Missed Beats?

I'd like to consult the group wisdom on what I assume are missed beats. The symptoms happen at night. I feel ‘beat, beat, pause, beat, beat, pause’ and this can go on a bit. I sometimes feel underlying atrial arrhythmia. Both are intermittent and don't happen every night. I wake up feeling groggy and a bit nauseous when they happen. Can anyone shed any light on these ‘missed heart beats’ and whether they could be settings related or progression of what has been described as first degree AVB or something else?  

Settings wise, I have an AVD of 200 ms programmed and a further programmed AVD extension of 150 ms. The extended AVD is applied when my PR interval exceeds 200 ms and can repeat up to x 3. This AVD extension must be used a great deal as my PR interval is longer than 200 ms.

Note: I have questioned these AVDs several times now, and have encountered very frustrating, unexplained reluctance to change them. 

My a.sensing level was also raised (not my choice) some months ago. This has helped with symptoms caused by over sensing which plagued me for months.  However, it has seemingly removed ECG evidence for AT and first degree block.  It seems too high. 

I became aware of the pauses after the sensing level was raised a few months ago. 

*Edited for sense. 


Oh Penguin

by piglet22 - 2023-10-20 07:09:07

Missed beats.

The story of my last 9 months.

What you describe is exactly what I experience.

As you probably know, mine is ectopics led and is under active investigation.

My old PM cannot cope with PVCs and rewards with those horrible missed beat sensations especially at night and relaxing. It sometimes leads to very unpleasant pre-syncope and unplanned falls.

I'm not optimistic that treatment is going any further than the knockout dose of 10-mg Bisoprolol which has helped, but now and again, I do get breakthroughs.

I'm not a conspiracy theory type, but the two days after the combined flu and Covid vaccinations both were plagued with missing beats.

Do you check at the time at a radial pulse or blood pressure monitor? When mine are bad, the oximeter won't get a reading at all.

Best wishes

No falls / pre-syncope

by Penguin - 2023-10-20 11:47:21

Piglet,  thanks for your response.

Re: Radial pulse / BP monitor - I become aware of them when I'm coming round in the early'ish morning and usually I'm not in the right head space to test when they happen - bit bleary eyed and half asleep. I agree that BP monitors are effective at picking up arrhythmia though.

The oximeter has been between 92-94 if I've felt breathless at all during the day. That doesn't seem worth making a fuss about. I'm not noticing missed beats during the day at all - and my pulse is sitting above 60 (often quite a bit higher) as it should be. 

Vaccines? There's no symptom correlation with any vaccine I've received either although I don't doubt the effect a double vax had on you. 

Something's not right, but I don't know what it is. IMO I definitely need those AVDs and the sensing looked into. 

Missed beats - we know them well

by Gemita - 2023-10-20 12:40:43


I think we can all relate to feeling missed beats which may occur either at night when we are at rest, or perhaps during vigorous exercise. The odd missed beat now and then would likely go unnoticed but when these missed beats, or perhaps we should call them skipped beats, pausing beats, thumping beats, followed by sudden short bursts of accelerated/decelerated rhythm occur for prolonged periods, we can perhaps be forgiven for thinking our heart rhythm is out of control.  Why does this happen and which arrhythmia might be present?  

Irregular heart beats can be triggered for lots of reasons from electrolyte disturbances, dehydration, infection, inflammation, anaemia, stress, too much caffeine (or too little!), alcohol, sleep disorders, a thyroid condition, high blood pressure, low heart rates, heart failure, other electrical disturbances, cardiomyopathy and other heart/health conditions.  There may be several arrhythmias present at the same time, coming from different sites.

You seem to speak of two separate rhythms Penguin.  The beat beat, pause type rhythm (perhaps an ectopic beat) and then you mention the underlying atrial arrhythmia.   What do you mean by the underlying atrial arrhythmia?   How does it differ from the beat beat, pause one Penguin?  Can you please try to describe the difference for us?  Is it an irregular, or a regular beat, fast, slow or alternating between fast and slow, regular, irregular?   Perhaps we shouldn’t be separating one rhythm disturbance from the other.  Perhaps they are part of the same rhythm disturbance?   

