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What Causes Lightheadedness, Shortness Of Breath, Bradycardia And Weakness?
Question: Hello Dr. Sharka,
I need to tell you that I personally have a medical condition that limits my ability to function in a consistently normal way. Consequentially, I'm often not able to respond to people as timely as I would like to. That was the case after you responded to my last question(s), regarding my Dad's heart condition. So let me say now, that in general I understand and appreciate all of your answers to my last responses. They were very helpful when it came time to meet with his electrophysiologist.
Now if I may..... I'd like to start this new official question where my last queries left off. To avoid confusion regarding my previous questions and these new ones, I'll use letters today instead of numerals.
A) Regarding CRT: I believe your suggestion regarding CRT was a good one. However, his electrophysiologist feels that his narrow QRS interval indicates that his heart is currently demonstrating good synchronization. I'm sending along in an attached documents with one of our 3-lead EKG tracings from 06-17-2015 to see what you think of that assessment.
So what do you think?
B) Regarding you comments about investigating other possible reasons for his symptoms i.e. low energy, light headed/shortness of breath, foggy mind, etc: I am comfortable (at least for the moment) that we have adequately considered metabolic dysfunction, liver and renal dysfunction, and mental dysfunction. We met with his electrophysiologist on 06-18-2015 (this was our first and only meeting so far), and based on all of the data and test results and information in my Dad's file, he is convinced that a pacemaker is called for --- specifically, a ICD 2-lead pacemaker. He was hesitant about altering the amiodarone or metoprolol for fear that an Afib episode might ensue, and it might take some length of time to return his heart back to a proper rhythm. Thinking about what's in my Dad's medical file, probably the most significant piece of information that you don't have, are the results of a 24-hour Holter monitoring test on 03-26-2015. I have the full 16-page report, with the tabular summaries, hourly summaries, major event log, period histograms, and QRS forms. Is it possible that data in that report might indicate a more certain conclusion that a pacemaker is warranted? (I would be happy to forward to you any part of that report if you would like. Just let me know.) So my question is ultimately this, the electrophysiologist believes my Dad should as soon as is practical, have a pacemaker put in.
Based on everything you know at this point, what do you think about that conclusion?
C) Regarding a significant error in my previous communication: Previously (on 06-15-2015) I reported that my Dad's 24-hour average heart rate was 50 bpm. That number was and is incorrect. We determined that the particular activity-tracking watch he was wearing was not able to identify his heart rate when he was very active. Consequentially, instead of having a heart rate reading for every one of the 1440 minutes in a 24-hour day, we were getting half that many data points. And the missing heart rates were invariably higher heart rates. I have given him my activity-tracking watch, which IS able identify his heart rate regardless of how active he is. He's only been wearing it for about a week and so far it's showing an average of about 60 bpm. There something important I want to point out in this regard. The 24-hour Holter test in March reported an average of 57 bpm. (And I'll point out that this was within a few days of his long Afib episode being resolved.) So instead of his average heart rate dropping from 57 bpm 3 months ago, to 50 bpm now, it has actually stayed the same, or even gone up one or two beats --- but probably it's the same.
Now the fact that his heart is beating an average of 10 beats per minute faster than we thought it was, doesn't change the fact that he does have bradycardic-like symptoms even though a strict diagnoses of bradycardia doesn't seem appropriate anymore. And this brings me finally to the other graphic included on my attached document. It is a compilation of 2 hours of data recorded with the newer more accurate activity-tracking watch. It shows the morning of 06-27-2015, between 07:00 am and 09:00 am. The heart rate information is in orange; everything else is self-explanatory. On this morning, he took a walk from 07:13 to 07:45. During that time his heart rate averaged about 104 bpm and he had no difficulty maintaining a brisk and steady pace. After his walk (but I don't think they are necessarily related to his walk) there was an Event (#1) that occurred just before 08:00 am and another Event (#2) that occurred just before 09:00 am. These events constitute the best picture of the typical kind of "light headedness/shortness of breath" that he sometimes experiences. Both events began with his climbing up the stairs between the downstairs and upstairs of his house. What I can't say for sure, is exactly when his symptoms occurred during these events --- during the highest heart rate, or maybe during the lower heart rate that followed? In both cases he had to rest before making it to the top of the stairs. Hopefully the next time this happens he will identify the exact minute he feels weak, and thereby the exact level of heart rate that precedes this kind of episode.
