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Copy of FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
“Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses.
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Do not implant pacemakers in patients with nonsymptomatic bradycardia. This includes the wide spectrum of sinus node dysfunction (SND), asymptomatic pauses in patients with permanent AF, and young patients with medication-induced bradycardia. Humans exhibit tremendous variation of heart rate, and impressively slow heart rates frequently cause patients no harm. As for heart rates, ”normal” is indeed a wide swath. Unlike the more sinister high-degree AV block, SND is not immediately fatal. In 2012, there exist many strategies for the treatment of arrhythmia that do not include exposing patients to the risks of implanting a permanent intravascular device.
Back to FAQs: Coping with Your A-Fib
Last updated: Wednesday, August 26, 2020
2020 AF Symposium Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
2020 AF Symposium: AF Management
Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
by Steve S. Ryan
One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.
While several cases were discussed, here I summarize just one case.
Dr Eric Prystowsky
Patient History: 75-Year-Old Female
Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN
Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.
She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.
Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.
Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.
Treatment by Dr. Prystowsky
Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).
Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.
She felt better for 5 days.
Moderate Pericardial Effusion; Medications Adjusted
The patient then developed a moderate (“significant”) pericardial effusion.
Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.
Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”
She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Minimizing Pacing; Medication Adjusted
The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.
A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.
He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).
Dr. Prystowsky’s Lament
He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”
One Year Later and Lesson Learned
A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”
Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.
He wrote me that it’s been over a year, and the patient is doing great.
If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2021
Return to 2020 AF Symposium Reports
A-Fib Pause: To Pace or Not to Pace…That is the Question
I’ve posted about my A-Fib retuning last Fall and subsequently having a Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM)—one of the world’s smallest cardiac monitors—inserted just under the skin near my heart. Each night my Reveal Linq wireless monitor transmits that day’s data by wireless connection to my EP, Dr. Shephal Doshi.
Surprise—I Didn’t Feel a Thing
One morning in the week following my successful RF catheter ablation, at 6:27 am unbeknownst to me, my Linq recorder captured this episode—a seven-second pause:
The ECG signal strip is a graphic tracing of the electrical activity of your heart.
The next morning Dr. Doshi was on the phone telling me to come into the office immediately. He showed me the printout, and I was amazed.
In this second graphic, called a scatter plot, you can clearly see the dots representing the pause (outlined by a red box). The differences between consecutive R-wave intervals reveal patterns in the rhythm.
Scatter plots use horizontal and vertical axes to plot data points. Here the differences between consecutive R-wave intervals are plotted in order to reveal patterns in the rhythm.
Wow, 7-seconds—that’s a huge pause! It’s no wonder Dr. Doshi and his office called me the next day. He wanted to install a pacemaker right away and scheduled it for a week later. He also told me not to drive a car.
Remember: Your Best Patient Advocate is You
Unlike when I had A-Fib back in 1997, this time I wasn’t feeling any dizziness during the day.
At A-Fib.com, we always encourage you to be your own best patient advocate (which can include your spouse or partner. too.) And to not blindly follow your doctor’s advice. Always educate yourself. So I read up on pacemakers.
What is a Pacemaker?
In this instance, pacemakers are used to treat a slow heartbeat in people with A-Fib. It’s a small device that monitors your heartbeat and sends out a signal to stimulate your heart if it’s beating too slowly. The device is made up of a small box called a generator. It holds a battery and tiny computer.
Source: Pacemaker illustration from solarstorms.org
Very thin wires called leads connect the pacemaker to your heart. Impulses flow through the leads to keep the organ in rhythm. There are also “leadless” pacemakers which are entirely installed inside your heart.
Installing a Pacemaker: The doctor programs and customizes the pacemaker for each patient to help keep their heart in rhythm. The surgery to put in the device is safe, but there are some risks, such as bleeding or bruising in the area where your doctor places the pacemaker, infection, damaged blood vessel or collapsed lung. You may need another surgery to fix it.
Life with a Pacemaker: Sometimes the impulses from a pacemaker cause discomfort. You may be dizzy, or feel a throbbing in your neck.
Once you have one put in, you might have to keep your distance from objects that give off a strong magnetic field, because they could affect the electrical signals from your pacemaker like metal detectors, cell phones and MP3 players and some medical machines, such as an MRI
In general, it is a permanent installation—you’ll have it for the rest of your life.