Atrial ectopic beats can often precede a rhythm disturbance like atrial fibrillation, whereas ventricular ectopic beats can often precede a rhythm disturbance like non sustained ventricular tachycardia so these ectopic rhythm disturbances, when frequent and prolonged may need controlling too and may not be so benign longer term if they develop into more established arrhythmias.

So a beat beat pause, beat beat, pause could well be part of the underlying atrial arrhythmia that you feel is there, not separate from it and as we both know there is only one way of finding out what exactly is going on, and that is to have longer term monitoring since our pacemakers may not always be set up to store and record all abnormal heart rhythms present.  The pacemaker simply wouldn’t haven’t the storage space in any event for this to happen.

We both know, unfortunately that ectopic beats, particularly atrial ectopic beats may not be recorded/stored on our pacemaker in the same way as are premature ventricular contractions and any atrial/ventricular tachy arrhythmia that fails to meet the criteria for its recording and storage, will not be stored either.  Sometimes my missed, skipped, pausing atrial beats are interspersed with arrhythmias like Flutter and Fibrillation and it can be difficult to know which arrhythmias are present at any given time. 

What else could be causing these irregular, pausing beats you ask?  Settings?  Most definitely.  A pacemaker fine tuned to suit the patient can help, although with any arrhythmia we may need to have frequent settings adjustments since an arrhythmia never stays the same (in duration, frequency) and usually progresses unless we can find the likely cause and change its likely course with lifestyle and other changes.  Patients with a high burden of atrial or ventricular ectopics can certainly develop reduced atrial/ventricular function.  To help lower the risk of PAC/PVC induced cardiomyopathy which may develop over time, frequent, prolonged PACs and PVCs should be firmly controlled.  Certainly a high burden of PACs has been associated with an increased risk of atrial fibrillation and other atrial tachy arrhythmias, and stroke.

Looking at your settings, they are far from ideal Penguin.  I feel there is scope for improvements and some trial and error to see where changes might help?  If they don’t try to make some changes, how will you or they ever know what might be possible.

They changed my atrial lead sensitivity earlier this year, to try to pick up more AF episodes, but it hasn’t actually made any difference to my % AF burden.   What they really need to be doing is lowering my AF detection rate from 171 bpm to a lower rate.  That would certainly pick up more in the way of lower rate atrial tachy arrhythmia episodes and I will be asking them about this early next year.  I know that other Medtronic members have a lower detection rate than mine, so it can be done.  How low will they be prepared to go, remains to be seen, since clearly a lower detection rate will increase mode switching and affect other settings, but I am going to have that discussion nonetheless to try to establish a more accurate AF % burden to help me to decide whether better AF control is now needed.

Lost Reply

by Penguin - 2023-10-20 13:33:35

Gemita, I'll reply later. I keep losing the replies that I post with error messages. 

Thank you for your reply. I've read it. 

Same here

by Gemita - 2023-10-20 13:44:29

I keep getting error messages too.  I lost my first message to you, but used back space to recover it.  Take your time Penguin.  Perhaps Admin is working on the software

Arrhythmia detection, Settings and Programming - Gemita

by Penguin - 2023-10-20 16:14:08


Thank you for your reply. 

I’m not terribly comfortable putting this online publicly, so I’ll necessarily miss out some details.

Arrhythmia - Typically my h/rate speeds up as I wake up. The rate is unnaturally fast (for me) and peaks in intensity before gently fading and self terminating.  The timing of it (sleep / waking related) is similar to when I get the missed beats, so yes two arrhythmia may be impacting on each other / aggravating each other. 

Oversensing - this explains symptoms I described some months ago in a previous post. You may remember that I assumed it was A.Fib as it was triggered by positional changes, small amounts of alcohol, eating etc. I was breathless a lot but didn’t find any AF on kardia mobile readings.  It took more than two weeks for the electrifying effects to die down and I’ve felt better since, but now my ECGs show that one of my ECG waves is not picked up by the higher atrial sensing in place.  I suspect this as a cause of missed beats, but don't know enough - hence the post. 

Re: Settings - I have tried and tried and tried to get to the bottom of where they are causing symptoms and how things could be improved, but this isn’t really my job is it?  

You say, ‘What they really need to be doing is lowering my AF detection rate from 171 bpm to a lower rate….  other Medtronic members have a lower detection rate than mine, so it can be done.’ Do you know how? That would help me too.

My over riding concern is that my own symptoms are caused by inappropriate programming.  It’s hard to believe that so many programming issues could remain unrectified / investigated.

