Pacemaker Necessity?

My cardiologist is telling me that he won't prescribe any drugs to try to control my AFib unless and until I am fitted with a pacemaker. My Halter monitor results show a minimum heart rate of 36 bpm (while sleeping, of course), and a single pause lasting more than 2.5 s (3.156 s, also in the middle of the night). The hourly minimum was 46 bpm. My average heart rate was 64 bpm. The monitoring period was almost 12 days. Also, I have data going back almost 20 years from a home blood pressure monitor showing that I often had a resting pulse below 60 bpm. At the time, I interpreted this to mean that I was in good physical condition, but perhaps it also indicates a predisposition to bradycardia. Is my cardiologist's position reasonable? Or is he being overly cautious? Might a different cardiologist think differently? I'm not keen on getting a pacemaker. I'm not keen on the drugs, either, but in the short term, I'd like to try them to see if they can get my AFib under control. Long term, a successful ablation procedure would be the most desirable course of treatment, in my opinion. But that's likely some time off, and I need a remedy in the here and now.



Edited 1 time(s). Last edit at 01/28/2025 02:12AM by Robertus.

I think your cardiologist is worried about lowering your heart rate further, which is definitely what rate control drugs would do. With a rate of 36 during sleep you don't have much room to go lower safely. So I think they're being very conservative but not unreasonable.

A second opinion is always a good idea, but you need to get it from an electrophysiologist (EP), not a general cardiologist, which is who it sounds like you're seeing now.

And why is an ablation so far off?

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Carey
And why is an ablation so far off?

Money. Logistics.

“Among the many numbers that sum up Lance Armstrong's illustrious, controversial career, there's one that feels even more mythic than his seven Tour de France titles. At the peak of his powers, the cyclist reportedly had a resting heart rate of 32 beats per minute.”

Lance doesn’t have a PM and your HR is faster.

Are you taking a Beta Blocker drug that is lowering your HR?

A PM is a permanent implant not to take lightly unless really needed. An option of a second opinion from a different EP might be warranted.

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susan.d
“Are you taking a Beta Blocker drug that is lowering your HR?

No, I'm not taking any drugs at present. As Carey pointed out, the issue is that, given my pre-existing low heart rate, my current cardiologist is reluctant to prescribe any drugs because they will certainly lower my heart rate further. Clearly, he thinks that could put me into the danger zone. The question is, is his judgment correct? Would it be excessively risky for me to take the drugs without having a pacemaker?

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Robertus

.... The question is, is his judgment correct? Would it be excessively risky for me to take the drugs without having a pacemaker?

Yes, his judgement is sound. At the very least he is duty-bound to treat you ethically, and he can't do that working against his learning and experience. What he has told you is in keeping with what he knows and understands.

As Carey said, you don't have a lot of headroom left, if you understand that term (engineering). It's what you have left to adjust or to 'play with', which is quite sparse at only 36 BPM, even if it's only during sleep.

This is where you seek another informed opinion or use your own gut. When I was young and fit, all gristle and ribs, my resting HR while seated on the toilet, AFTER running up two flights of stairs, was 38. That happened to be my age at the time. If you're older, have a disordered heart, and are seeing specialists in order to improve your outcome, 36 is quite a bit on the thin side; no headroom left.

I received a PM 2 years ago due to long pauses. I was on Sotalol. I am happy it stopped the pauses which could have caused accidents while driving or even falling. The PM is a bit of a bother depending on the situation such as heavy lifting, throwing , swimming etc. It can and does pinch once in a while, sort of like wearing a wrist watch and it catches the wrong way.

I have since had an ablation and had a talk with my EP about the PM. I wondered if I would have needed it if I have had an ablation and been off the Sotalol. His answer was " Very good question and he wondered the same thing"

I went off the Sotalol 6 weeks after ablation and my life has changed for the better.

I had up to 15 second pauses for two days every 5-10 minutes. I had no choice but agree to a pacemaker. The icu nurse told me to make my funeral arrangements.

The problem was I’m allergic to titanium which the alloys in the pacemaker are made of. My chest swelled up like Elvis’ legendary Fool's Gold Loaf and it still bothers me from time to time. My watchman I don’t notice and it’s I think half titanium and nickel. But it’s better than dying if I didn’t get my PM so I suck it up.

FYI—The FDA has to approve a gold plated PM on an individual basis as a non titanium option. My surgeon told me it takes up to 6 months to gets approved.

I then got in contact with a lab in Germany that tests for metal reactions. Although titanium lit up in its score, the alloy palladium used with gold plated lit up higher in score reactions.

I then took a silicone test. I had called up Metronics those two days I was pausing before my PM implant and found the two leads gets screwed to the pacemaker. They then cover the two screws with silicone caps.

My surgeon just made sure he tighten the lead wires tightly and avoided using the silicone cap covers. I get X-rays and testing periodically to make sure the wires are ok.

Yet they still test me. The last time was 1-11-25 and six weeks before that in an ER when a fresh new doctor wanted an X-ray and a PM interrogation to test her speculation of a loose screw.

[en.m.wikipedia.org].



Edited 1 time(s). Last edit at 01/28/2025 10:25PM by susan.d.

