quarterly remote transmission results June 20,2023

Food/supplement correlation

by AgentX86 - 2023-06-21 22:52:19

Be careful attaching a lot of significance to food and arrhythmia correlations, particularly over just a few periods, even over three months.  Humans tend to make correlations where none exist.  Food/arrhythmia correlations are suspect. There are so many variables, in addition to the fact that arrhythmias are chaotic, that it would be very hard to show any causation.

Agree with post above

by Penguin - 2023-06-22 04:39:46

NewtoPace, 

I've followed your journey with supplements and food sensitivity and am very sympathetic to the problems you face. However, I tend to agree with AgentX on this one. There may be variables / causes that are not on your radar because your focus is on supplements and sensitivity reactions.  It's all too easy to make the thing that has troubled you the most (in your case food / chemical sensitivity) the sole focus when seeking explanations / causation. I've done it myself! Keeping an open mind as to other causes - including settings - may be helpful. 

Having said that I'm not discrediting your reactions as one of the plausible causes. 

Re: Event Log - your device may be set up so that events have to meet programmed criteria before they are entered into the log. E.g. Events of a certain length or type. ECG evidence is usually subject to similar criteria for the simple reason that tt wouldn't be possible to event log and provide ECGs for 1744 Atrial High Rate Episodes. 

Re: Mode Switching - You say that your PM is programmed to AAI->DDD.  This setting allows the device to mode switch from atrial pacing (AAI) -> DDD or a non tracking mode when it detects atrial arrhythmia. Devices usually provide a count of the amount of mode switches, so the interrogation should show the number of mode switches.  You don't mention any in your post? **EDIT

This statistic would give you some idea of how many episodes are being detected and dealt with via this setting if this is the main way that your device deals with your arrhythmia. 

**EDIT: Re: Gemita's correction below, I now see that you say, 'There was a 17.9% switched cumulative atrial arrhythmia burden,11.1% last quarter.'

My mistake - I missed that! Apologies

I hope this is helpful. 

Just a few thoughts

by Gemita - 2023-06-22 06:27:15

Hello new to pace, thank you so much for your “extensive” update which as an arrhythmia sufferer is of immense interest and help to me. 

I can see that your atrial high rate episodes detected (mode switches) have increased since the last quarter from 841 to 1744 episodes although the episodes still appear in the main to be of short duration, with only three greater than 1 hour duration.  Episodes often seem to happen when at rest, so they would seem to be often vagally mediated (another subject for another time).  Have you been checked for sleep apnea new to pace?   The fact that you got a little dizzy as you hit your pillow on occasions might be significant and I am surprised that you were not contacted, or that you didn’t report these episodes at the time.  This tells me that you are able to tolerate any high atrial rate episodes very well indeed, something initially that I couldn’t do.

I believe it is important that you continue to try to identify your arrhythmia triggers since I know how important this is for you and for many other members too, including myself.  Sometimes though correlating a sudden onset arrhythmia to a particular event, diet, lifestyle, activity, stress, health condition, inflammation, infection is complex and to pinpoint its exact trigger when so many potential triggers may coexist, is going to be difficult.  But we have to keep going, to keep learning, to keep trying to help ourselves reduce our arrhythmia burden don’t we?  I don’t think our doctors have all the answers either.

You ask why certain arrhythmias have been flagged and others not.  Episodes of arrhythmias will only be stored when they are of significance (like in either duration of an episode, high atrial/ventricular rates, arrhythmia type like non sustained VT or a very rapid atrial arrhythmia like AF, Flutter).  Minor in and out episodes, so numerous, would not be stored since there is limited space to store episodes on pacemaker intra cardiac ECGs.  Even significant arrhythmias will not be stored for the full duration of an episode.  

I believe your number of mode switches has also been given/shown as a “% cumulative switched atrial arrhythmia burden”.   I see it has increased since last quarter from 11.1% to 17.9% and that you had one 12 beat run of non sustained VT.  I see you have a high percentage of pacing in the right ventricle at 73.7% with a lower pacing % in the right atrium although you are in AAIR<=>DDDR pacing mode.  I would want an explanation for this.  For example, could it mean that your heart condition has changed and you need more ventricular support, hence your higher % pacing in the ventricles or is the higher ventricular pacing due entirely to your arrhythmia burden and mode switch activity?  I would want to know if your current AAIR<=>DDDR mode and settings are appropriate for you or whether your settings might benefit from an adjustment to enable a higher % pacing in the right atrium to see if this might help reduce your total arrhythmia burden?  Although I have a similar mode switch/arrhythmia burden to yours I am paced almost 100% in the right atrium and less than 5% in the right ventricle.  I am also in AAIR<=>DDDR mode (although Rate Response is currently turned off).

So new to pace, a few other thoughts for your discussion with your doctor as well as the cause for your raised CRP levels and whether the source for this needs further investigation?  Thank you again for allowing us to see your extensive records.  That is how we all learn

update

by new to pace.... - 2023-06-22 08:29:04

Thanks  AgentX86, Penguin and Gemita for your thoughts and what questions  I might ask in August.  One good thing not mentioned on this report is no Flutter.