We are both "fighters" and I know it will get better for you

by Gemita - 2023-10-21 06:04:37


Arrhythmia - from your description, it seems your rhythm disturbances are triggered by pausing, slowing heart rates occuring mainly when you are at rest, since you don’t seem to notice symptoms during the day when you are active.   This suggests to me your symptoms are bradycardia/vagally induced.  Your rhythm disturbances start with the missed, pausing beats and then your nervous system kicks in to bring your heart rate back up and triggers the faster rhythm disturbances that you experience on waking.  Indeed you may be waking prematurely because of this.  I have noticed on my own records time and time again the comment “Slow rates pre arrhythmia followed by a rapid ventricular response rate”.  Slow rates for some of us are clear arrhythmia triggers.  I believe both your missed beats and tachy events are connected and part of the same rhythm disturbance.  Long term external holter monitoring would help confirm how the arrhythmia starts and ends, the frequency, duration of episodes and how best to treat your symptoms.

Although heart rate and blood pressure naturally increase on waking, when we notice uncomfortable symptoms of a faster heart rate on waking (whether waking in the middle of the night or on waking after a full night's sleep), it can signal something is causing this like dehydration, electrolyte imbalances, hormones, sleep disorders triggering electrical disturbances or electrical disturbances themselves as in progression of AV Block, worsening bradycardia, a new arrhythmia?

Oversensing - a vast subject and perhaps worthy of another discussion.  Atrial lead contact problems have caused oversensing and difficulties for my technicians in the past in interpreting a stored arrhythmia episode.  The internal ECG had to be sent to the Medtronic rep for interpretation and arrhythmia diagnosis:  multi focal atrial tachycardia.  I know only too well how “positional” changes at night can trigger or stop an arrhythmia and how difficult these night-time episodes can be.

Settings - I understand your frustration getting your settings optimised, but your statement “it isn’t really my job is it?” sounds as though you have given up trying.  From reading posts here, you will find that it is very much our job to see where our settings could be improved to treat any symptoms.  Perhaps you are not persuading your team or using maximum charm as one member here keeps reminding us.  Perhaps ask to see a new technician with new ideas, more enthusiasm to try something new, or ask to see the manufacturer rep who will know their own product best?  Just keep at it Penguin and remember electrical disturbances like heart block/bradycardia/arrhythmias never stay the same, they are constantly changing to keep us guessing, so we will need to keep up, to keep adjusting those settings, our medication to respond to any changes.  It is the primary reason for regular settings adjustments, adjustments that many of us do not always get when we need them.  It is for us to keep pushing to improve our pacing experience, to report and to correlate our symptoms to a particular rhythm disturbance.  If we don’t do this, who else will in the present climate?

The detection rate setting for a high rate arrhythmia can be lowered by the technician during a pacing check.  They did this for my husband who only has a single lead to his right ventricle.  For us, this would then mean other features would become more active like Mode Switching in response to a lower tachy arrhythmia detection rate. It would clearly be more work for them to get our settings finely tuned to suit us.  As we both know, changing one setting will affect another which would then need adjusting, which is why I suspect they would rather leave settings alone unless there is a good reason to make a change. 

I understand your overriding concerns about your programming issues and your belief that these are connected to your symptoms.  I believe this is partly true.  I also believe your bradycardia induced arrhythmia at rest is triggering the missed beats and higher heart rates.  I believe your Settings need adjusting to keep pacing delays to an absolute minimum to help with these new disturbances and to try to overdrive pace these slower rhythms whenever they occur.  You will need to look at several settings to keep pacing delays to a minimum and this should be part of a separate discussion, but you and your team should not be overly concerned about using up more battery from any adjustments since your main concern surely has to be to “feel better”.


by Penguin - 2023-10-21 06:38:29

Some good points made - thank you.  They all make a great deal of sense and may well be relevant. I've learned to 'wait and see' though and to take good advice like yours as a guide as to what 'may be happening'. 

I have largely given up. I've felt better for a few months and these symptoms are nothing like the symptoms I had from over sensing. They're minor in comparison, but as you say they need to be looked into. 

I feel as if I've had an implement for torture rather than treatment implanted into me.  It's hard to be optimistic and persistent when every attempt to sort things out underlines the unsuitability of this device. 


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