Heart going below lower bpm setting

Unfortunately, I spent about four hours in the emergency department today in the wee hours. I have been coughing for three days with a lot of mucus, and a runny nose. I had awakened at 2:30 AM with a super tight, burning throat and felt like I wasn't getting enough oxygen.😵‍💫 My pulse oximeter read 90 and my normally low bp was rising. I went to the hospital emergency room thinking maybe I had pneumonia. 
 

Two chest xrays and tests for flu and covid were normal. However, I tested positive for RSV.😫 I was sent home with no meds, as they said no meds help this virus. I was told to drink honey lemon tea, take Tylenol, use nasal saline, a humidifier and salt water rinses. I have laryngitis from it and was told I might lose my voice. I'm being very quiet😉

It can last one to two weeks. Ugh. It's also disappointing to still feel the same after leaving the ER as I felt upon going there.

My question is this: while hooked up in the hospital to the monitor, my pulse was initially high but as I laid there it dropped and dropped. It hovered 60-62bpm. What surprised me was seeing it drop a few times to 58, then 57, at one point 55bpm. 

How can this happen since my pacemaker low rate is 60? 


13 Comments

Ectopic beats?

by Gemita - 2024-02-10 03:23:24

Lavender, I am so very sorry to hear you have been back to ER and that you are feeling so poorly.  I do hope you are staying well hydrated, having plenty of rest and eating good wholesome food and have not picked up anything more from the Emergency Room?  The number of folks around us with these viruses are increasing too.  

Did they do a check of your pacemaker while in the ER?  I am not at all surprised that your heart is throwing a few wobbles.  It sounds like ectopic beats because they are usually the cause for my lower heart rates (below the set lower rate limit).  Unfortunately they always tell us that these are early benign beats, followed by pauses which home monitors fail to pick up accurately, but they certainly don’t feel like normal beats that we can ignore.  In my experience, my pacemaker cannot usually help with these short, long, short sequence beats which appear to adversely affect my blood pressure and lower my heart rate and I am not the only member who has reported this.

The reality is that many of us do feel these inefficient beats, the pausing, the slowing and these beats can indeed cause symptoms such as those you describe.  In fact we have had many members post here about this very dilemma, for which our pacemaker usually has no answer.

From research I have learnt that ectopic beats, whether coming from the atria or ventricles may affect pacemaker timing and trigger other abnormal rhythm disturbances.  I am thinking here about pacemaker mediated tachy or brady arrhythmias.   All I can suggest is that you get help promptly should your rhythm disturbances or symptoms deteriorate, or better still send a transmission to your pacing clinic for them to have a look at your stored ECGs.  It maybe that you will need some medication or a slight settings adjustment to help with this until your symptoms from the virus ease.  Having said this, a five bpm drop, if we are fairly symptom free wouldn't be anything unusual for me.  It really depends how you feel and what symptoms you are getting with these lower heart rates?  During ectopic beats my BP monitor is often showing rates in the low 40s bpm for long periods and I certainly notice this.  Ectopic beats are frequent triggers for my Atrial Fibrillation.  

My doctors have tried to explain (not successfully!!) that when I see and feel my heart rates going lower than my base rate, it will be due to the ectopics resulting in the pacemaker not pacing due to a sensed beat. They reassure me that my heart rate would not drop below my lower rate limit which is 70 BPM.  However, they admit that the "effective" cardiac output from an ectopic beat will be significantly less than it would be from a normal (ectopic free) heart beat which is why I get symptoms with ectopics and feel as though my heart rate is in the 40s.  

Lavender, please don’t ignore any difficult symptoms which may need treating.  Did they check your electrolytes while in hospital and other possible causes for heart rhythm disturbances?  I do hope so.  A warm hug from both of us and I hope you will recover quickly xx

 

 

Low heart rates

by piglet22 - 2024-02-10 05:46:19

Lavender

For the last year I have been experiencing the effects of ventricular ectopics on pacemaker performance. It is currently under investigation and being treated with 10mg Bisoprolol daily, which may have it's own downside.

I was on an IPG base rate of 60 BPM which was regularly dropping to the 40's and sometimes 30's.

They raised the base rate to 70 with no effect.

Firstly, you have to be careful how you measure the "pulse" rate.

There may be an underlying electrical rate that includes things like ectopics that are sensed by the pacemaker but are not effective at pumping.

A personal point of view is that the palpable pulse is the most important as this directly affects how you feel, how much oxygen is circulating.

A low palpable rate is definitely something you will feel as pre-syncope, i.e tightness sensation in your head, or you simply blackout.

I'm not sure that oximeters or even full hospital grade ECGs deal well with ectopics.

I always turn to either the BP cuff monitor or manual radial pulse measurement to record what is going on. In the past, the oximeter, the same type as used by the GP, is great for normal heartbeats but is erratic when dealing with ectopics.