I have been wondering if some of my problem now is that have been told that my OsteoArthiritis is showing up in different areas. Now have it in my left elbow.    Last night i started another supplement to help lubricate the joints, tendons  and ligaments.  Slept the whole night which have not been doing.  Have taken this one before i had the pacemaker and it really helped me to move better.

  I did not add these columns below:                                                             under "in the current programing"                                                                              RA                                     RV                                                            Voltage:  1.50                           Voltage   2.00                                            Pulse width (ms)0.40                 Pulse width (ms)0.40                                 sensitivity:0.30                            Sensitivity  0.90                                                 Then in another space  on the report the following information:

       RA                                                  RV                                                  Amplitude (mV)   1.9                        Amplitude (mV)   5.9                            Impedance(ohms)  5.13                 Impedance (ohms) 513                          Pacing Threshold (V)0.625            Pacing Threshold(V)  0.750                Pulse Width (ms)  0.30                  Pulse Width (ms)0.40     

 A good thing this morning i learned after nearly 4 years of being on this site. How not to start a new paragraph when writing in a column.  That said hard to beleive the pacemaker and i have been together this long.

new to pace

Thank you for the additional data

by Gemita - 2023-06-22 14:46:54

Hello new to pace,

I have read with interest your .pdf’s that were sent by email, much of the data you have also included in this thread.  I have compared some of your Medtronic parameter settings with mine, as well as your % time in AF.  There are some considerable differences and I am still studying these.

From what I can see you have no “Therapies” switched “On” other than Mode Switch which could help with your arrhythmia episodes.  See under Parameter Summary “Therapies” where it states:  All Rx Off.  Perhaps you could ask whether you have Atrial Preference Pacing and if so, whether this could be turned On to see if it helps with your arrhythmias?  It is very helpful for me.

Although we have a similar number of high Mode Switch events, it appears that your total AF burden is far higher than mine coming in at 4.3 hours/per day or 17.9% of the time for your last quarterly monitoring period.  

I go back to my clinic in August when I will get my most recent results, but my last results for the year ending July 2022 were excellent with my AF only occurring 0.3 hours/per day, or 1.2% of the time, even though the total Mode Switches were quite high because of rapid in and out short lived episodes of AF on frequent occasions during the monitoring period. 

I am getting some infrequent longer episodes of AF, up to 8 hours, whereas you appear to be getting many episodes up to 2 hours frequently, hence your higher AF burden.  

Unfortunately looking at your Parameter Summary we are not always comparing like with like because your Mode Switch is set to be triggered when an atrial arrhythmia reaches 162 bpm, whereas mine is set to trigger a Mode Switch when my atrial arrhythmia reaches 172 bpm.  Both of us could be having AF at much slower rates too that will not be classified as a high atrial rate episode and therefore will not be counted in the total number of Mode Switches/High Atrial Rate Episodes, so our true AF burden may be considerably higher, perish the thought! 

My atrial lead Programmed Sensitivity setting has been changed now so that more of my AF episodes will be captured.  Setting was made more sensitive by lowering setting from 0.30 mV to 0.15 mV (where the lower the figure = the more sensitive).

Your diagnosis is the same as mine:  SSS (Tachy-Brady Syndrome).  We have the same pacemaker manufacturer (Medtronic) and dual chamber pacing, although not the same model.  We have a few different settings and I can see your Rate Response setting is On, while mine is Off.  I have anti-tachycardia pacing therapies turned On, yours is apparently Off and I do not know why?  It could be that some specific therapies would help you, especially Atrial Preference Pacing. 

I cannot understand why you have such a high pacing percentage in the Right Ventricle whereas mine is minimal.  I see your lower rate limit is set at 60 bpm, mine is at 70 bpm. 

I see you have Managed Ventricular Pacing turned On to prevent unnecessary ventricular pacing as I do and this is correct, but even so, you are still pacing in the right ventricle at 73.7% of the time.  This I think needs looking into and an explanation?  Are you getting heart block as well as having SSS, or is this a pacing/settings problem or a problem with a lead???  A high % of ventricular pacing can increase our AF burden.

Some additional observations for discussion with your doctor:-

Under Parameter Summary, Your Paced AV at 300 ms seems long.  Mine is set at 180 ms.  I would ask about this and whether it is appropriate for you?

Under “Observations” it states:  RV Capture Management:  Actual Safety Margin (2.7 X) more than programmed margin (1.5 X).  I would bring this to the attention of your doctors and ask why this is and whether these settings are appropriate for you?

Also note under Observations that AF has occurred for around 2 hours for 72 days during the monitoring period.  Your AF seems to be quite persistent now although fortunately you still appear to be asymptomatic.