So, based on the 2 hours of heart rate data shown in this graphic, is there anything relevant you can say about his heart and its functioning? (I don't know if this is clinically significant or not, but I'll mention it anyway. There appears to be a small increase in skin perspiration leading up to both events.)
Thank you very much.
XXXX
I need to tell you that I personally have a medical condition that limits my ability to function in a consistently normal way. Consequentially, I'm often not able to respond to people as timely as I would like to. That was the case after you responded to my last question(s), regarding my Dad's heart condition. So let me say now, that in general I understand and appreciate all of your answers to my last responses. They were very helpful when it came time to meet with his electrophysiologist.
Now if I may..... I'd like to start this new official question where my last queries left off. To avoid confusion regarding my previous questions and these new ones, I'll use letters today instead of numerals.
A) Regarding CRT: I believe your suggestion regarding CRT was a good one. However, his electrophysiologist feels that his narrow QRS interval indicates that his heart is currently demonstrating good synchronization. I'm sending along in an attached documents with one of our 3-lead EKG tracings from 06-17-2015 to see what you think of that assessment.
So what do you think?
B) Regarding you comments about investigating other possible reasons for his symptoms i.e. low energy, light headed/shortness of breath, foggy mind, etc: I am comfortable (at least for the moment) that we have adequately considered metabolic dysfunction, liver and renal dysfunction, and mental dysfunction. We met with his electrophysiologist on 06-18-2015 (this was our first and only meeting so far), and based on all of the data and test results and information in my Dad's file, he is convinced that a pacemaker is called for --- specifically, a ICD 2-lead pacemaker. He was hesitant about altering the amiodarone or metoprolol for fear that an Afib episode might ensue, and it might take some length of time to return his heart back to a proper rhythm. Thinking about what's in my Dad's medical file, probably the most significant piece of information that you don't have, are the results of a 24-hour Holter monitoring test on 03-26-2015. I have the full 16-page report, with the tabular summaries, hourly summaries, major event log, period histograms, and QRS forms. Is it possible that data in that report might indicate a more certain conclusion that a pacemaker is warranted? (I would be happy to forward to you any part of that report if you would like. Just let me know.) So my question is ultimately this, the electrophysiologist believes my Dad should as soon as is practical, have a pacemaker put in.
Based on everything you know at this point, what do you think about that conclusion?
C) Regarding a significant error in my previous communication: Previously (on 06-15-2015) I reported that my Dad's 24-hour average heart rate was 50 bpm. That number was and is incorrect. We determined that the particular activity-tracking watch he was wearing was not able to identify his heart rate when he was very active. Consequentially, instead of having a heart rate reading for every one of the 1440 minutes in a 24-hour day, we were getting half that many data points. And the missing heart rates were invariably higher heart rates. I have given him my activity-tracking watch, which IS able identify his heart rate regardless of how active he is. He's only been wearing it for about a week and so far it's showing an average of about 60 bpm. There something important I want to point out in this regard. The 24-hour Holter test in March reported an average of 57 bpm. (And I'll point out that this was within a few days of his long Afib episode being resolved.) So instead of his average heart rate dropping from 57 bpm 3 months ago, to 50 bpm now, it has actually stayed the same, or even gone up one or two beats --- but probably it's the same.
Now the fact that his heart is beating an average of 10 beats per minute faster than we thought it was, doesn't change the fact that he does have bradycardic-like symptoms even though a strict diagnoses of bradycardia doesn't seem appropriate anymore. And this brings me finally to the other graphic included on my attached document. It is a compilation of 2 hours of data recorded with the newer more accurate activity-tracking watch. It shows the morning of 06-27-2015, between 07:00 am and 09:00 am. The heart rate information is in orange; everything else is self-explanatory. On this morning, he took a walk from 07:13 to 07:45. During that time his heart rate averaged about 104 bpm and he had no difficulty maintaining a brisk and steady pace. After his walk (but I don't think they are necessarily related to his walk) there was an Event (#1) that occurred just before 08:00 am and another Event (#2) that occurred just before 09:00 am. These events constitute the best picture of the typical kind of "light headedness/shortness of breath" that he sometimes experiences. Both events began with his climbing up the stairs between the downstairs and upstairs of his house. What I can't say for sure, is exactly when his symptoms occurred during these events --- during the highest heart rate, or maybe during the lower heart rate that followed? In both cases he had to rest before making it to the top of the stairs. Hopefully the next time this happens he will identify the exact minute he feels weak, and thereby the exact level of heart rate that precedes this kind of episode.
