Athletes and Cardiac Pacemakers


We’ll talk today about athletes and cardiac pacemakers. I was reminded by a reader over the weekend that rhythm problems in athletes sometimes necessitate the implantation of a pacemaker. I’ll follow-up on today’s article with another on athletes and internal cardioverter-defibrillators (ICDs) since I also mentioned these devices a couple weeks ago here at the blog.

The Heart’s Electrical System

The heart has a very elaborate electrical system that is designed to initiate and carry electrical impulses throughout the heart, causing the heart muscle to contract (in just the right way) and pump the blood that it holds.

The electrical impulses start in an area in (or near) the top of the right atrium called the sinus node. These impulses are generated automatically and, for most people, have a rate of 60-100 beats per minute. The electrical impulses then spread out over the left and right atria and travel to a way station called the atrioventricular (AV) node. The AV node builds in a slight delay and then the impulses travel to the lower, or pumping, chambers of the heart–the ventricles. As the electrical impulses travel through the ventricles, the pumping chambers contract, ejecting the blood that they hold.

Common Problems That Are Treated With a Pacemaker

There are many disorders of the electrical system of the heart–far too many to discuss here in this article. Indeed, entire textbooks have been written about these problems. For affected athletes who are reading here, it would be wise to discuss your PERSONAL situation with your doctor so that you understand the PARTICULAR electrical problem that you have. Today, we’ll focus on just 2 common problems that are sometimes treated with a pacemaker: a slow heart rate (bradycardia) and heart block (the situation where there is undue delay getting the electrical impulses throughout the heart).

Bradycardia is defined as a heartrate less than 60 beats per minute. Sometimes the heartrate can become so slow that affected individuals have problems such as light-headedness–or even black out. We call that symptomatic bracycardia.

Individuals with heart block may have electrical impulses that start at 80 beats per minute at the sinus node, but because of the block, these electrical impulses are delayed (or lost entirely) and the ventricles might beat at only 30 beats per minute–far too slow to manage the necessary pumping function of the heart.

In both of these situations, a pacemaker may be the appropriate treatment.

What Is a Pacemaker?

A pacemaker is an implanted medical device that corrects for a problem with the heart’s electrical system. The pacemaker usually consists of 2 parts: 1) a battery (or “generator”) that is implanted beneath the skin of the upper chest and 2) a set of wires that are threaded through a vein and fastened to the lining of the heart.

With the most modern pacemakers, the generator is about the size of a stack of 3 half dollars. The battery lasts for several years and will then need to be replaced. The wires (or “leads) are designed to remain in place for a long time–many years, or potentially, forever. The generator and leads are placed during a operative procedure that usually lasts less than an hour and can be done with either local anesthesia and sedation or with general anesthesia.

In the most typical configuration, one lead is placed into the right atrium and another is placed into the right ventricle. These leads are designed to sense the heart’s own electrical activity. This information is gathered by the computer that is part of the generator, and then the computer uses those same 2 leads to deliver electrical impulses, as needed, to speed up the heart (in the case of bradycardia) or to provide missing electrical impulses (in the case of heart block).

For patients with pacemakers, the pacemaker can be checked periodically using a hand-held computer device directly over the pacemaker. This device gathers information about the functioning of the pacemaker and about the battery’s lifespan and this information can be transmitted either directly or by telephone to the patient’s doctor for review. Sometimes adjustments must be made to the settings of the pacemaker to guarantee the most appropriate functioning of the pacemaker.

Issues for Athletes

The first important issue for athletes with pacemakers is the healing time after the pacemaker implantation procedure. Like for any surgical procedure, some time is needed for the body to heal after the operation. For pacemakers, it also takes time for the heart to heal at the location where the leads have been implanted. Until this healing process is complete, the leads can become dislodged inadvertently with vigorous activity. It’s common for implanting physicians to recommend no arm activity (on the side of the implant) and no vigorous activity, in general, for a period of several weeks after the pacemaker procedure. After that time, most implanting physicians will allow a gradual return to pre-implantation activities.

In the long term, there continues to be a small risk of lead dislodgement and some physicians recommend that patients avoid athletic activities that place a patient at risk of severe body blows. Many athletes, though, can return to their sports after implantation of a pacemaker, but it’s important to have a detailed discussion with their physician about this issue.

