Boston Scientific Accolade Exercise Settings

I  enquired ( by e-mail)  from my hospital pacemaker physiologists  whether I could get  some relief from breathlessness on exercise initiation, which remains a problem for stairs, lifting, and the start of length swimming etc. Her kind response is the following:

"I am more than happy to look at your rate response again .I am aware of the Boston literature; however my personal experience is that the main benefit is in patients whose only form of exercise is cycling . In other forms of exercise is tends to “ stunt” the accelerometer response .
We cannot curtail the MV aspect just to initial exercise , it would remain throughout your exercise .I think if we add the MV again we could possibly lose the other benefits that you describe."

I have looked at and noted what others in this club have suggested previously with mixed results.

The pacemaker manual

( https://www.vingmed.dk/wp-content/uploads/sites/3/2015/11/Proponent.pdf)

suggests that REACTION TIME may be the best answer. ( ref.2-29) Also, upon exercise, the blended response ( that is the minute volume [MV]/breathing blended with the accelerometer)  will promptly (within 4 seconds) increase the rate based on the Accelerometer response. As the rate continues to increase, the blended response will be moving toward the MV response, but will always remain between the Accelerometer and MV responses. At higher rates, the changes in Accelerometer input will have a lesser effect on the blended response (only 40% at MSR), whereas changes in MV will have a more significant effect.

My pacemaker physiologist thinks that bicycling benefits from the minute volume response ( called RightRate® by Boston Scientific) . I wondered whether there is anyone reading this  who has tried the blended response for swimming,  dancing, or  flights of stairs  to try to avoid the breathlessness (gasping!) that comes from starting these activities.

  Clearly my physiologist urges caution as my accelerometer response, once I do get warmed up is OK for swimming lengths. My physiologist thinks that switching on the MV response would adversely affect the accelerometer response.

Many thanks for your response.

Best wishes to you all for 2024.

Selwyn 


6 Comments

Previous similar question

by Shroselo - 2023-12-28 10:34:47

https://www.pacemakerclub.com/message/40355/shortness-of-breath-on-starting-to-exercise

Boston Accolade Exercise Settings

by Selwyn - 2023-12-28 12:07:47

Thank you Shroselo - as I said above, "I have looked at and noted what others in this club have suggested previously with mixed results.", your  http does point me to my previous deliberations to try to get this problem fixed.  Sadly,  I remain the same, 2 years on.

 Anyway, I am off to the clinic tomorrow morning to try to improve on the situation with a blended response between minute volume and accelerometer. I think maybe the REACTION TIME is the answer. If this can get down to 4 seconds, maybe there is hope, though clearly I don't want to be running unnecessary high heart rates.

As crustyg says, it is a minority problem. One for the last few years I have struggled with. Hopefully, I can report some improvement. This will clearly be of help to others in the same situation. 

My NHS electophysiologist has not given up. Today, she offered to see me tomorrow. Thank you Liverpool Heart and Chest Hospital. 

 

 

Breathlessness

by doublehorn48 - 2023-12-28 12:31:05

I saw my EP a couple of months ago. I told her that I thought my settings were right on my pm, but that I still get breathless going up stairs. She told me that I should tap on my pm before starting upstairs or any physical activity. Your pm senses movement and this would fool it into thinking there was movement.  My only problem is remembering to tap on my pm before starting up the stairs and then trying to remember why I went up the stairs in the first place. It does seem to help.

Hope things will improve for you soon

by Gemita - 2023-12-28 14:24:29

Hello Selwyn,

I am sorry you are still struggling with breathlessness at the start of exercise, particularly during certain activities.  It is difficult to know just how much this is caused by your particular heart condition, including some break through intermittent tachy arrhythmias which I think you are still getting, or whether you can do better with those settings? 

There is no doubt that in the presence of any rhythm disturbances your electrophysiologist will have a harder task but she sounds charming and certainly willing to try something new.  