VIDEO: Traditional and Leadless Pacemakers Explained. Peter Santucci, MD, is a cardiologist with Loyola University Medical Center; he describes the traditional pacemaker and it’s installation using graphic animations.Then compares with the miniaturized leadless version. 2:30 min. Posted by Loyola Medical. Go to video.
Considering a Pacemaker: Pros and Cons
Patti and I discussed the pros and cons of a pacemaker. In this instance, my heart was beating too slowly. But that’s normal for me. Because of years of running and exercise, my resting heart rate is in the high 50s, which is very low compared to others with A-Fib.
The three-month “blanking” period following my ablation is when my heart is healing and learning to once again beat in normal sinus rhythm. That’s why it’s common for A-Fib to recur during this time.
Illustration showing placement of the Medtronic Mica leadless pacemaker
It doesn’t mean your ablation was a failure—think of it like planting a fruit tree. The tree might not produce fruit right way, but give it time to acclimate, absorb the nutrients in the soil, to grow stronger and bask in the sun. So I’m giving my heart some time, too.
Hitting the Pause Button on a Pacemaker for Now
In the meantime, I haven’t had another pause and have remained A-Fib free. I am hoping that this 7-second pause was a one-time thing and that my heart will stay in normal sinus rhythm in the months to come.
Dr. Doshi wants to install a “leadless” pacemaker which would be entirely installed inside my heart. Having that installed is a big step for me, one that I’ll have to live with for the rest of my life.
So, I decided to wait on having it installed. I’ll reconsider a pacemaker after my 3-month blanking period is behind me.
I’ll keep you posted on the status of my A-Fib post-ablation.
VIDEO: Pacemakers—Traditional and Leadless Explained
Dr.Peter Santucci, is a cardiologist with Loyola University Medical Center; He describes the traditional pacemaker and it’s installation using graphic animations. Then compares with the miniaturized leadless version. 2:30 min. Posted by Loyola Medical.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click on arrow icon to select.
If you find any errors on this page, email us. Y Last updated: Friday, August 16, 2019
Now A-Fib Free: A 23-Year Atrial Fibrillation Ordeal, Trial, Tribulations and Recovery
By Charn Deol, Richmond, British Columbia, Canada, May 2017
Charn Deol, B.C., Canada
My medical issues with atrial fibrillation started when I was 43 in August of 1993 when I was aware of having a few skipped heartbeats. I had just returned to Canada having been working extensively for the last few years in Southeast Asia. About a week later, the irregular heart beating got worse in duration.
At the same time, a dull aching pain started in the left chest region the size of a 50-cent piece.
A-Fib Drugs Don’t Work, Chest Pain Condition Worse
Upon being sent to a heart specialist in September 1993, numerous drugs were prescribed to keep my heart in rhythm (digoxin, flecainide, sotalol). They did not work, some had serious side effects, and every few days I would go into atrial fibrillation.
The atrial fibrillation happened once or twice per week and lasted from a few hours to 24 hours. Then it would stop on its own, and the heart would go into normal sinus rhythm.
Second medical condition: At the same time, the very centered pain in the upper left chest area kept getting worse and added to the debilitation of daily life. These medical conditions started my long journey to find relief (cure) from two medical conditions that were not being controlled or cured by conventional medical treatments.
Alternative Healthcare Practitioners―India & China, Too
In my search for a cure(s), I met a family practitioner and other medical and alternative specialists who used treatment protocols that could be labeled ‘experimental’ or ‘out of the box’, as they say.
While discovering alternative medical treatments in 1994, I also went to India for Ayurvedic treatment [one of the world’s oldest holistic healing systems] and even to China for treatment. Most alternative (non-allopathic) medical practitioners look at the body as an interconnected processing unit and believed in my case that the pain in the left chest and the atrial fibrillation were connected. This was not the thinking of the allopathic doctors, so I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.
Having been to a multitude of healthcare practitioners, numerous chiropractors, massage therapists and other more esoteric healthcare practitioners (100s over the 23 years), there was no resolution to my medical condition.
Encainide Drug Therapy: Up and Out
The heart specialist that gave me sotalol [an antiarrhythmic drug] in 1995 gave me a dose that dropped the heartbeat to 30 beats per minute putting me into the emergency room, but the drug had no effect on my atrial fibrillation.
In 1996 seeing my third cardiologist, I was put on a drug called encainide [also an antiarrhythmic drug], to be used on an as needed basis [pill-in-the-pocket]. It worked and would stop my atrial fibrillation in approximately 20 minutes.