So, based on the 2 hours of heart rate data shown in this graphic, is there anything relevant you can say about his heart and its functioning? (I don't know if this is clinically significant or not, but I'll mention it anyway. There appears to be a small increase in skin perspiration leading up to both events.)
Thank you very much.
XXXX
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello XXXX!
I am sorry for this delayed response, as seems that my daily job commitment in ICCU, to be occasionally a defiant of punctuality.
Returning to your questions, I would explain my opinion as follows:
A) Regarding CRT option, I would say that when judging the selection criteria for CRT, there are some small differences when comparing XXXXXXX European and German Society of Cardiology guideline. So, the indication is met when LV EF is /=120 ms on XXXXXXX and European guideline, but needs to be >150 ms on German guideline, and so on.
Also an approved criteria for CRT (besides QRS widening or presence of LBBB) is also a frequent RV pacing, even without primary QRS criterion.
I can't judge exactly about your dad's QRS length on the uploaded ECG, as it is not a millimetric letter.
Nevertheless, my personal opinion is that a biventricular synchronous pacing mode would be a preferred choice, if a permanent pacemaker is going to be implanted. as his electrophysiologist. This would avoid ventricular asynchrony imposed by frequent RV (right ventricle) pacing only.
Nevertheless, it depends on his electrophysiologist's discretion (as I have mentioned before), to make the right necessary decision.
B) Regarding the indication for a pacemaker implantation, I would explain that just a relatively low heart rate ( around 60 bpm and so on), is not a clear and strong indication on its own, for PM implatation, unless a sick sinus syndrome is confirmed. But, as your uploaded recording clearly shows, your dad's heart rate response to physical efforts is relatively adequate during those events (when moving up-, down-stairs). So a persistent bradycardia (which is a frequent finding in sick sinus syndrome) is excluded.
I would also explain that the two most important diagnostic clues to consider when investigating a possible sick sinus syndrome are Holter monitoring report and invasive electrophysiological study conclusions. So, his Holter results are of utmost importance for ruling in/out a possible sick sinus syndrome and other atrio-ventricular conductance disturbances (which are all indications for PM implantation).
So, if you you could upload his Holter test results, it would be helpful for giving a professional opinion.
C) Regarding the activity-tracking watch records, I would say that they are important to exclude a heart rate incompetence during those unpleasant events (a good chronotropic response with physical exercising). Probably these conclusions, raise again strong suspicions on a low LV ejection fraction (low cardiac performance) implication on your dad's complains.
As I said you before, low energy, light headed, foggy mind, etc should be properly differentiated between HF implications, an AV conductance disturbance implication, or a neurological implication. These are the three most probable etiological causes of your dad's clinical scenario, on my opinion.
I strongly insist again, that there will be no clinical independent judgments about any cardiac (arrhythmic or AV conductance disorders), without eliminating first current medications underlying effects.
Hope to have been helpful to you!
Feel free to contact me again, whenever you need! Greetings! Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello XXXX!
I am sorry for this delayed response, as seems that my daily job commitment in ICCU, to be occasionally a defiant of punctuality.
Returning to your questions, I would explain my opinion as follows:
A) Regarding CRT option, I would say that when judging the selection criteria for CRT, there are some small differences when comparing XXXXXXX European and German Society of Cardiology guideline. So, the indication is met when LV EF is /=120 ms on XXXXXXX and European guideline, but needs to be >150 ms on German guideline, and so on.
Also an approved criteria for CRT (besides QRS widening or presence of LBBB) is also a frequent RV pacing, even without primary QRS criterion.
I can't judge exactly about your dad's QRS length on the uploaded ECG, as it is not a millimetric letter.
Nevertheless, my personal opinion is that a biventricular synchronous pacing mode would be a preferred choice, if a permanent pacemaker is going to be implanted. as his electrophysiologist. This would avoid ventricular asynchrony imposed by frequent RV (right ventricle) pacing only.
Nevertheless, it depends on his electrophysiologist's discretion (as I have mentioned before), to make the right necessary decision.
B) Regarding the indication for a pacemaker implantation, I would explain that just a relatively low heart rate ( around 60 bpm and so on), is not a clear and strong indication on its own, for PM implatation, unless a sick sinus syndrome is confirmed. But, as your uploaded recording clearly shows, your dad's heart rate response to physical efforts is relatively adequate during those events (when moving up-, down-stairs). So a persistent bradycardia (which is a frequent finding in sick sinus syndrome) is excluded.
