Slow heart, and chest pain, help please

I do not have a pacemaker yet, but my heart rate at rest is often in the 40s and dips into the upper 30s at night.  I am not an athlete, but fairly active.  I have sinus rhythm, but have had a slow heart for 10 years, was told it is Sick Sinus Syndrome.  I haven't had any significant symptoms until now.  I have chest pain (angina?) often, everyday, and I read that can be from untreated slow heart, bradycardia.  My cardiologist is holding off putting in a pacemaker.  But the chest pain is uncomfortable and hurts more on the heart beats.  Has anyone had anything similar?  And how low a heart rate is too low?  Doesn't the 40's seem too low?  I am sick with worry, so any response would be welcome.


get another opinion

by Tracey_E - 2019-08-16 21:59:30

I don't know why some doctors hold off. If you are borderline and not symptomatic, sure. But if you are borderline and don't feel well, if you can't do what you want to do,if it's affecting your ability to enjoy life, why put off something fairly simple that can fix it?? I would get another opinion. When was your last holter?

Under 60 is bradycardia. Under 50 means it's time to think about pacing. 

Bradycardia symptoms and treatment

by ar_vin - 2019-08-16 22:02:32

Welcome to the PM club!

Please take a moment to complete your profile so you may get reasonable responses.

It's unclear why your "cardiologist" has not already referred you to an EP (electrophysiologist) for diagnosis and possible PM implant. It might have something to do with where you live (country of residence).

In the US (and I imagine in other countries, but I'm unsure)  it would be very unusual for some one in your situation to not be already implanted with a PM if indeed you have a confirmed bradycardia and/or "sick sinus syndrome" diagnosis.

I'd suggest seeking a second opinion ASAP from an board certified electrophysiologist (EP) - this is a physician who is trained as a cardiologist but has further training in the electrical system of the heart.

I won't try to diagnose you but I'd guess the symptoms you're experiencing sound like the ones I experienced after being diagnosed with "sick sinus syndrome". You need immediate professional EP care NOW!


Hold off on pacemaker--why?

by Gotrhythm - 2019-08-17 15:25:21

Ditto everything ar-vin and Tracey said.

But finding a new cardiologist is not as easy as ordering from Amazon. if you're not quite ready to ditch this cardiologist, you at least need to understand his thinking so that you know for sure if what he thinks is important is tnhe same as what you think is important. 

One way to get information from a doctor is not to ask direct questions like "do I need a pacemaker or don't I?"  Instead ask him to tell you how he sees the the pros and cons of "holding off" vs installing pacemaker now.

Of course, if he doesn't want to discuss it with you...reread Tracey and Ar-vin's answers.

And recognize that you may have to travel to find the EP/cardiologist you need.

Delay Pacemaker?

by AgentX86 - 2019-08-18 00:06:26

That's nuts.  Angina is a very strong warning sign.  IMO, there is no excuse for a cardiologist to delay treatment for angina.  It's your body's warning that your heart is starving for oxygen.  There's no guarantee that a PM is the fix but you cardiologist should be finding a fix - now!  As the others have said, there is no reason to delay a PM, if that's the fix, either.

Thank you and more questions!

by Pondreef - 2019-08-18 16:00:22

Thank you everyone for responding!  I feel better just from that.  I now have an appointment with an EP this coming week and have a better idea what questions to ask now.  If I need a PM, I am ready to get one.  Has anyone had angina go away after PM installation?  What type PM do they use for SSS?  Will I be on drugs too?  


by Tracey_E - 2019-08-18 16:22:09

Any pacer will work for SSS, but depending on your activities some types of rate response might be a better choice than others. Rate response is when it senses that you are moving and raises your rate for you if it doesn't go up on its own. Some use motion ( accelerometer), some use breathing (minute ventilation) and some use Closed Loop Stimulation which I don't really understand. It learns you and is the most sophisticated. If you like to ride a bike, the one with the motion only is not a good choice because it won't pick up on the movement. This is a discussion to have with your doctor. You also want one that your doctor knows inside and out, because they are only as good as the programming. 

If all you have is a slow heart rate, you will not need any drugs. If you also have racing or afib, then they will prescribe meds to go with the pacing, but just a slow heart you shouldn't need anything else. 