But it had no effect on the chest pain which was getting worse now with a pain spot in the left shoulder blade area also the size of a 50-cent piece having started out of nowhere.
About 6 months after starting on the encainide, one of my friend’s son with a heart condition since childhood passed away. And I was told he had just been started on a new drug for him called “encainide” along with “sotalol”. The same cardiologist had been providing this drug free of charge to me, so I was pleased that it worked for me and cost me nothing.
The problem I found out was that it was illegal for the cardiologist to prescribe this drug because it had killed too many people. When he got caught, then encainide was no longer available. (Encainide is a class 1C antiarrhythmic drug no longer used because of its frequent proarrhythmic effects.)
Chelation for Very High Levels of Mercury
While all the above was going on, I was tested for heavy metals through urine analysis. It was discovered that I had the highest level of mercury ever seen by the lab in any of their patients (7400 nmol/dl). So I started protocols to take the mercury out of my body using chelation treatments with EDTA and then DMPS and DMSA (metal chelators).
At the same time, my other medical practitioners had me on oral and IV multivitamins and mineral protocols.
Mercury Cleared, Atrial Fibrillation Stops!
By 2000, the mercury was finally out of my system and my atrial fibrillation stopped! It is known mercury can concentrate in nerve tissue. While only a correlative relationship―mercury out of system―my atrial fibrillation did stop.
Chest Pain Condition Worse than Ever
From 2000 to 2010 I had no atrial fibrillation. But the chest pain condition did not stop, and it got worse extending into my gut region. All medical protocols tried could not alleviate this pain, nor was any etiology discovered as to what was the underlying cause of the pain condition.
Thanks to my resiliency, I was still able to go hiking, skiing, travel and work part-time on my own schedule. But it took great perseverance.
After 10 Years A-Fib Returns―and Heavy Levels of Lead (This Time)!
In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week.
I was immediately tested for heavy metals again, and this time I had high levels of lead, not mercury. Even with thorough investigations of potential sources for this lead contamination in my body, no source was discovered. We worked (and continue to work) on getting these lead levels down (I had no high lead levels back in the 1990’s when tested―only mercury).
Amiodarone Bad Side Effects
I again began doing alternative treatments to deal with the atrial fibrillation and the pain condition, nothing worked. I went to China again for treatments, IV EDTA infusions again, etc., but the pain persisted at high levels and the atrial fibrillation kept getting worse.
In 2012, I saw a new cardiologist who put me on flecainide again. And when it did not work, he provided me with a new drug called amiodarone. This drug lead to paranoia and left me with an epididymitis in my right testicle which I suffer from to this day. (Epididymitis is inflammation of the tube at the back of the testicle that stores and carries sperm.) He had no compassion for my dilemma. This is another cardiologist I dropped.
Ablation in Vancouver, B.C. Fails―A-Fib Worse and More Chest Pain
By late 2014, the atrial fibrillation was occurring on average every second day and lasting 24-38 hours. My next cardiologist sent me to the Atrial Fibrillation clinic in Vancouver where I was evaluated by an electrophysiologist. The A-Fib was very debilitating, so I was ready for surgery.
I asked for the most experienced electrophysiologist at the clinic to do the surgery. I waited an extra 3 months for the surgery because this highly qualified electrophysiologist was in so much demand.
Finally, in November 2015 I had the ablation therapy (it took approximately 2.5 hours). I came out of the surgery worse than ever. The atrial fibrillation did not stop, and the pain was worse than ever in my left chest, left shoulder-blade and gut regions.
AV Node Ablation & Pacemaker?―No! No! No!
The electrophysiologist wanted to wait for the 6 month recuperation period after the ablation therapy to see if I would go into regular sinus rhythm. By September 2016 (9 months later), I was worse than ever. In November, I saw my electrophysiologist under the impression that he would do another ablation treatment, since I was told and with my own research had confirmed that ablation treatments may be required for up to four times for the treatment to work.
This “top” electrophysiologist recommended I have a pacemaker put in and the AV node be ablated instead, so that the pacemaker could take over the regular beating of the heart. I asked the electrophysiologist why not do further ablation treatments as per the standard practice. He said if that is what I wanted, he would do another ablation. This was quite disconcerting―I am relying on his extensive knowledge to help me in a field where I am no expert. We agreed to set up a surgical date for a second ablation on December 12, 2016.