I would also explain that the two most important diagnostic clues to consider when investigating a possible sick sinus syndrome are Holter monitoring report and invasive electrophysiological study conclusions. So, his Holter results are of utmost importance for ruling in/out a possible sick sinus syndrome and other atrio-ventricular conductance disturbances (which are all indications for PM implantation).
So, if you you could upload his Holter test results, it would be helpful for giving a professional opinion.
C) Regarding the activity-tracking watch records, I would say that they are important to exclude a heart rate incompetence during those unpleasant events (a good chronotropic response with physical exercising). Probably these conclusions, raise again strong suspicions on a low LV ejection fraction (low cardiac performance) implication on your dad's complains.
As I said you before, low energy, light headed, foggy mind, etc should be properly differentiated between HF implications, an AV conductance disturbance implication, or a neurological implication. These are the three most probable etiological causes of your dad's clinical scenario, on my opinion.
I strongly insist again, that there will be no clinical independent judgments about any cardiac (arrhythmic or AV conductance disorders), without eliminating first current medications underlying effects.
Hope to have been helpful to you!
Feel free to contact me again, whenever you need! Greetings! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi, I have provided some attachments. Please review them.
Dr. Iliri,
Thank you very much for your very informative observation, comments, and advice. There are several things I want to ask, but I think it would be more efficient and productive to wait and see what your thoughts are after reviewing the Holter Test Results. I've uploaded a PDF of the full 16-page report. Take your time looking it over, there's no reason to rush.
In fact, I hope you'll have some time later today as the sun goes down, to catch the very close conjunction of a very bright Venus and a relatively bright Jupiter. They've been getting ever closer over the past two weeks and tonight they will almost touch. If the skies are clear where you are the two planets will be unmissable low in the Western sky --- becoming visible even before the sun actually sets. They will dominate the vista for the next two hours as they follow the same path as the sun and then they'll disappear below the horizon. (Obviously, I enjoy gazing into the night sky.)
Thank you, XXXX
Dr. Iliri,
Thank you very much for your very informative observation, comments, and advice. There are several things I want to ask, but I think it would be more efficient and productive to wait and see what your thoughts are after reviewing the Holter Test Results. I've uploaded a PDF of the full 16-page report. Take your time looking it over, there's no reason to rush.
In fact, I hope you'll have some time later today as the sun goes down, to catch the very close conjunction of a very bright Venus and a relatively bright Jupiter. They've been getting ever closer over the past two weeks and tonight they will almost touch. If the skies are clear where you are the two planets will be unmissable low in the Western sky --- becoming visible even before the sun actually sets. They will dominate the vista for the next two hours as they follow the same path as the sun and then they'll disappear below the horizon. (Obviously, I enjoy gazing into the night sky.)
Thank you, XXXX
Brief Answer:
I think that ICD-biventricular pacing mode device would be appropriate.
Detailed Answer:
Hello XXXX!
I reviewed your dad's Holter results, and would say that there are frequent episodes of bradycardia, most of them associated with first degree AV block.
From the other side, there is a persistent sinus bradycardia interrupted by repeated episodes of faster supraventricular arrhythmia (like short runs of atrial fibrillation, or chaotic atrial rhythm).
I do insist again that, when thinking about a probable sick sinus syndrome, we can't have an indipendent judgement about the special electric system (sinus and AV node, conductance pathways) of your dad's heart, as long as he is on a potent antiarrhythmics coctail (Amiodarone plus Metoprolol).
Nevertheless, I think also that we may be in front of a hidden cardiac electrical conductance system impairment (due to many factors, such as degenerative changes with aging, ischemic heart disease, etc), which has been revealed even more by antiarrhythmics use.
Coming at this point, and facing with his actual cardiac conditions (low EF cardiomyopathy), I would conclude that an ICD-biventricular pacing mode device would be an appropriate option for your dad's heart disease, leading to preservation and even improvement of his cardiac performance (preserving cardiac synchrony, improving LV EF, protecting from inappropriately low bradycardic rhythm, etc).
In this way, it would be safe to continue the antiarrhythmics cocktail also.
You need to be in close contact with his cardiologist (electrophysiologist) and discuss the above mentioned management strategy opportunities.
Hope to have been helpful to you!