My low heart rate during sleep is commonly in the high 30's, low 40's. At 69, it is no longer in the low 40's at rest during the day (like @gloaming was was as well) like it was 30 years ago for me. I've had afib for 20+ years. Initially my afib resting heart rate was below 100 and no rate control was needed. Now it can be 110-150 but episodes are mostly less than 3 hours and very infrequent, so I don't need a rate control med during an episode. I do use the rhythm med, flecainide, on-demand to convert episodes. However my episodes are relatively infrequent. I also use a minimum (for me) effective dose, which is 1/3 less than the max dose I was prescribed. Flecainide is normally prescribed with a beta blocker or other rate control med to mitigate the (low, but non-zero) risk of it creating atrial flutter with 1:1 conduction. I have chosen not to take this med and to accept the risk. I also have used flecainide daily for a relatively small amount of time the 20+ years it has been prescribed. Here I again just take the flecainide alone, but take it at low doses of 50 mg or 25 mg once a day (non-standard dosing). My understanding is the flutter 1:1 conduction risk increases with the dose.

Question is, would the rate med for you be prescribed for daily use? If so, is that indicated in your case or could it be used only during episodes?

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GeorgeN
Question is, would the rate med for you be prescribed for daily use? If so, is that indicated in your case or could it be used only during episodes?

My current cardiologist would have me take the flecainide together with a beta blocker because he said that without the beta blocker, I could go into 250 bpm flutter and would end up in the ER. He said the pill-in-the-pocket approach is like "chasing your tail," and so would have me take the meds daily. But as I stated at the beginning of this thread, he won't let me start this without a pacemaker.

I already mentioned that I have a relatively low resting heart rate—typically between 55 and 65 bpm. During my AFib episodes, my measured heart rate is usually somewhere between 70 and 90 bpm.

I have an appointment scheduled with an electrophysiologist specialist with more impressive credentials than my local doctor, but have an almost six-week wait until then.

I understand his logic and most won't prescribe the flec without the BB for liability reasons.

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Robertus


I have an appointment scheduled with an electrophysiologist specialist with more impressive credentials than my local doctor, but have an almost six-week wait until then.

May I suggest you call and ask to be on a cancellation list? Usually that helps me get an earlier appointment

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gloaming
As Carey said, you don't have a lot of headroom left, if you understand that term (engineering). It's what you have left to adjust or to 'play with', which is quite sparse at only 36 BPM, even if it's only during sleep.

What's at risk? Might my heart just stop and I die in my sleep? For sure I won't be driving a motor vehicle or operating heavy machinery in the middle of the night. Perhaps I might risk passing out if I require a middle-of-the night bathroom visit (I have BPH), but I'd be willing to deal with that risk.

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susan.d
May I suggest you call and ask to be on a cancellation list? Usually that helps me get an earlier appointment

I've already been able to move the appointment up twice, from its original date in May.

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Robertus
What's at risk? Might my heart just stop and I die in my sleep?

Well, frankly, yes.

Your brain needs a certain amount of blood flow to keep functioning. Your heart and other organs do too, but the most vulnerable is your brain so let's just look at that. If your natural heart rate while sleeping is 36 and a drug takes that down another 10 bpm, now you're at 26 bpm and you're on the edge of survivability. Got a little plaque in the carotids or some other contributing factor? Well, I hope not because if your brain doesn't get enough blood to keep telling your chest muscles to breath for you then yes, you will die in your sleep.

Drastic example, I know, but I've seen it play out in real life.

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Robertus
May I suggest you call and ask to be on a cancellation list? Usually that helps me get an earlier appointment

I've already been able to move the appointment up twice, from its original date in May.

Keep calling and see if anyone cancels. Maybe someone in February will cancel. You won’t know unless you call frequently

And then your heart rate may go low while sleeping and then you get a significant pause—not good! I have a pacemaker and it was prescribed because of tachy-brady syndrome, but I also had pauses and it was such a relief to have an end to those pauses.

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Robertus
As Carey said, you don't have a lot of headroom left, if you understand that term (engineering). It's what you have left to adjust or to 'play with', which is quite sparse at only 36 BPM, even if it's only during sleep.

What's at risk? Might my heart just stop and I die in my sleep? For sure I won't be driving a motor vehicle or operating heavy machinery in the middle of the night. Perhaps I might risk passing out if I require a middle-of-the night bathroom visit (I have BPH), but I'd be willing to deal with that risk.

Sorry, I missed this. The risk is you awaken, stand up to go to the bathroom, and suddenly, if you're lucky, you awaken a second time, except you're looking up a the ceiling and you don't know why, and you're sore. At worst, you might never awaken because you hit your head on something on the way to the floor. Bed frame, door handle....the floor itself....

I understand your question. I'm in bed, asleep, my heart goes down to 30, and I'm in reasonably good shape. What could go wrong? Nothing, probably, but as I have suggested, it's the unforeseen, unanticipated, things that can be life-changing. You get a phone call, sit up, reach for the phone, and if you are able to answer it, you might be unintelligible. Of fall forward, or backward...who knows.

If you accept the risk, good on ya. I hope it turns out to be nothing.

My past cardiology practice was very concerned about my (sometimes) low heart rate. For most of that time I was taking an antidepressant that brought my heart to the low 40s. They did not want to discuss the antidepressant, it was almost a taboo, so my PCP gave me a different one that didn't affect my heart (and my heart speeded up to a normal rate). I understand that since one drug can lower my heartrate, the feeling is maybe another one would do the same. But in fact that isn't how it worked for me. I'm now in a different cardiology practice and no one (cardiologist or EP) seems to have looked far back enough into my records to see that I was once flagged for a very slow heart rate. Or if they have, they haven't paid attention to it, and I haven't pointed that out to them. So I've been taking diltiazem and have not had problems with it.