Upon leaving the office and arriving home, I informed my wife of the unpleasant appointment I had with the electrophysiologist, especially his lackadaisical attitude towards my serious heart condition. As a patient, the relationship is somewhat like that of a child with a parent. The patient is naïve, scared, distraught and looking for a path of reassurance from the medical profession. This was not the case in this situation.
This is when “gut instincts” come into play. My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital and search for an alternative path. (And I canceled my December 12, 2016 scheduled ablation.)
Counseling with Steve Ryan
Having been a reader of Steve Ryan’s website, I reached out to him and agreed for him to become my advocate and provide me with advice on how to deal with my current concerns over either going along with having a pacemaker placed in my chest along with ablation of the AV node OR to try a second ablation. Steve recommended a second ablation and the Bordeaux Clinic―it was too early to place a pacemaker/ablate the AV node at this stage.
Following this detailed discussion with Steve, I spoke with my wife and got a hold of the Bordeaux Clinic in France on December 2, 2016. With some back and forth email communication, ablation therapy was arranged for December 12, 2016. Somehow with luck and quick action, my wife and I were on an airplane to France and arrived in Bordeaux on December 10.
Second Ablation in Bordeaux and Use of CardioInsight Vest
The surgery on December 12 was done by Prof. Mélèze Hocini. Instead of taking the standard time of 2.5 to 3 hours for the surgery, it took well over 6 hours until approximately 4 pm. Dr Hocini was on her feet and exhausted.
I was informed the next day that my surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter. It appeared the “top” specialist I had used in Vancouver had not done his job properly. (Remember that I had been worse for the year after my first ablation).
Dr. Hocini was able to see the numerous sites leading to the atrial fibrillation/flutter in my heart due to an advanced computer assisted mapping vest (CardioInsight) which helps the electrophysiologist see in more detail cells in the heart that are acting erratically. This system is just starting to be used in the U.S. by a few doctors. (See Bordeaux ECGI CardioInsight)
Successful Ablation—No A-Fib, But Chest Pain Condition Continues
I felt great the day after the surgery, no atrial fibrillation or flutter. Pain syndrome still there. I remained in the hospital for 4 more days and all went well, and then stayed in France for 7 more days sightseeing. No problems. I was to continue on Xarelto to keep the blood thin [for risk of stroke].
At Home A-Fib Returns with Persistent A-Flutter
Upon arriving back in Canada, the atrial fibrillation and flutter returned. Dr Hocini recommended cardioversion which I did twice but I still ended up in persistent atrial flutter with a heartbeat in the 130 range but no longer irregular.
Beta Blockers were tried to lower the heartbeat for a few weeks which did not work. Dr. Hocini recommended another cardioversion with sotalol prescribed for after the cardioversion. This was done on February 17, 2017. The heartbeat converted to sinus rhythm (65 heartbeat and was regular).
Normal Sinus Rhythm―4+ Months So Far
I have now remained in rhythm since February 17, 2017 with a quick flutter occurring once in a while. Since I am sensitive to prescription medications, I was placed on a low dose of 40 mg sotalol 2 times per day.
Minerals, Vitamin IVs for Inflammation of the Heart
With my other medical practitioners, I also had mineral and vitamin IVs during this time to help alleviate the inflammation in my heart from the surgery. I also took (and continue to take) vitamins and supplements as recommended by the other medical professionals treating me to keep the inflammation in the heart down.
Dr. Hocini had stated that since my ablation surgery was so complicated, I might have to go back to Bordeaux for another ablation. I have to get through the recommended 6 month recuperation time frame to see if the surgery has been successful. The last 3 months have me heading in the right direction of recovery.
Lessons Learned: After 23 Years with A-Fib
From this experience I’ve learned to obtain as much knowledge as possible of your condition. Trust your gut feelings if you feel uncomfortable with your surgeon. Increase your intake of nutritious foods and supplements prior to and after the surgery. Steve Ryan’s website provided me with the knowledge to make educated decisions.
If you have the funds and/or a complicated atrial fibrillation situation, please find the best surgeon you can and then still question him/her. Get a second [or third] opinion if your gut tells you to.
Doctors are just human beings with positive and negative traits like the rest of us. My first surgeon did not do his job properly in my first ablation and was flippant in his attitude in recommending a second surgical treatment.
With luck, trusting my gut instinct, educating myself, and a great family support system, I was able to find the best clinic in the world to treat me for this very debilitating medical condition.
I welcome your email if I can be of help to you.