The second major issue for athletes relates to the settings for the pacemaker. Each pacemaker system contains a microprocessor that can be programmed to work optimally for an individual patient. One important setting for athletes is the maximal rate setting. As an example, let’s consider an athlete with heart block. She exercises vigorously and her sinus rate rises to 180 beats per minute. Ideally, the pacemaker would stimulate her ventricles at the same rate of 180 beats per minute. If the maximal rate setting were only 140, she would have the feeling of “not enough oomph” from her heart to continue the exercise. This is just one example. Athletes will need to have ongoing discussions with their physician about the settings for their pacemaker….and it may take some trial and error to set things up satisfactorily.

For More Information

There are probably many web-based information sources that are useful to athletes who have–or are considering–a pacemaker. After a quick look around, a couple that I like are:

http://www.pacemakerclub.com/ This is a free online “club” designed as a support group for patients with a pacemaker or ICD and their families. There are topical-oriented forums where members can network with people with similar problems and concerns.

http://www.americanheart.org/presenter.jhtml?identifier=4676 This link is to the American Heart Association (AHA) page that deals with pacemakers. At this page, there are additional links for more detailed information on a variety of topics.

http://www.medtronic.com/your-health/bradycardia/index.htm This link is to a page at the Medtronic (a company that manufactures pacemakers) site that deals with bradycardia and pacemakers. There are also additional links to information about related topics.

I’ll be back next with an article on Athletes and ICD’s.

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Comments

  1. says

    Hello Doc!
    What would be, in your opinion, the indications to have an Automatic Cardioverter Defibrillator (ACD) implanted in an athlete? And how much of an expense is it?

    Thanks
    -a Med Student

  2. says

    Hasan,

    Good questions.

    ICD’s are used for patients who are known to have–or are at high risk for–ventricular arrhythmias. Those arrhythmias could be caused by any of several different underlying conditions such as hypertrophic cardiomyopathy (HCM), coronary artery disease (CAD), or heart failure.

    The ICD’s are very expensive. The device plus implantation procedure would typically cost $10’s of thousands of dollars. The cost really depends upon a patient’s insurance coverage, because the insurance company will set the “allowable,” the amount that will be paid to the doctor(s) and hospital.

    Larry

  3. says

    Doc

    Question on Bradycardia. Back in April I experienced a traumatic injury. I now am symptomatic with extreme fatigue, dizziness, light-headed, weak, chest discomfort, and so forth. I am seeing a cardiologist who did numerous tests and recently put me on a two-week heart monitor and it showed upper 20’s and in the 30’s. My doctor is giving me time to see if my heart/body corrects the issue itself. Recently he went to get another cardio’s opinion and they said my heart has issues speeding up and that I am a candidate for a pacemaker. Doc says I have an athletes heart (enlarged, big chambers). I am an athlete who runs, cycles and swims (not currently). My question is…What do you think? What advice would you give? It has been over two months and remain symptomatic. I get really frustrated when it happens because I know how good of shape I was in and now I have issues walking around the neighborhood or just pruning my trees. Has anybody else experienced this? Do you now have a pacemaker? I was really freaked out with the whole idea of a pacemaker, but after reading your website and others I am starting to think it might be for me. Just looking for insight and other experiences.

    Smith

    • Sharon says

      Hello,

      I am a runner and avid cross trainer. I am a 46 year old female.
      I had a low heart rate, sometimes as low as 20, and typically in the 30s. I also have hypertrophic cardiomyopathy. I had symptomatic bradycardia also. I had sinus pause and sinus escape. I was fainting, dizzy and had a tight chest and stomach aches very often. Despite this I ran three nights per week and worked out five days per week for strengthening.
      I recently had a pacemaker inserted. My heart rate is now normal with a base of 50. I’m not sure what my upper limit is but I will learn that on November 7th at the pacemaker clinic. I have three more weeks to get through before I can run and feel that wind and cool air on my face. I am so looking forward to it. I’m a bit bummed about losing strength and fitness during the six week recovery time but what can I do? I have coined six sets of stairs at school without problems so I am hopeful that my return to running will be uneventful. I hope the same for you.