Thank you for the additional information; I will try to see those beautiful sky scenes (despite a relatively cloudy sky tonight).
Feel free to ask me whenever you need!
Best regards! Dr. Iliri
I think that ICD-biventricular pacing mode device would be appropriate.
Detailed Answer:
Hello XXXX!
I reviewed your dad's Holter results, and would say that there are frequent episodes of bradycardia, most of them associated with first degree AV block.
From the other side, there is a persistent sinus bradycardia interrupted by repeated episodes of faster supraventricular arrhythmia (like short runs of atrial fibrillation, or chaotic atrial rhythm).
I do insist again that, when thinking about a probable sick sinus syndrome, we can't have an indipendent judgement about the special electric system (sinus and AV node, conductance pathways) of your dad's heart, as long as he is on a potent antiarrhythmics coctail (Amiodarone plus Metoprolol).
Nevertheless, I think also that we may be in front of a hidden cardiac electrical conductance system impairment (due to many factors, such as degenerative changes with aging, ischemic heart disease, etc), which has been revealed even more by antiarrhythmics use.
Coming at this point, and facing with his actual cardiac conditions (low EF cardiomyopathy), I would conclude that an ICD-biventricular pacing mode device would be an appropriate option for your dad's heart disease, leading to preservation and even improvement of his cardiac performance (preserving cardiac synchrony, improving LV EF, protecting from inappropriately low bradycardic rhythm, etc).
In this way, it would be safe to continue the antiarrhythmics cocktail also.
You need to be in close contact with his cardiologist (electrophysiologist) and discuss the above mentioned management strategy opportunities.
Hope to have been helpful to you!
Thank you for the additional information; I will try to see those beautiful sky scenes (despite a relatively cloudy sky tonight).
Feel free to ask me whenever you need!
Best regards! Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Iliri,
Thank you for reviewing the Holter results. And thank you for your latest council.
It sounds like you concur with his doctor’s diagnosis of sick sinus syndrome. Based on everything you know, you believe that an ICD biventricular pacing device, as opposed to a dual chambered ICD would be the best treatment option for him right now. At our appointment, I asked his doctor, Dr. Hanich, that very question. Specifically, if he was planning to employ CRT.
And he explained why he thought a different approach was called for.
I take digital audio recorder with me to every doctor’s appointment I go to, because otherwise, I would never be able to “take in” everything at any given meeting, and I would never be able to remember all that was discussed. I’ve listened to the audio recording from that appointment with Dr. Hanich, several times so far. But I wanted to listen to it again, so I get write down here for you exactly what he said about this issue. So I did. And his comments were as follows.
Essentially, he believes that resynchronization isn’t necessary because Dad’s QRS complex is so narrow. He also said that CRT would add an additional level of complexity, that increases the probability of encountering complications or problems, and that would be for very little benefit. He believes that the fundamental problem with Dad’s heart is with the rate (in the atria,) and with the poor strength (in the ventricle). And he believes those can be well addressed with a dual-chamber/dual lead ICD.
He further explained that with the lead in the right atria we would be able to constantly monitor and record the rhythm of Dad's heart, so that over time, we can use that data to lower Dad’s amiodarone dose. Ultimately Dr. Hanich thinks, that the amiodarone may be the most direct cause of Dad’s current negative symptoms.
So, do those comments in any way alter your conviction that a CRT approach would be more desirable? (Q-1)
Regarding the fact that an independent judgement (or, a definitive determination) can not be had without removing the intervening medications (amiodarone and metoprolol) from the diagnostic equation, what should, or could be done? If you had an identical patient with your practice, what exactly would you do in this situation? (Q-2)
And lastly, his doctor explained the following to us about what to expect from the pacemaker. He said, that if the fatigue, infrequent dizziness, and other similar symptoms Dad has been experiencing are related to the slow rate of his heart, then the pacemaker should have an immediate and positive effect for him. But if his symptoms are related to his heart's poor EF, then the pacemaker is not going to have an immediate positive effect. My question to you is two fold. Is this the conventional understanding? (Q-3)
And if it is, is there any kind of exercise or procedure or something, that we can do right now to give us clue about whether it’s the rate or the volume that is causing the symptoms? (Q-4) It seems like it should be a very simple thing to clarify. (For example, there are several procedures I can think of that involving the simultaneous measuring of things like baroreceptor response, heart beat response, and blood pressure response.)