Charn Deol, May 2017
charnee@gmail.com
P.S. FYI: My chest pain problem persists and goes undiagnosed, but that’s a story for another website!
Editor’s Comments:
Three month ‘blanking’ period: Charn’s A-Fib returned after his successful second ablation. This is quite common in more difficult cases. Your heart is ‘learning’ to beat normally again. That’s why doctors wait for at least three months before declaring your ablation a success. In Charn’s case, during the first two months, a couple rounds of cardioversions were followed by a third with sotalol prescribed after the cardioversion. This worked to get his heart back into and stay in normal sinus rhythm (NSR).
Three month ‘blanking’ period: Charn’s A-Fib returned after his successful second ablation. This is quite common in more difficult cases. Your heart is ‘learning’ to beat normally again. That’s why doctors wait for at least three months before declaring your ablation a success. In Charn’s case, during the first two months, a couple rounds of cardioversions were followed by a third with sotalol prescribed after the cardioversion. This worked to get his heart back into and stay in normal sinus rhythm (NSR).Be a proactive patient: Charn’s story is truly inspiring and an example of being proactive and not giving up. Do research yourself, get advice, and check out alternatives! We’ve been conditioned to trust doctors. Sometimes we just have to say “NO! That doesn’t make sense to me”. It’s okay to fire your doctor!
I told Charn an AV Node ablation is a treatment of last resort; it destroys the AV Node, the heart’s natural pacemaker. There’s no going back and you are forever pacemaker dependent.
Instead, I advised Charn to seek a second ablation and supplied him a list of Master EPs who routinely treat difficult, complex cases. Kudos to him for deciding to go to the Bordeaux group, considered the best in the world. [For more about Bordeaux, see my article, ‘2016 Cost of Ablation by Bordeaux Group (It’s Less Than You Might Think)’].
Chelation therapy: Chelation is FDA approved for lead removal and is the preferred medical treatment for metal poisoning. But few doctors perform chelation therapy or provide heavy metal testing. To find a doctor for these therapies, go to: http://www.acam.org. (They also do IV therapy for vitamin C and other vitamins and minerals which seems to have helped Charn.)
Amiodarone drug therapy: Amiodarone is considered the most effective of the antiarrhythmic drugs, but it’s also the most toxic and is notorious for bad side effects, including death. It’s generally prescribed only for short periods of time such as for a few months after a catheter ablation and under very close supervision. (For more about Amiodarone, see my article, ‘Amiodarone: Most Effective and Most Toxic‘.
Charn’s second ablation Operating Report: Charn’s ablation was more difficult than most. He had been in A-Fib off and on for 23 years. In addition to having to work around a previous failed ablation, Dr. Hocini had to track down and ablate many non-PV triggers. Using the CardioInsight system, Dr. Hocini found A-Fib sources in the septum and in the anterior Left Atrium (LA) region, and his left and right inferior PVs had to be re-isolated.
But Dr. Hocini didn’t stop there. Using pacing again, Dr. Hocini found peri-mitral flutter in Charn’s left atrium which terminated by completing an anterior mitral line and required high energy because of the thickness of his heart tissue. Dr. Hocini had to work on Charn for six hours to the point of exhaustion.
Charn’s chest pain continues: Charn’s debilitating chest pain seemed to start when he first developed A-Fib. I’m disappointed that being A-Fib-free didn’t get rid of the pain he still experiences. I’ve never heard of pain like this coming from A-Fib. Charn has seen many doctors and tried alternative strategies to no avail.
If anyone has any ideas, strategies, or insights to help Charn’s pain, please email me.
Return to Patient A-Fib Stories
If you find any errors on this page, email us. Y Last updated: Sunday, June 4, 2017
With 3-4 Second Pauses, Do I Need a Pacemaker?
We’ve answered a new FAQ about understanding A-Fib with long pauses and if a pacemaker is appropriate.
“I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?
My cardiologist recommends a pacemaker to prevent blackouts during a pause as well as other serious heart problems. I am willing, but want to learn more about these pauses first.”
I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.
Pauses are “Normal” in A-Fib
Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.
Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant…Read the rest of my answer… .
FAQs Understanding A-Fib: With A-Fib Pauses—Do I Need a Pacemaker?
FAQs Understanding A-Fib: Pacemaker for Pauses?
“My cardiologist recommends a pacemaker to prevent blackouts during a pause as well as other serious heart problems.
I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?
I am willing, but want to learn more about these pauses first.”
I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.