Everyone is different, but I'd felt so bad for so long that I was practically giddy when I got the pacer. I suddenly felt normal and it was wonderful. I was awake and alert and not dizzy.  I've never looked back. My doctor put it off because of my age, which is why that's a giant pet peeve of mine now. If it will fix the problem, just do it. Why wait? Good luck. If you have more questions, don't be shy. 

PM for SSS

by ar_vin - 2019-08-21 14:14:13

Tracey_E already provided a great response. 


[Please note: The following is not meant to be a diagnosis but pure speculation based on my similar experience of sick sinus syndrome. The best part was that all these symptoms disappeared once my PM was implanted.]

What you experience as "angina" might actually be PVCs and other secondary ("ectopic") beats. When the sinus node (the primary pacemaker in your heart) fails to fire, many other parts of the heart take on the pacemaker function. These beats are felt as weird sensations in the chest and could be mistaken for angina and squeezing in the chest area and diaphragm.

if your diagnosis is "sick sinus syndrome" and nothing else you'll most likely get a dual lead PM: one lead for the right atrium and the other placed traditionally in the right ventricle  but quite commonly now on the bundle of His ("His bundle pacing").

Medtronic, Boston Scientific and Biotronik are the common PM vendors.

If you're pretty active you must ask your EP for a PM that will help you continue your activities post implant. Biotronik with the CLS algorithm seems to be the best for the widest range of activities. It uses an additional sensor beyond the accelorometer that Medtronic PMs use; the additional sensor tracks levels of hormones in the blood in the heart. This hormone (norepherine among others) signals stress - both emotional and physical (exercise). The PM uses the sensed hormone levels to pace your heart accordingly just as a healthy sinus node would thus providing a more "natural" pacing level. 

All the above three PM brands also use an accelorometer to sense activity to pace you accordingly - this is called rate response which can be turned on or off and it can be adjusted to your activity. 

Watch this:



More questions

by Pondreef - 2019-08-21 22:15:24

I can't thank you all enough for all the information everyone has provided.  It is a great comfort to me.  I live in Alaska and flew to the Cleveland Clinic.  The EP I saw ordered an ECHO/STRESS test for me.  The test showed that the pumping part of my heart was good.  However, the upper left chamber of my heart is severely dilated.  He said that puts me at a high likelihood of developing Afib.  He doesn't know why it is stretched, because I have always had normal blood pressure.  As far as the chest pain/angina, he wants a Holter test to help determine what is going on.   I'm assuming that will show PVCs and ectopic beats.  Does anyone know if having a pacemaker implanted increases the risk of Afib?  Either during the procedure or anytime afterwards?

PMs and AFIB

by ar_vin - 2019-08-22 01:50:11

Being diagnosed with some form arrythmia predisposes one for future potential rthythm disorders though this is not always true. PMs in general are not known to cause AFIB but some people that have PMs (for rthythm disorders) go on to develop AFIB. A lot of people that have AFIB are often unaware that they do have AFIB; others are very aware of the AFIB. 

I'm sure many who have AFIB on this forum will weigh in with their experiences.

That said PMs ARE a known cause of "pacemaker syndrome". This seems to develop most commonly in PM recipients who are paced in the ventricle; it doesn't seem to show up in those that are paced predominantly in the atrium.

Studies have shown that "His bundle pacing" results in lower rates of "pacemaker syndrome". I'd urge you to discuss "His bundle pacing" with your EP even if initially you'll be primarily atrially paced. It is by now a pretty common procedure and in fact the preferred way of placing the second lead at many centers around the US.


PM's and AFIB

by charlene - 2019-09-21 00:09:42

I had a PM implanted on July 5 of this year. 

I have a history of SSS and AFIB.  My Cardiologist has put me on Sotalol to help, along with the PM, to keep the HR in "line".  I also take Lipitor and Xarelto.

Thus far, I had one small episode the day following surgery because I had just changed to Sotalol and didn't have enough of the med in my body.

At this point, I can say that all has been going much better than I expected and I feel like my old self again.  There was an adjustment period, of course; however, the meds and PM have been working well together and there hasn't been so much as a hint of AFIB. I can always tell when an episode is about to occur.

That's my story. Hope it helps.

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