The consultant I saw was fairly clear that ectopics were the cause of my low palpable beats and that PM manufacturers had yet to provide a solution.

I've been keeping records of heart rate for decades now and using BP monitor data, my rate rarely deviated when resting from the base rate.

Maybe 59 or 61, but never down to 55.

I've only seen rates less than 55 since ectopics were diagnosed.

The base rate is what it says, the minimum rate.

I wouldn't be unduly worried by numbers you saw on the screen, but I would be worried if I felt at my wrist or saw less than 55 on the BP monitor.

Thank you

by Lavender - 2024-02-10 07:37:01

I was thinking pvcs. I wonder though if I have a resting rate built into my pacemaker because it happened while lying down and resting/nearing sleep. I have never heard of a resting rate??


I do have a home monitor which would pick up and transmit anything out of set parameters to my cardiologist. It does a nightly check. 
My heart felt fine when it happened and within a second, it seems, it went from 55 to 62. While in the hospital, they're watching my monitor at a central desk at all times. They know I have a pacemaker. No-they didn't do a pacemaker check at that time. No blood tests were done. I have been hydrating a lot because of the sore throat and coughing phlegm and actually asked to use the bathroom twice while in the hospital, so I'm not dehydrated. 🙃


I did make note of the date and time of occurrence and will discuss this with the pacemaker tech and cardiologist at my next pacemaker check. 

RSV is a pain in the neck/throat. I probably should have gotten the RSV shot, but oddly enough, my pcp advised against it back in October when I asked. My sister in law said her pcp also advised her not to get it.  The ER doctor said that as soon as I am well, to get the shot.

I am scheduled for a follow up appointment on February 19 and will ask more questions then about why my heart rate dropped. 
Thank you both for your thought provoking responses.  I surely was stunned when the rate went below 60. I honestly believed it could not do that with my pacemaker. I had zero symptoms from it and wouldn't have known it dropped if I hadn't looked at the monitor screen. 🧐

No blood tests? Unusual

by Gemita - 2024-02-10 08:48:52

Some of us have a night time sleep rate.  Mine is turned off because I do better with a 70 bpm rate 24/7, whereas some could not sleep with such a high rate.  

Resting heart rate will be different for each one of us depending on age, health condition, level of fitness, activity (e.g. sleeping, sitting, standing; whether we are anxious or calm and so on).   Some of us could go very low at night without problems.  I would struggle to do so, since a falling heart rate would trigger arrhythmias faster than anything else.

My base rate rarely changes.  It seems stuck at 70 bpm whether I exercise or not, except when I have rhythm disturbance like ectopics or other disturbances like Atrial Fibrillation.  Then I see both heart rate and blood pressure become volatile, going up or down rapidly.  You felt fine though when it happened and that is what counts, so I would say the virus probably triggered some rhythm disturbances and the visit to ER wouldn’t have helped either.

No blood tests were done in ER?  That doesn’t sound right at all and I certainly wouldn’t have been reassured or prepared to leave the hospital without some general blood checks.  It may have been a virus, but we can still have other conditions present that might need to be treated and a simple blood test would have given reassurance that nothing was being missed.  I once presented with a virus but also came away with antibiotics to treat a bacterial infection too.  Hope they haven’t missed anything, although I see you are due a follow up on February 19th.

Wishing you well

by Good Dog - 2024-02-10 09:44:29

As usual, I agree with everything that Gemita posted. I think that she said all that needs to be said! So I just want to wish you well! I want to add that I am amazed that even through all of this you seem to be able to maintain a positive attitude! You are an amazing person and I value your input here so much. Please take care and do as Gemita said, do not hesitate to re-visit or contact the ER if your symptoms become worse or more troublesome. 

Get well soon and know that we are thinking about you. God Bless you!

Sincerely,

Dave

Bloodwork

by Lavender - 2024-02-10 09:47:43

Yes I was expecting an IV to be started immediately but was surprised they didn't do that or take blood. I was told they are swamped with RSV cases so I think my description of symptoms set them straight to the nose swab multi test for flu, covid and RSV.

According to my discharge :

The Xpert Xpress Cov-2/Flu/RSV plus RT-PCR assay is cleared by the FDA, and the Xpert Xpress Cov-2 plus RT-PCR assay is under the FDA's Emergency Use Authorization.

That was done within fifteen minutes of seeing the doctor and RSV was found. Two views of the chest were ordered but not taken for hours because they were so busy and understaffed. 
Those results from the radiologist were:

No acute cardiopulmonary abnormality. 

CLINICAL HISTORY: Dyspnea. TECHNIQUE: Two views of the chest were performed. COMPARISON: 10/28/2023. FINDINGS: The heart size is within normal. There is no mediastinal widening. Biventricular pacemaker is in place with leads overlying the right atrium, right ventricle and coronary sinus. There is no acute consolidation effusion or pneumothorax. Soft tissues and bones are unremarkable.