Pauses are “Normal” in A-Fib
Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.
Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant.
Monitoring Your Symptoms
Are you symptomatic? Do you fall or faint from these pauses? (This is different from occasionally feeling lightheaded or dizzy.)
If your cardiologist hasn’t yet suggested it, you may need to wear a holter or similar monitor for a few days (or up to a month or longer).
Monitoring will tell your doctor exactly how long your pauses are and how often you have them.
Avoid Getting a Pacemaker, if You Can
I can understand your cardiologist’s concern, but try to avoid getting a pacemaker, if you can.
If you do have to get a pacemaker, make sure the cardiologist guarantees that it can and will be easily removed once you are restored to normal sinus rhythm (NSR). You don’t want to be saddled with a pacemaker for life when you don’t need it.
Depending on how a pacemaker is installed, it may make a catheter ablation more difficult. You may have to go to a more experienced EP for your ablation.
Be assertive. You may have to be very assertive about this. Most cardiologists will insist that you keep the pacemaker forever. (But it isn’t so.)
Cure Your A-Fib=No More Pauses
Ask your doctor about antiarrhythmic drugs. They generally don’t “cure” A-Fib but may reduce your pauses.
If your pauses cause you problems, consider a catheter ablation to cure your A-Fib.
Once you no longer have A-Fib, those pauses should stop and your heart should beat again in normal sinus rhythm.
To read a first-hand story about pacemakers, see Personal A-Fib Story #50: Pacemaker & A-Fib Ablation—You Can Have an A-Fib Ablation if You Have a Pacemaker
Go back to FAQ Understanding A-Fib
FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
“Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses.
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Back to FAQs: Coping with Your A-Fib
Last updated: Tuesday, August 20, 2019
Pacemakers & ICDs
Pacemakers & Implantable Cardioverter Defibrillator (ICD)
Pacemakers
Pacemakers
A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a regular heart rate. In general, pacemakers are not very effective for preventing A-Fib and are not specifically used to treat A-Fib. A pacemaker does not cure A-Fib. But they can be of benefit to some patients. Newer dual chamber pacemakers can possibly terminate A-Fib episodes with pacing and supress Premature Atrial Contractions (PACs) from triggering A-Fib by overdrive pacing.
Implanting a pacemaker seems to be most helpful if you have a slow heart rate or pauses (5+ seconds) as a result of taking A-Fib medications. But there is a danger for patients with this approach. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath. Some people, particularly athletes, can have a very slow heart rate and be perfectly healthy. The same holds for asymptomatic pauses.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with non-symptomatic bradycardia (slow heart rate).1
Non-symptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker. Another consideration is that implanting pacemaker leads in the veins of the upper chest often prevents or hinders future procedures that require vascular access like a Pulmonary Vein Ablation/Isolation (PVI/A).
A pacemaker usually isn’t implanted unless your heart rate is too slow2 or you have Sinus Node and/or Atrioventricular (AV) Node problems. But be advised that pacemakers tend to have bad effects over the long term, “…a long-term morbidity (is) associated with a pacemaker.”3 Leadless pacemakers seem to have less complications than traditional ones.
For more information on Pacemakers, you may want to visit the pacemaker chat site: pacemakerclub.com. (Thanks to Mara for alerting us to this site.)
[I admit to not knowing much about pacemakers. Happily one of the A-Fib.com’s contributors installs pacemakers and offers the following observations.
“I like to tell patients who receive pacemakers that, after a couple of months, they can have a VERY active, normal lifestyle. All of the current pacers have a “rate responsive” mode, meaning they are designed specifically for activity. The more active you are, the faster the pacer goes. Three triathlon runners, and two NFL players have pacers. Most people forget they have a pacemaker.
A recent trend is to implant the ventricular lead on the septum vs. the right ventricular apex, which gives better cardiac output and a more ‘normal’ heartbeat. You might want to ask your doctor about this possibility. Even if your doctor does not prefer this technique, he/she will be impressed that you did your homework.
In addition, you always want a dual chamber pacer which will give better cardiac output. It will also attempt to synchronize between the atria and ventricles, unless the patient is in Chronic A-Fib. If the A-Fib is intermittent, the pacer will temporarily switch modes to VVIR (ventricular only pacing) during the A-Fib, and then back to normal DDDR (dual chamber) pacing when the A-Fib terminates. This is all done by the device memory/logic program.
So, during A-Fib, the DDDR pacer will switch to VVIR and pace only the ventricle during the A-Fib.”