These are the physiological sensors I can employ the appropriate task: an EKG/EMG sensor, a BP cuff, a stainless steel temperature probe, a surface temperature probe, a hand dynamometer, a respiration belt, and the 24-hour activity watch with its four measures.
Thank you, XXXX
Thank you for reviewing the Holter results. And thank you for your latest council.
It sounds like you concur with his doctor’s diagnosis of sick sinus syndrome. Based on everything you know, you believe that an ICD biventricular pacing device, as opposed to a dual chambered ICD would be the best treatment option for him right now. At our appointment, I asked his doctor, Dr. Hanich, that very question. Specifically, if he was planning to employ CRT.
And he explained why he thought a different approach was called for.
I take digital audio recorder with me to every doctor’s appointment I go to, because otherwise, I would never be able to “take in” everything at any given meeting, and I would never be able to remember all that was discussed. I’ve listened to the audio recording from that appointment with Dr. Hanich, several times so far. But I wanted to listen to it again, so I get write down here for you exactly what he said about this issue. So I did. And his comments were as follows.
Essentially, he believes that resynchronization isn’t necessary because Dad’s QRS complex is so narrow. He also said that CRT would add an additional level of complexity, that increases the probability of encountering complications or problems, and that would be for very little benefit. He believes that the fundamental problem with Dad’s heart is with the rate (in the atria,) and with the poor strength (in the ventricle). And he believes those can be well addressed with a dual-chamber/dual lead ICD.
He further explained that with the lead in the right atria we would be able to constantly monitor and record the rhythm of Dad's heart, so that over time, we can use that data to lower Dad’s amiodarone dose. Ultimately Dr. Hanich thinks, that the amiodarone may be the most direct cause of Dad’s current negative symptoms.
So, do those comments in any way alter your conviction that a CRT approach would be more desirable? (Q-1)
Regarding the fact that an independent judgement (or, a definitive determination) can not be had without removing the intervening medications (amiodarone and metoprolol) from the diagnostic equation, what should, or could be done? If you had an identical patient with your practice, what exactly would you do in this situation? (Q-2)
And lastly, his doctor explained the following to us about what to expect from the pacemaker. He said, that if the fatigue, infrequent dizziness, and other similar symptoms Dad has been experiencing are related to the slow rate of his heart, then the pacemaker should have an immediate and positive effect for him. But if his symptoms are related to his heart's poor EF, then the pacemaker is not going to have an immediate positive effect. My question to you is two fold. Is this the conventional understanding? (Q-3)
And if it is, is there any kind of exercise or procedure or something, that we can do right now to give us clue about whether it’s the rate or the volume that is causing the symptoms? (Q-4) It seems like it should be a very simple thing to clarify. (For example, there are several procedures I can think of that involving the simultaneous measuring of things like baroreceptor response, heart beat response, and blood pressure response.)
These are the physiological sensors I can employ the appropriate task: an EKG/EMG sensor, a BP cuff, a stainless steel temperature probe, a surface temperature probe, a hand dynamometer, a respiration belt, and the 24-hour activity watch with its four measures.
Thank you, XXXX
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello dear XXXX!
First of all we don't need to complicate to much the matter.
Seems that it is a general agreement regarding the indication for a pacemaker implantation.
But there are some divergences about pacing mode.
I would support my conviction about CRT on the following facts (Q-1):
(a) As I explained you before there exist differences on QRS widening criteria for CRT selection (confronting current guidelines).
(b) It is true that a sinus bradycardia needs predominantly cardiac pacing, as his doctor refers too. But as we are in front of a sick sinus syndrome, and Holter results show presence of first degree AV block (that means an abnormally prolonged AVI: atrio - ventricular interval), if we choose to implant a dual chamber pacemaker, inevitably we will encounter frequent right ventricular pacing too (prolonged AVI).
As I explained before, frequent RV pacing is a source of ventricular dyssynchrony, hence an indication for CRT.
Don't forget that your dad suffers from low EF cardiomyopathy, an CRT (facing the above mentioned clinical conditions) would be valuable in improving his cardiac performance.
Regarding drugs therapy option (Q-2), it is necessary to reduce the existing antiarrhythmics effects.
As your dad suffers from low EF cardiomyopathy it would be elusive claiming that any antiarrhythmics would totally suppress cardiac arrhythmia (Holter results confirm such reasoning).
Furthermore, strong suspicions are raised about potential aggravating adverse effects.
