Beta Blocker

In November, a 2-lead pacemaker was implanted. I was placed on blood thinners and one month later I was cardioverted. For several years leading up to the implant I had Atrial Flutter. It was episodic but at times it lasted up to 3 hours. My typical pulse was 40-45 primarily because I was a distance runner. When in flutter the upper chamber would beat 300-500 bpm while my lower chamber would remain at 60. The pacemaker was implanted when my pulse  eventually dropped to 25 on the day of surgery. In addition, the atrial flutter changed from episodic to constant. The implant increased my pulse, at first, to 60. It is now set at 55 even though the doctor said it can be lowered to 40 because of my running (I still run distance everyday with only a short break. to recover from surgery). The cardioversion reset heart rhythms and the constant atrial flutter was resolved. However, about 2 months after my doc said they saw right ventricle myopathy. Another echocardiogram was orderd and I was placed on beta blocker with aspirin. The doctor, at the time, was preparing me for another surgery to go from a 2 lead to a 3 lead pacemaker. Psychologically I was prepared. I isolated myself from the world about two weeks before California went under mandated stay at home. Than things changed. With the virus the doctor said I should stay away from the medical center as much as possible. I was syptomatic. I lose my breath easily and experienced horrible fatique. But... all of a sudden I no longer needed surgery because there was no advance in the right ventricle myopathy. However, I was to remain on meds. Eventually I was allowed to go in because I kept complaining about  how I felt. Techs and a nurse practioner adjusted the pacemaker. Apparently the function of how a pacemaker adjusts to the level of activity a person engages was turned off. It was corrected. All symptoms were gone. I able to run longer and harder without additonal distress. I'm wondering, do I need to be on Metoprol and aspirin? I am not going stop on my own. Only if the doc says so. However, getting straight answers right now is not going to happen. All the docs at UCLA Med Center in Westwood and Santa Monica are under a lot of pressure dealing with the numbers of patients with covid sypmtoms. Isn't beta blockers for people with high blood pressure? I don't have that. When I was first placed on the med the entire week I felt HORRIBLE. I struggled to get out of bed. Now I seem to be ok but I fail to see the benefit especially after the pacemaker was adjusted. I also am wondering, post vaccine development will I all of a sudden have to get that 3-lead pacemaker again? LOL

Phillip Cohen


3-lead (AKA "CRT")

by AgentX86 - 2020-04-22 00:53:31

A 3-lead pacemaker is normally only used for patients with cardiomyopathy and a low left-ventricle ejection fraction.  I'm not sure about th right ventrical.  I'd worry about pulmoary hypertension but I'm not a doctor.  Whether or not you need one isn't clear.  Your doctor know a lot more than we do.

A cardioversion is only bandaid.  It might work for a while, it might not.  As they say, a cardioversion always works and lasts between 10 seconds and ten years.  My first was good fr 7 years.  After that it went down fast.  I had one right after my CABG surgery that didn't last until I got back to my room.  That's not to say it's useless.  It's a simple and safe procedure and probably worth a try.

Aspirin is useless as an anticoagulant for Afib/flutter.  If you need an anticoagulant, you really need something better.  Warfarin and Eliquis are the most common for this.  Eliquis is the safest but it's a lot more expensive.

Yes, metoprolol is still needed.  Lowering blood pressure is really a side effect of beta blockers.  If that's all that was needed, they'd use something else. Beta blockers main function is to lower heart rate.  If you have Afib/flutter, this is paramount.  High heart rates for long periods of time damage the heart and, if not treated can cause Vtach or Vib and death.  Metorporlol slows conduction in the heart so this doesn't happen.  Your heart rate is OK but that can change quicly.  With an atrial rate of 300+, things can go South quicly.  Metoprolol is a very common drug with fairly benign side effects.  The main side effect is lethargy and drowsiness.


by runpacer - 2020-04-22 15:00:57

Thanks AgentX86. I think you responded to other questions I posted in the past. I returned from a morning run. For the 4th or 5th day in a row I ran 6.2 miles or more. Everything, ever since techs adjusted my pacemaker, went really well. I was placed on Eliquis after the pacemaker was implanted and up to a month after the cardioversion for a total of two months. 

You may be correct about which ventricle was initially in need of that extra lead.. right or left... I would have to search notes from the doc. I haven't been in extended flutter since the cardioversion in December. The doctor thought that it would hold for the balance of my life. Either he thinks it would hold for many years or he believes I'm about to kick the bucket. It is disappointing to read that the cardioversion effect on flutter may not last that long. 

I worry about the Metoprolol. If it lowers heart rate when I normally have a slow heart rate from running doesn't that place me in danger? Also I have low blodd pressure. I've always had. Wouldn't the Metoprolol lower it to some dangerous level? 

I have another question. The area where you had the incision for placement of the pacemaker did it ever leave you with sensations that it was going to open up or pull apart? I sometimes get transient sensations at the surface level of the incision that it is about to tear. It may happen when I absent mindedly rub that area.

thanks for the info.


Pacemaker tuning

by AgentX86 - 2020-04-22 23:02:54

Good to hear that your PM tech was able to help get you back to running.  My running days are long over (knees and feet would never put up with it) but I walk a lot (17mi today).

The ventricular lead always goes in the right ventricle.  The left ventrical isn't accessabe from the veins (they'd have to go into the pumonary vein which only goes from the lungs to the left side. Accessing the lungs to tap that vein would be problematic.  ;-)  When they add the second ventricular lead it's not really in the ventricle, rather a vein in the right ventrical that supplys blood to the left side heart muscle.  That's why it's a difficult procedure.  The EP has to hit that vein in the RV and snake the lead through the vein to the left side.  It takes a very talented EP.

Or he's trying to BS you.  as I said, sometimes it works for a while but the problem is still there.  Flutter is caused by a "re-entrant" circuit.  Some part of the heart starts a heartbeat (not necessarily the SI node).  Then the signal goes around the heart and ends up at that area of the heart, triggering it to launch another beat.  The length of the loop determines the atrial rate.  All a cardioversion does is temorarily stop the heart so the ectopic beat doesn't start.  The circular pathway is still there waiting to be kicked again.

Yes, metoprolol lowers the heart rate but you have a pacemaker to keep it up.  This is a common use for a pacemaker.  My EP wanted to do that for me, so he could use more drugs for my flutter that would make my heart rate dangerously slow.  The drugs, instead, caused SSS so I needed the PM to survive. That was it for the drugs.  I'm still on metoprolol, though, to try to settle down the flutter (it's still there but I no longer feel it).

Sure, there are all sorts of sensations while the wound is healing and some (perhaps a long) time after. Nerves have been cut and it takes some time for them to regenerate.  While that's happening all sorts of pain, itching, and touch sensitivty can crop upt.  The scar tissue can often pull, as well.  This is all normal as the wound heals and some time after as the nerves heal.

Even after five years, my sternotomy scar/area will get really sore or itch.  My PM incision will also (two years).

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