Key to the acronyms.4
Implantable Cardioverter Defibrillator (ICD)
Implantable Cardioverter Defibrillator (ICD)
An implantable cardiac defibrillator (ICD) is a device that is put within the body and is designed to recognize certain types of abnormal heart rhythms (arrhythmias) and correct them by delivering precisely calibrated and timed electrical shocks, when needed, to restore a normal heartbeat.
Having a defibrillator implanted in your heart is, from the point of view of most A-Fib patients, not a probable option. A defibrillator shock is painful, like being “kicked in the chest.” Most people would rather have A-Fib than risk being shocked throughout the day and night. Also, it does not address the underlying problem or condition of your heart that causes your A-Fib.
Fewer than 10% of patients get shocked when a shock isn’t needed, according to Edward K. Kasper, MD of The Johns Hopkins Hospital..5 In another study 18% of patients with A-Fib received inappropriate first shocks.6
More than 30% of people who have ICDs develop emotional problems such as anxiety and depression—in part due to worry and uncertainty over whether the device will deliver an unnecessary shock and the fear of being shocked.7
What’s it like living with an ICD and A-Fib? Roby T. shared:
“The worst part was the ICD firing,” he recalls. “It hit me like a baseball bat and knocked me over.” His wife, Mary, was afraid to leave him alone. And the anxiety levels took their toll, even during sleep. “He became really anxious expecting a firing at any time,” she says. “You could see the fear in his eyes,” she reluctantly remembers. “He had to start taking antidepressants.”8
Our A-Fib.com pacemaker expert writes:
“Defibrillators are far more complicated (than pacemakers). When people report getting a big shock (500-700 volts) from the unit, that was probably for V (ventricular) Fib, not A-Fib, if the unit is programmed properly.
One good thing about the V-Fib is that it is usually (not always) proceeded by Ventricular Tachycardia, a much slower, organized rhythm that often responds to painless anti-tachycardia pacing. We will attempt anti-tachycardia overdrive pacing for several different patterns before we finally give up and go to the full output shock.”
Last updated: Friday, December 25, 2020
Return to Treatments for Atrial Fibrillation
- Mandrola, John “Choosing wisely: The electrophysiology list of five don’ts http://www.medscape.com/viewarticle/802018↵
- “Atrial Fibrillation Educational Material” University of Pennsylvania. 2002, p. 3.↵
- Prystowsky, “Should atrial fibrillation ablation be considered first-line therapy for some patients?” Circulation 2005;112:1214-1231, p. 1228.↵
- Key to the acronyms used in the Pacemaker quote:
“DDD” signifies a dual chamber pacer, capable of sensing and pacing in both the atrium and the ventricle
“VVI” is ventricle only
“AAI” is atrium only
“R” signifies Rate Response, a programmable on/off feature which increases the pacing during activity↵ - Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9.↵
- Cesario, D. et al. The Role of Atrial Fibrillation in CRT-D Patients: The ATTITUDE Study Group. The Journal of Innovations in Cardiac Rhythm Management. 6 (2015), 1873-1880.↵
- Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9↵
- Roby’s Arrhythmia Story. Published on MyFastHeartBeat.com Last accessed November 5, 2012.↵
A Primer: Ambulatory Heart Rhythm Monitors
Source: www.afa.org.uk patient education brochure
By Steve S. Ryan, PhD, Last updated: November 2, 2020
In order to make a diagnosis of an arrhythmia, some form of electrocardiographic recording (i.e. ECG/EKG) must be made at the time the arrhythmia is occurring.
If an arrhythmia becomes persistent and is present day-in and day-out, as often is the case for A-Fib, the diagnosis is quite easy with a routine ECG done in the physician’s office.
The challenge is when an arrhythmia occurs intermittently what doctors call “paroxysmal ” (on and off) or is self-limiting. In this case, when an ECG is performed in between A-Fib episodes, the ECG will appear completely normal. To circumvent this problem, one would go to the next level of evaluation with a long-term monitor.
Example: ECG tracing of Atrial Fibrillation shows tiny, irregular and erractic “fibrillation” waves between heart beats..
Long-term monitors
When your arrhythmia is intermittent, your doctor may have you wear a mobile type of heart rhythm monitor to capture the electrical activity of your heart.
Long-term monitors basically are ECG recorders that patients can take with them (ambulatory). They fall into two major categories: continuous recording (Holter) and intermittent recording (Event).