I do not know if your AF is increasing because of joint problems, pain or  increased inflammation in your body, or whether your pacemaker settings need important adjustments.  In your shoes new to pace I would want to have that all important discussion with my cardiologist now to try to stop AF from progressing.  I wish you nothing but the best

Update:   just seen your edit to your original post, where your doctor says lack of essential fatty acids has caused your inflammation due to deficiencies in diet?  Maybe this is one answer to the increased AF but not perhaps the only one?  I would look at pacing itself too and whether your heart condition has changed;  whether you now have heart block as well as SSS and this is why you are pacing so much in the right ventricle?

Gemita's Post

by Penguin - 2023-06-22 19:09:53

Hi NTP, 

As you know I don't have a Medtronic device and therefore I find some of descriptors a bit confusing. I also don't know what's possible and what's not possible on your device. 

I agree with Gemita re: the issues to bring up with your doctors.

With reference to her reply and the questions she suggests that you raise: 

1.  I'm assuming that your 'paced AV' of 300 ms is a paced AV delay?  300 ms is a long AVD and long AVDs can cause problems as I know all too well.  The reason for an AVD is to delay ventricular pacing and to decrease the quantity of it. You have 73% V.pacing in spite of this long AVD.  That's a very high % VP for someone with managed VP in place and a long AVD of 300ms, given that you have no AV conduction disorder diagnosed (to my knowledge).  You need to question the VP % and ask why it is so high I think. 

2. The Observation re: Safety Margin is very important.  I've had one of these notices before and it is a red flag for the techs who should know that they need to sort out your programming because it isn't set up safely. Have they done this? If not, ask them to do it. 

3. Re: Essential Fatty Acids - I don't understand enough about the role of fatty acids and their effect on inflammation to comment.  Does inflammation cause AF?? I really don't know - sorry. 

I hope you can get this sorted out. Your settings may need to be looked at rather than your diet on this occasion. 

Best Wishes

fatty acids are related to the high C-Reactive Protein

by new to pace.... - 2023-06-22 19:41:36

which i plan to start a new topic for the CRP..

 Thanks  Penguin and Gemita for your helpful questions for me to ask in August and comments.

My Pacemaker has never had any settings changed at the past in office checks.  I of course will ask for the log events and summary from June 20- Aug.24.  Next remote transmission is Sept 19.  .

From the Changes/comments section the sentence that says "Health trends do not demonstrate significant abormality."  What   concerns me is  I believe that no doctor has looked at this.  Generally the report has the Doctors electronic signature,. this time none.   Will be interesting to see if someone ever looks at this.

Bottom line is that at 83 I feel good and able to continue all my activities.  

new to pace

AF needs a firm hand

by Gemita - 2023-06-22 21:39:54

Hi new to pace, “bottom line is that at 83 I feel good and able to continue all my activities” sounds good to me too.  We always say it is how we feel that counts, not those percentages.  However in the case of AF, we need to control it because otherwise things could deteriorate very quickly and lead to worsening symptoms, especially for those of us who experience AF at high heart rates as we both do. 

The comment “health trends do not demonstrate significant abnormality” I believe refers more to your general health including that of your heart health.  You clearly do not have any major health problems at 83, certainly no heart disease requiring intervention other than electrical disturbances requiring a pacemaker.  You haven’t had any strokes either which is amazing and I hope you remain stroke free with your supplements alone.  However looking at your pacemaker records, with some of the observations noted and pacing anomalies, there are clear concerns which hopefully your cardiologist will address when you see her.  

Any inflammatory condition can certainly be a cause for AF and AF itself can cause inflammation too, so your high CRP is a warning that all is not well.  I hope your inflammation levels normalise quickly

inflammatory

by new to pace.... - 2023-06-22 22:12:59

Thanks Gemita i now have a list of more foods that i should be eating and will try to incorporate into my diet for at least the next couple of weeks. Until July 10 blood test. Of course will have to make a slight change to my vegan diet.  All for  less AFib episodes.  Who knows maybe  that will slow my Af episodes.

new to pace

V.Pacing and Fatty Acid Metabolism

by Penguin - 2023-06-23 11:42:13

This paper deals with the subject of dyssynchrony which 'can' be caused by V.pacing (referred to below as non physiological RV pacing). Dyssynchrony is one of the 'negative' effects of v.pacing that may affect some people - not necessarily you. The paper isn't necessarily relevant but there's a snippet in it which suggests that v.pacing can affect fatty acid metabolism. (See underlined section below). I have no idea 'how' but it goes on to mention that effects of dyssynchrony (including metabolic effects) 'may' be picked up in the blood. 

This doesn't mean that you have dyssynchrony or any other negative effect from v.pacing, but it is known that v.pacing above 40% carries risks and causes symptoms for some people. 

It may be totally irrelevant but I thought I'd share it with you. 

'As a result of non-physiological RV pacing, changes in ventricular blood perfusion, neurohumoral innervation and fatty acid metabolism have also been observed. Moreover, dyssynchrony results in changes in local myocardium oxygen demand. Different effective workloads of particular ventricular segments also cause changes in segmental myocardial perfusion and regional myocardial perfusion defects, even in the absence of coronary artery disease (CAD).[29,30]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9376832/