The ER dr was so young and she had those purple and red streaks in her hair  lol looked like a hippie, but in reading her background after getting home, I was impressed that she is a professor who teaches other ER doctors and has great credentials, her bedside manner and patience in answering my questions was wonderful. Her chart notes:

Lung auscultation was unremarkable. Presentation does not seem consistent with ACS, PE, aortic pathology, myocarditis, pericarditis, pneumothorax. I did order chest x-ray imaging for further evaluation though my suspicion for bacterial pneumonia is low. I sent COVID/flu/RSV testing for further evaluation. 

Chest x-ray, as interpreted by myself, does not demonstrate any focal consolidation, nodule, or atelectasis. There is no mediastinal widening. The cardiac silhouette is not enlarged. There are no pleural effusions or pneumothorax. The bony windows do not demonstrate acute fracture.

I think given my symptoms and the high influx of current RSV cases, they followed their protocol. I have never been there that they didn't place an IV and take blood and urine. I was told to see my pcp within one to two weeks and when I called for that-they gave me February 19 and said to call them or return to ER if I get worse. 
 

Dave, thank you for your supportive words. ☺️What choice do we have when we are sick? I am so tired of illness but it seems that I just have to move forward. In hindsight, I should've gotten the RSV shot, but we do trust our pcps. He felt I should not have gotten it. It's one of those second opinion things-the ER doc thinks everyone should get the shot. 🤨

Diagnosis:  Acute laryngitis due to respiratory syncytial virus (RSV)

I may call Boston Scientific or my cardiac nurse on Monday for an explanation of how my bpm can fall below my setting of 60. I saw it was 59 for a moment on my home pulse ox when lying down this morning- so maybe it's always done this and I never noticed. 🤔🤷🏼‍♀️

I can say that RSV is the worst sore throat ever and tons of coughing. Just awaiting getting past the worst of it which is supposed to be from day 3-5. I am on day five. Tylenol helps some. Steam from a cup of hot tea helps. Salt water rinses help as does cough drops but it's getting old. 😷

Oh and

by Lavender - 2024-02-10 10:21:12

My boyfriend probably has RSV too. He's been sick 12 days. He saw the pcp three times and was diagnosed with flu. I never thought it was flu but they never tested him for RSV or flu.  He tested negative for strep and covid at the pcp. He was given prescriptions for steroids, antibiotics as well as cough pearls. No bloodwork done. 
 

While he was with me in the ER, the ER dr heard his coughing and he told her his symptoms.  She told him he probably had RSV all along too and that none of those meds would hurt but wouldn't help the RSV. 😑 We did notice the meds not improving him.  
 

I am about to nail a quarantine sign on the front door. It will be a party of two here for the Super Bowl. We don't care who wins and are sick of Taylor Swift media coverage. We will have our pjs on, humidifier going, kleenex nearby, cups of tea and favorite blankies as we watch those commercials and halftime show...if we aren't napping. 🥴

Sending Warm Wishes for a Speedy Recovery

by SeenBetterDays - 2024-02-10 11:37:10

Hi Lavender

I'm so sorry you have been feeling so poorly, the symptoms sound miserable.  It sounds like the two of you are keeping cosy and warm though and at least you can cuddle up without fear of infection if you both have it!

You are always the one who is so full of warmth and reassurance for all of us when we are going through challenges so just wanted to send you all my love and really hope you are feeling better soon.  I know that whenever I have a virus or infection I tend to feel palpitations and ectopic beats which can be unnerving.  I have also experienced rates below my base rate and think, as other members have noted, that the pacemaker senses these half beats and so does not provide a signal during these times.  I am not sure if there is any way around this but definitely query it if you feel you are getting these low rates more regularly or they are making you feel lightheaded or unwell. Hopefully once this pesky virus has cleared you will return to a steadier more consistent rate again and all will be well.

Sending you hugs and hoping that Taylor Swift doesn't tip you over the edge! Keep smiling Lavender.

Rebecca x 

I am reassured!

by Gemita - 2024-02-10 13:43:21

Thank you for the full discharge results Lavender.  You have convinced me that you were well cared for in ER by such a smart young atypical professor!   If things deteriorate after your hibernation period, then you will know what steps to take next but it sounds as though you will recover well.

I shall be interested to know what your Boston Scientific Rep or Cardiac nurse offers in the way of an explanation for your slightly lower base rate.  As already mentioned, a slightly lower base rate is usually not significant if we are not getting symptoms.  We all experience this from time to time.  There are a couple of things that I know about that can cause a change in our Base Rate and I list them below, but generally unless my base rate drops more than a few beats below 70 bpm and stays there causing symptoms, suggesting my heart is struggling, I don't usually worry about it.