On my professional judgement, I would stop Metoprolol, and possibly reduce Amiodarone daily dosing.
Regarding the third question (Q-3), I totally agree wit his doctor, but it is important to choose the right pacing mode as I explained above. That's my opinion.
Regarding the last question (Q-4), I would suggest measuring cardiac index (echo or alternative approaches), as well as cardiopulmonary stress test to investigate his chronotropic response to exercise, and peak O2 consumption, measurement of lactates, etc.
Best regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello dear XXXX!
First of all we don't need to complicate to much the matter.
Seems that it is a general agreement regarding the indication for a pacemaker implantation.
But there are some divergences about pacing mode.
I would support my conviction about CRT on the following facts (Q-1):
(a) As I explained you before there exist differences on QRS widening criteria for CRT selection (confronting current guidelines).
(b) It is true that a sinus bradycardia needs predominantly cardiac pacing, as his doctor refers too. But as we are in front of a sick sinus syndrome, and Holter results show presence of first degree AV block (that means an abnormally prolonged AVI: atrio - ventricular interval), if we choose to implant a dual chamber pacemaker, inevitably we will encounter frequent right ventricular pacing too (prolonged AVI).
As I explained before, frequent RV pacing is a source of ventricular dyssynchrony, hence an indication for CRT.
Don't forget that your dad suffers from low EF cardiomyopathy, an CRT (facing the above mentioned clinical conditions) would be valuable in improving his cardiac performance.
Regarding drugs therapy option (Q-2), it is necessary to reduce the existing antiarrhythmics effects.
As your dad suffers from low EF cardiomyopathy it would be elusive claiming that any antiarrhythmics would totally suppress cardiac arrhythmia (Holter results confirm such reasoning).
Furthermore, strong suspicions are raised about potential aggravating adverse effects.
On my professional judgement, I would stop Metoprolol, and possibly reduce Amiodarone daily dosing.
Regarding the third question (Q-3), I totally agree wit his doctor, but it is important to choose the right pacing mode as I explained above. That's my opinion.
Regarding the last question (Q-4), I would suggest measuring cardiac index (echo or alternative approaches), as well as cardiopulmonary stress test to investigate his chronotropic response to exercise, and peak O2 consumption, measurement of lactates, etc.
Best regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Illiri,
I am still absorbing everything in your last message. But there are two small issues I want to clarify.
And then, I'll close out this very fruitful discussion.
C-1 Regarding what you said about Metoprolol and Amiodarone, would you stop those before putting in the PM, or after?
C-2 I've been seeing references to CRT-P (pacing) devices and CRT-D (defibrillator) devices. Are there CRT devices that do both?
That's all.
Thank you very very much for your wonderful advice over the last week.
XXXX
I am still absorbing everything in your last message. But there are two small issues I want to clarify.
And then, I'll close out this very fruitful discussion.
C-1 Regarding what you said about Metoprolol and Amiodarone, would you stop those before putting in the PM, or after?
C-2 I've been seeing references to CRT-P (pacing) devices and CRT-D (defibrillator) devices. Are there CRT devices that do both?
That's all.
Thank you very very much for your wonderful advice over the last week.
XXXX
Brief Answer:
A stepwise approach would be advisable.
Detailed Answer:
Hello XXXX!
As I have explained you before, I would have stopped immediately Metoprolol, and after that depending on the ongoing strategy (a near pacemaker implantation or a watchful waiting), would thing for a possible Amiodarone dose modulation.
I would not stop Amiodarone even after a pacemaker implantation.
Regarding your last question, the answer is Yes!
I would explain that cardiac resynchronization therapy is in fact a biventricular pacemaker (CRT-P), but additional special functions, such as an ICD may be incorporated in the same device.
Hope to have been helpful!
Best wishes,
Dr. Iliri
A stepwise approach would be advisable.
Detailed Answer:
Hello XXXX!
As I have explained you before, I would have stopped immediately Metoprolol, and after that depending on the ongoing strategy (a near pacemaker implantation or a watchful waiting), would thing for a possible Amiodarone dose modulation.
I would not stop Amiodarone even after a pacemaker implantation.
Regarding your last question, the answer is Yes!
I would explain that cardiac resynchronization therapy is in fact a biventricular pacemaker (CRT-P), but additional special functions, such as an ICD may be incorporated in the same device.
Hope to have been helpful!
Best wishes,
Dr. Iliri
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