I hope your appointment goes well.  Please let us know which settings are changed and whether the Reaction Time can be effectively reduced without triggering other problems.  We are all individual with very different conditions so this can only be trial and error until you find what works best for you.  It is frustrating I know to still be in this position 2 years on but your goals are certainly demanding!  And why not?

Boston Scientific Accolade Exercise Settings

by Selwyn - 2023-12-29 10:05:58

My visit to the department today - what I learnt:

1. I have been in atrial flutter with partial A-V block since 11th December  ( Hence my heart rate has been controlled, though my ability to exercise is reduced as I am not getting any atrial active filling).  Hence the breathlessness on starting exercise, I have to wait for the accelerometer to kick in and then my venticles are paced.

2. Previously they tried the Minute Volume setting for me  and it made my  exercise tolerance worse - this is because it partially  knocks off the accelerometer response.

3. My rate response speed of onset has today been increased from 14 to 16.  ( 12 being about 'middle of the road').

I have been referred back to my electrophysiology consultant . I discussed with my physiologist the possibility of yet another cardioversion ( Last time they burnt my chest!). Although I have had a flutter ablation , who knows whether another would be of benefit.  Rate limiting therapy is not an option (given the partial A-V block), I would be looking at rhythm altering therapy - Flecainide is contraindicated in structual heart disease, I think perhaps I would be looking at Amiodarone for 12 months after cardioversion, and if that failed a further ablation, if possible.

Gemita - you were quite right about the problem. Wisdom beyond words.

My thanks to the NHS Liverpool Heart and Chest. Not only have I been seen within 24 hours of asking, I am now being referred directly  to my cardiologist without having to go via my GP. 

On the positive side of things, I did manage to swim a mile after my fine tuning of the PM this morning. My Kardia  ECG is just a mess - very difficult to see the flutter when being paced, though once I waited for the rate response to settle you can now see some flutter waves ( saw-tooth pattern baseline).

4. What I have learnt today is that I should blame my underlying pathology  first before blaming the pacemaker if I have a change in my exercise tolerance.

Thank you for your thoughful and kind  comments to this posting. 

What Settings are activated to help with your arrhythmias?

by Gemita - 2023-12-29 13:48:22

Selwyn, it is disappointing news, but not unexpected with your history.  I am glad you have been referred back to your EP.

It seems you were partly asymptomatic (other than the exercise initiated breathlessness) while in Atrial Flutter, so maybe that is a good sign that your pacemaker has helped to reduce your symptoms.   I think though we have every right to be disappointed and to expect more from our pacemakers.  I know I am always questioning what more can my pacemaker do to manage my intermittent arrhythmias?  I hope pacemakers will have a greater role to play in the future, since clearly medication and ablations alone are not always the answer.

Yes I too got a burnt chest during my last 3 x cardioversions during an EP Study when they couldn’t stop my AF until they gave intravenous Flecainide.  They discharged me on Flecainide but I do not have structural heart disease.  They offered Amiodarone but I felt Flecainide would be safer as a starter med and it proved to be so.

I hope the rate response speed of onset set at 16 will help and not cause worsening Flutter.

I think one question to ask your EP might be whether all your settings are optimally set to help control arrhythmias?  I know some Boston Scientific members find the Rate Smoothing algorithm helpful to control the pacemaker’s response to atrial or ventricular rate variations which can be a frequent trigger for arrhythmias like AF, Flutter, NSVT.  

I find atrial premature beats (APB), particularly the pauses after APBs, most definite atrial arrhythmia triggers.  Many devices have algorithms that may be activated in order to reduce the number of episodes of atrial arrhythmias by suppressing APB activity or reducing the short–long sequence seen with an APBs.  Rate Smoothing is one such setting, but it can be tricky to get right, so you may need to work with your technicians.  Since you have started exploring the pacemaker route Selwyn to find a fix, I wonder whether it is worth further exploration of any arrhythmia Settings before you go down the ablation and/or Amiodarone route which will be more invasive.

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