    • GFunk says

      I just got a Medtronic pacemaker– it increases heart rate based on an internal “accelerometer” so my body has to move in space or shake somehow to get heart rate up for more intense exercise. I am a cyclist. I can’t work out on the trainer in the garage anymore– no heart rate response. I did 100 miles this week outdoors in three short rides 2.5 weeks after pacer insertion. I am 61 years old I had an attempted Cryoablation for afib- but my Cardiologist accidently killed my SA node with an internal supercooled balloon. I have been told that Boston Scientific has a pacer that advances rate based on “‘minute volume” of breathing= breath harder- HR goes faster. I don’t know it it would be any better than mine. I’m still trying to figure this all out. But I can dash around the house, hike, jog, walk and prune trees ( and ride bike cautiously- I am on thinners now!).

  4. says

    Smith,

    A pacemaker is an excellent treatment for patients who have bradycardia with symptoms. If your own heart rate falls too low, the pacemaker can “kick in.”

    Your cardiologists will be in a good position to know if this is the best treatment option for you.

    A pacemaker won’t limit your activities.

    Larry

  5. says

    Hi
    I am a triathlete who began experiencing problems exercising early this year as well as development of VEB at rest. After holster monitor investigation I was diagnosed with RVOT-VT and further testing revealed no structural heart disease. This condition was corrected through ablation, however in the weeks leading up to the ablation and ever since the ablation I began experiencing progressively worse heart block on exercise (as well as the continued frequent ectopic beats at rest). I can only last 5-15min exercise before an episode of heart block (HR will drop by half and I feel too “lactic” and dreadful to continue – this has been diagnosed as 2:1 heart block). Recovery is 40-50sec and then I can begin again, however time to episode is shorter after each episode. Obviously can’t continue exercising this way. Any ideas?

    Lyndal

  6. says

    Yes, I have now had a pacemaker implanted (3.5 weeks ago) – Biotronik Evia DR-T. While I have recovered well from surgery, the pacemaker has not alleviated my exercise-induced 2:1 heart block at all. If anything, I am experiencing a feeling of being “out of sync” just before the heart block sets in. I am hopeful that further “tweaking” of the settings will resolve my symptoms!

    Lyndal

  7. ShellyAnne says

    My daughter has had a pacemaker since she was four years old for complete heart block. Ironically, years of being paced has led to increasingly frequent bouts of tachycardia so as well as the pm for a slow heart rate she also now needs beta blockers to prevent it going too fast. My question is, however, how do implantable devices fit in with rules concerning competition? Is it allowed to compete in say, an Olympic sprint with one?

    • Larry Creswell, MD says

      I’m not entirely sure. I believe that rules about devices, if any, would come from each sport’s international (or national) governing body, rather than from the International Olympic Committee.

      I’m not sure what type of “sprint” you refer to.

      You might contact your national governing body for the particular sport to see if there are any relevant rules.

  8. Brendon Long says

    A question from one of my students; “could a pacemaker be used in an athlete for an unfair edge in competition/training?”
    (the hypothetical question relates to a healthy athlete with no need for a pacemaker)
    If the maximum HR could be artificially raised, does it stand to reason that the person’s aerobic capacity would also be raised?

    • Larry Creswell, MD says

      In short, no.

      I canvassed my cardiology Tweeps yesterday on Twitter. Nobody could think of how a pacemaker could be used in the “healthy” heart of an athlete to improve athletic performance or to facilitate some sort of training effect.

      Perhaps interestingly, when a patient’s pacemaker is stimulating the contractions of the heart, the situation is somewhat less efficient. There is nothing (yet) better than nature’s own electrical system for the heart.

      Also interestingly, pacemakers can be used (with high heart rates over long stretches of time) to produce heart failure in animal models.

      In the end….probably no good effects from cardiac pacemaker that would provide an advantage to an athlete with a “healthy” heart.

  9. Eric Mueller says

    Hey Doc,

    I’ve enjoyed your blog.

    I was just diagnosed with a AV Heart Block. (My heart rate will not increase to meet demand.) The doctors have mentioned that a pacemaker is probably the only solution.

    Do you know of any situations where a similar diagnosis returned to normal with adjustments to diet and exercise (rest)?

    Thanks!
    Eric

    • Larry Creswell, MD says

      Not sure I can do this justice without knowing more about your situation. You should ask your doctor(s) this question for sure.

      That said, when heart block is severe enough to require a pacemaker, that’s usually the only appropriate treatment. Severe degrees of heart block are not usually caused by (poor) diet or too much exercise.

