thinking of pushing yourself to your limits while on Flecainide and with episodes of paroxysmal AFib.  I hope that once your chest problems have improved, you will notice an improvement in your AF symptoms and frequency of any episodes too.  Any acute or chronic illness may increase the chances of worsening AF, requiring more medication and then perhaps more settings changes.   I would work with a cardiopulmonary physiotherapist to learn how best to manage your symptoms “safely” if you are not already doing so?

I was on Flecainide for AFib for several years.  It helped in the beginning but it eventually became pro arrhythmic and I developed Atrial Flutter mainly because I wasn’t on a rate control medication at the same time which would have effectively slowed conduction through the AV Node to prevent the ventricles from contracting too quickly.  Completely my fault, since I was struggling with low blood pressure, so didn’t take my low dose beta blocker as prescribed.  Now only taking low dose beta blocker Bisoprolol and doing so much better arrhythmia wise.  I hope for the very best for you too

RE: Anti arrhythmic med Flecainide

by dlbdata - 2023-01-12 16:07:15

Gemita, thanks for sharing your experience with flecainide. I've been reading more about it and possible side effects, and really don't like the sound of it. It seems like even after months of taking it, it continues to keep driving my HR lower and lower.  But I don't really like the idea of getting another ablation either. When I got the pacemaker I was also ablated for atrial flutter and AV node slow pathway. The AFib started a few months after the procedures when exercising.

I didn't even think about a cardiopulmanary PT, might have to consider that.

I'd probably have the same problem with beta blockers, I have low BP and also Raynauds (cold hands). 

Thanks again, best to you also!

Now a Beta Blocker

by Navpilot - 2023-01-13 18:19:32

dlbdata, all,

After 4 weeks of great results from my Metronic MRI Surescan CRT, I started finding some irregular rythems in heart beat.  I contacted the on call EP and they relayed it was ok and not to worry.  I started doing some research on the issue and called Metronic.  They recommended that we provide the EP a pushed Pacemaker Analysis through my phone app.  We did that on Jan 3.  By Jan 4 the irregular rythems subsided and the pacemaker has been working normally for 8 days now.  Upon review...I think I messed it up by using a Gas Powered Backpack Leaf Blower.  Not providing the normal distance from the ignition source and pacemaker.  Yesterday I received a email from my EP's PA stating the the EP recommends that I go on a Beta Blocker and he provided the perscription.  As  stated in my previous email.  I intend to start riding bikes again on Monday and have my first Pacemaker Check on Tuesday.  I would perfer to wait to start the Beta Blocker, if required,  after another Pacemaker Analysis that I assume I will receive on Tuesday and probably will show that all is ok...if my assumption about the leaf blower is correct.   I relayed this back via email to the EP but have not heard back as of this date.  I am still walking around 4 miles per day with great rythem and response.  I really do not want to go on the Beta Blocker at the same time that we may be adjusting the PM due to my riding....especially if it is not necessary because I inadvertantly caused a bad PM Analysis due to being stupid and using that leaf blower.  Any advise out there...something that I need to consider.

RE: Now a Beta Blocker

by dlbdata - 2023-01-13 20:04:52

NavPilot,

I've never been on beta blockers. Most if not all of my AFib episodes were when I was exercising, and they started me on flecainide which seems to have elimnated the AFib episodes.  But it really suppresses my HR. I can understand you not wanting to introduce other variables (drugs) while trying to get the pacemaker tuned. I don't know but wouldn't a small engine interfere with the pacemaker, then if it was moved away from the pacemaker, the pacemaker would return to normal?  Your EP would know how serious (or not) the arrythmia was so I would discuss it with them and whether the leaf blower backpack could have caused the issue.

Good luck, I know you must be anxious to get on the bike!

Now a Beta Blocker

by Navpilot - 2023-01-14 09:44:17

dlbdata...Thanks.  I received a note from my EP late yesterday.  The Pacemaker Analysis that he reviewed revealed Nonsustained Ventricular Tachycardia.  He went back all the way and reviewed my PM from the day after installation and saw short periods of that arrthythmia going back to Nov 22 which was the day after the installation procedure.  I guess I will do as he recommends and take the BB.  I just remember being on a Beta Blocker before years ago and trying to do the 440 mile Natchez Trace Ride. The BB seemed to have my heart set on a 110 bpm governor and some of those hills up in Northern Ala and Tennessee...need at least 140 bpm to get over the top.  Made for a really tough week of biking. Sounds like I will have to do as you ... low intensity and slower endurance rides.  Will let you know how things progress after I start riding and my first PM check.

Steve triathlete

by stevebne - 2023-01-15 21:10:14

In my experience,  the problem is the pacemaker is not a replacement of normal heart function but a tool to keep you alive and well. The exercise algorhythms are a series of compromises and are not as sophisticated as a normal heart response, especially if you are exercising beyond the minimum. Running works best, cycling (esp stationary cycling) is so so and swimming is poor.

For me personally, the biggest problem is the resetting of the baseline that occurs during exercise that limits the HR response as time progreses. As CrustyG explains, the baseline changes over time depending on the sensors input.  For example, in triathlons, the baseline seems to reset in in transition between sports and so when I head out on the run my HR response is always low for the first 10+ minutes  before it realises I am still exercising!   Very annoying but not really fixable, Note that I have the BS PM set on endurance where in theory. the baseline does not reset for 4 hours, yet this problem occurs every time,

In the end, I am just getting used to the limitations!  

:)

Now a beta blocker / Steve Triathlete

by dlbdata - 2023-01-16 04:12:24

NavPilot / stevebne

Ugh... I just type in a long reply and website lost it.

It sounds like beta blocker has a similar effect to flecainide.  I now have such a narrow HR range between easy and hard efforts. I'm also learning to work within the limitations and compromises of the pacemaker. Similar to before the pacemaker, the more gradually I ramp and work into an effort, the better it feels. And starting up again for a 2nd ride in a day after a break, is tougher than the first ride, it takes a while to feel like I'm breathing comfortably. Cardiologist told me the same thing, that exercising with my pacemaker is not as effective or efficient as with a normal heart rhythm. But it definitely helps with regular daily functions, which is really important!