When doctors review device diagnostics such as electrograms or rate histograms they may see paced or sensed atrial or ventricular rates below the programmed Lower Rate Limit. Frequently, these “lower” rates are normal device function resulting from programmed features or standard sensing algorithms.  Atrial and/or ventricular rates below the Lower Rate Limit can be the result of over-sensing or caused by Rate Hysteresis, Atrial to ventricular conduction delays, or due to PVCs that can upset the timing of a pacemaker.  I am trying to put together a FAQ paper on this subject about abnormal rhythms in which the pacemaker plays a role.  

😷

by Lavender - 2024-02-10 15:23:06

SeenBetterDays-(haven't we all? Lol)-Thank you for your response. Yes BF and I are both tucked in and coughing in synchrony at times 🫢misery loves company. It's eye opening to know that others have experienced going below our set low rate. I had no idea this was even possible. Lol about Taylor Swift. She was actually the opening act (when she was 16) at a concert I attended to see others! A total unknown-people ignored her, walked around and paid little attention to her. I thought she looked like a little girl with a big dress on and extremely long curly hair. It's a big joke in the states that she's taking the attention off the football game when she's in the stands. 
I appreciate your supportive cyber encouragement and feel the hugs. Thank you. 
 

Gemita-I do intend to ask why/ how we can go below our set rate. Will get back to you. Right now my voice isn't even such that I will call anyone on the phone to ask. As usual, you have me learning. I had to look this up:

Hysteresis is a programmable feature that allows the pacemaker to begin ventricular pacing only if the spontaneous rate falls below a set rate (in this case, 50 bpm); then pacing continues at the programmed base rate (60 bpm) unless intrinsic ventricular activity is sensed. The purpose of hysteresis is to allow a slight delay before stimulation at the base rate (ie, more time for a spontaneous QRS to occur), which preserves battery life and avoids unnecessary pacing.

Thanks so much for putting my mind to work and also at ease 🤗

Hysteresis & Sensing

by Penguin - 2024-02-12 08:30:54

Hi Lavender, 

Sorry to hear that you are going through this. My best wishes to you.

Re: Hysteresis - If you have one of these programmed it should be in your interrogation paperwork under settings / parameters. 

Re: Sensing - Oversensing (which Gemita mentions) happens when the sensing parameters are programmed at a lower setting than usual. Oversensing cause the PM to pick up sensations / stimuli that it would normally ignore. This may 'con' the device into thinking that the stimuli (referred to as 'artifact') are your own electrical impulses and it may therefore decide not to pace or get confused if there are a lot of them. 

Med Mastery on Youtube have a very good tutorial (simple to understand) on oversensing here: 

https://www.youtube.com/watch?v=rj0qwxHgs_s

Usually sensing is programmed to around 2.0mv.  If you look on your interrogation papers and the sensing is programmed much below this, your problem 'could' be oversensing, but it would be rare for it to happen out of the blue and if you've not had problems before. 

Hope this helps you sort out what's hopefully 'not' going on

Penguin

by Lavender - 2024-02-12 12:42:05

Thank you for your comments. I have a call out to the cardiac nurse as to why my bpm went below 60. Will advise everyone once they get back to me. 
 

In looking at my last pacemaker report I find no settings for hysteresis.

Ventricular Tachy EGM Storage   On

detection rate 160 bpm

 

Brady/CRT Settings

DDD Mode

60 ppm Lower Rate Limit

130 ppm Maximum Tracking Rate

130 ppm Maximum Sensor Rate

180 - 180 ms Paced AV Delay

120 - 120 ms Sensed AV Delay

240 - 280 ms

A-Refractory (PVARP)

230 - 250 ms

RV-Refractory (RVRP)

250 ms

LV-Refractory (LVRP)

BiV

Ventricular Pacing Chamber

 

LV Offset

0 ms

My voltage settings are:

Pacing Output

 

Atrial

2.5 V @ 0.4ms

Right Ventricular

4.0 V @ 1.0ms

Left Ventricular

2.0 V @ 1.0ms

Sensitivity

 

Atrial

Fixed 0.75 mV

Right Ventricular

Fixed 1.5 mV

Left Ventricular

Fixed 2.5 mV

Leads Configuration (Pace/Sense)

Atrial Bipolar

Right Ventricular Bipolar

 

 

 

Format

by Penguin - 2024-02-12 13:23:34

Sorry Lavender, but that's a bit tricky to read in that format.

I have a lot more settings than that showing on my interrogations, but if a hysteresis isn't shown under settings it's unlikely that it's programmed. 

I meant to say that the average atrial sensing is usually around 2.0 mv but it can be made lower / higher. 

I forgot that you have a CRT. I don't know where they set sensing for the left and right ventricle. 

Let us know what advice you receive. 

Good luck x

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