  10. Frank says

    I had a Medtronic Advisa DR MRI A2DR01 implanted in Nov’15 due to bradycardia & heart block events during runs. After beginning running again in Jan’16 the pacemaker (or maybe my natural heart function) did a great job of maintaining around 140 bpm throughout 40 to 50 minute runs. Then, in Mar’16 My heart began blocking again at 20 to 30 minutes into the run (from 140 down to below 120 bpm) making further running anerobic. Yesterday my Medtronic rep evaluated and turned “Rate Adaptive AV” from Off to On and made following settings: Upper Sensor Rate – 160bpm, Rate Adaptive AV Start Rate – 90bpm, Rate Adaptive AV Stop Rate – 150bpm, Min Paced AV – 140ms, Min Sensed AV – 110ms. I’m no medical professional but this reset seemed to me (and the rep) that it would fix the blocking problem. However, today my heart blocked at about 20 minutes into a run and at about 130bpm. Do you have any ideas pertaining to the settings made to the Rate Adaptive function. (Or, are there other functions in the pacemaker that could correct heart blocking?). Also, during this past month my average resting heart rate has declined from above 60bpm to 50bpm. I would much appreciate any ideas. Thank you.

    • Larry Creswell, MD says

      I wouldn’t want to short change the Medtronic rep, but this is probably an issue where you’ll need the help of your cardiologist to sort things out.

    • Larry Creswell, MD says

      This issue relates primarily to the risk of lead dislodgment, which decreases with time after the procedure. This risk is related to upper extremity as well as whole body exercise.

      Usually, a few weeks’ break from strenuous exercise may be best.

      Your implanting cardiologist is the best person to ask because there are different types of leads….and the risk probably depends upon the type.

    • Larry Creswell, MD says

      Ordinarily, patients with defibrillators have been discouraged from participating in sports. Best to talk with your doctor(s) about the potential risks and settle, together, on what’s safe for you.

  11. Joe Zias says

    I’m a 75 year old athlete, former wrestler who began running on a daily basis 49 yrs ago. My heart rate has dropped every year the past 10-15 yrs whereas resting rate is in the lows 30 and with halter dn to 23 in sleep with a pause here and there, though no major ones. I have no symptoms, no dizziness but am finding running slower and slower with each passing year. The fatigue effect is what bothers me as after ca 20 minutes of running I am losing motivation and start walking, not the survivors shuffle, but will walk for a minute or two and then start running again. On a mt bike i don’t feel the fatigue effect, should I have a pace maker as my MD is not 100% convinced in the absence of any symptoms and I run the competitive 10 K’s twice a year?

    • Larry Creswell, MD says

      The heart’s own internal pacemaker can wear out over the years and cause problems like a low heart rate.

      Pacemakers are available for patients who are symptomatic from low heart rates and those where there are long pauses between beats.

  12. Heather says

    Hi,

    I have had a pm for the past 10-years and am 40-years old. I’m very active and have begun wearing a HR monitor during my runs, mountain bikes and road rides.

    I had my pm replaced last year because of low battery and have noticed that when I head out on my runs the first quarter mile my HR is high (150) and my chest is tight and my breathing is heavy. Also, this happens if I need to quickly run after my kids or up the stairs for an item. Also, when I am road biking my average HR will be at 150 for a 46 mile ride. I do love in CO, so high altitude may be a factor.

    Yesterday I went to run and after a quarter mile I had to stop because my HR did the same as usual, climbed up to 150, but would come down…it was jacked up to 165 and I was running down hill. It was terrible. I called my doc and have a halter monitor for the weekend.

    I’m wondering if anyone else is having these issues?

    Thanks,

    Heather

  13. Denise says

    What can our tell me about brachicardia tachycardia syndrome and would a dual chamber pacemaker be a good approach to treat this? I am 57 and an endurance athlete with asthma and Hashimoto thyroiditis. I cycle, backcountry ski tour and climb/hike every weekend with regular exercise during the week. Thanks!

    • Larry Creswell, MD says

      For the others who might be reading here, we’re talking about a form of sick sinus syndrome, where the heart’s own “built-in” pacemaker doesn’t work properly.

      I’m not familiar with the details of your specific case, but yes, a pacemaker can be a reasonable treatment for some patients.

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