The Holter Monitor
Mortora H12+ Continuous 12-lead Holter recorder
A Holter Monitor (named after Dr. Norman Holter, go figure) records continuously the ECG of a patient, usually for 24 – 48 hours. More modern Holter units record onto digital flash memory devices. The data are uploaded into a computer where software analyzes the input, counting ECG complexes, calculating summary statistics such as average heart rate, minimum and maximum heart rate, and finding candidate areas in the recording worthy of further study.
The advantage of a Holter is that every single heartbeat during that day is recorded and can be analyzed. The disadvantage is that if an arrhythmia did not happen on that particular day, the Holter data would not be useful.
The Event Monitor
Cardionet wireless event monitor
An Event Monitor, on the other hand, is a long-term monitor that can be used for up to 30 days or longer. The advantage is that the longer the recording period, the better chance of “catching” an intermittent arrhythmia. The disadvantage is that an Event Monitor must be activated by the patient and downloaded telephonically, a task that requires a certain amount of manual dexterity and may be difficult for some patients.
Some event monitors are patient activated when having an episode and save the last several minutes of data; others detect the irregular heart rate and automatically record the data.
Number of Electrodes
The number and position of electrodes varies by model, but most Holter monitors employ between three and eight, whereas the Event Monitors typically use two. Both the Holter and Event monitors record electrical signals from the heart via a series of electrodes attached to the chest. The Loop (event) monitor is not attached to the patient but is instead pressed to the chest by the patient when experiencing an A-Fib episode.
Implantable ambulatory event monitors
Medtronic Reveal® DX insertable continuous monitor
Implantable event monitors are also available for those instances where individuals experience such infrequent symptoms that extended monitoring is needed.
These devices are inserted just under the skin in the chest area during an outpatient surgical procedure. The device may remain implanted for over one year.
Implantable loop recorders have the ability to record events either automatically (auto activated) or by manual activation (self-activated).
Real Time Remote Cardiac Recording
CardioNet MCOTos wireless event monitor
An example of the newer monitoring technologies is the Ambulatory Cardiac Telemetry (ACT), a wireless cardiac telemetry system. This event monitor is designed for remote arrhythmia monitoring in any location.
A small transmitter worn on the patient sends the ECG data to a portable handheld device where it is analyzed. If an arrhythmia is identified, the data is automatically transmitted to a Monitoring Center for immediate review. Integrated into a state-of-the-art mobile phone, the ACT provides next generation cardiac arrhythmia monitoring. What’s interesting is the transmitter is a dongle type device worn around the neck with leads placed on the chest. You carry or have available what, in essence, is a mobile phone (it’s actually more than a phone). It is small and not cumbersome.
No patient input is required. Data collected from the monitors is transmitted to the monitoring center via a cellular network, the internet, or over the phone (based on model). Data from the monitors is not intended to be used directly by the patient but rather by the monitoring center and your cardiologist.
Next-Generation: the ‘Smart Band-Aid’ Patch
BardyDx Carnation Ambulatory Monitor
The ‘Smart Band-Aid’ provides the next-generation ambulatory cardiac monitoring service with beat-to-beat, real-time analysis, automatic arrhythmia detection and wireless ECG transmission. The Zio XT Patch by iRhythm Technologies, the BardyDx Carnation Ambulatory Monitor by Davis Medical, and the BodyGuardian Mini by Preventice Solutions are next generation ambulatory monitors.
The sensors can be modified to monitor a number of different tasks as they can also provide a comprehensive suite of post-symptom, looping, and auto trigger event monitors as part of its turn-key cardiac event monitoring service. https://a-fib.com/part-2-has-my-a-fib-returned-21-day-results-from-my-medtronic-reveal-linq-loop-recorder/
For Steve’s first-hand account of the Medtronic Reveal LINQ loop recorder and the 7-day BardyDx Carnation Ambulatory Monitor, see our post: Has My A-Fib Returned? 21 Day Results from My LINQ Loop Recorder.VIDEO: The Zio® Patch Ambulatory Cardiac Monitor
The single use Zio® Patch cardiac monitor (iRhythmi Technologies) looks similar to a 2-by-5-inch adhesive bandage and sticks to a patient’s chest. The single-use ambulatory, continuously cardiac monitor records for up to 14 days with no need to remove it during exercise, sleeping or bathing. (2:04 min.) Go to video->
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If you find any errors on this page, email us. Y Last updated: Monday, November 2, 2020
