Dr. Alex Germano // #GeriOnICE // www.ptonice.com
In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses the different types of implantable cardiac devices that might be encountered when working with patients & how to guide your treatment sessions accordingly. Take a listen to learn how to better serve this population of patients & athletes.
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01:43 Dr. Alex Germano, PT, DPT, GCS, CF-L2
All right. Good morning, everyone, and welcome to the PTI and ICE Daily Show, brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today’s segment of Jerry on ICE. I’m Alex Germano, member of the older adult division. Once again, being inspired here by our current cohort of MMOA advanced concepts in today’s episode topic, we just finished up our Cardio Pulmonary Week and the topic of pacemakers came up. What’s the deal with them? Should we be nervous about them? What should I expect them to do during exercise? How does high intensity interval training work for people with pacemakers? These are all great questions, and we felt like it warranted a podcast in order to dive a little bit deeper. First, let me tell you about some of the current offerings of the older adult division before jumping out into these incredible questions. Coming up this summer, we have MMOA Live on the road. We are in Watertown, Connecticut, July 15th and 16th, Watkinsville, Georgia, and Boise, Idaho, July 29th and 30th. We’re back in Frederick, Maryland on the East Coast, August 5th and 6th. We have our MMOA Summit, which is not to miss because we’ll have a revamp of all the new live material in Lexington, Kentucky, August 12th and 13th. We also have courses in Minnesota, Texas and California to round out August. So summer is looking busy for the older adult division. Okay, let’s start talking pacemakers. And really the term isn’t pacemakers, it’s implantable cardiac devices. This sounds like something maybe a bit boring on the surface, but these do have profound impacts on our patients’ exercise tolerance. And as providers who see people with these pacemakers more, we see them more regularly than say their cardiologists. And we should be aware of when these devices work well, when they don’t, and then when we need to communicate back with those providers. So first we can have four different types of implantable cardiac devices. We can have loop recorders, pacemakers, implantable cardioverter defibrillators, which I will just call ICDs from now on, or cardio-resynchronizers. The use of these devices is very high in older adults and will only continue to increase as our lifespan continues to increase and as this older adult population continues to grow. Over 80% of pacemakers out there are actually implanted in elderly individuals. So we’re guaranteeing that you’ve either worked with plenty of people who have these devices or will in the near future. So let’s go through each device and we’ll talk specific considerations surrounding each one. Loop recorders first, potentially the least sinister, I guess. Loop recorders, these are devices that are implanted to monitor heart rhythms over a few years, so up to three years. Especially in, and they put these in people who they have difficulty finding and catching these arrhythmias that they’re having, right? So maybe they put that monitor on them for a few days, but it still didn’t catch an arrhythmia because it’s so infrequent. Or maybe this is somebody who’s had symptoms of arrhythmias but had normal ECGs when they were done. So these get implanted so that they can monitor over longer periods of time. Sometimes these are paired with pacemakers if they think that the patient needs the pacemaker on top of it, so our patients might have both. But the key feature here, something to consider if somebody has a loop recorder, you need to ask them how they’re supposed to monitor when they feel symptoms. They are either going to have an app on their phone, they might have an external little button they’re supposed to press. What they’re trying to do is pair the familiar symptoms the patient’s having with potentially an odd heart rhythm to make sure that they can sync this data up and be able to diagnose the patient’s abnormal rhythm. Now, these abnormal rhythms could definitely happen during exercise, so it’s absolutely worth it to have that button nearby during exercise, have that app ready to go, that if your patient starts to experience that familiar symptom, they can record that event. Okay? So that whoever’s looking at the data can see that symptoms happened and maybe this weird heart rhythm happened and then they can get a diagnosis. Next, we’re going to move on to the single lead pacemaker. Usually the lead is attached to the right ventricle but could also go to the right atrium. These devices are used to control heart rates and rhythms. They’re typically implanted in those with bradycardia or other rhythms that can cause long pauses between heartbeats. This could include chronic aphid, sick sinus syndrome. Pacemakers can work continuously where they’re going to give somebody a fixed rate. That means the patient’s always going to be paced at 60-62, somewhere between 60 and 70. It’s important to know that because you’ll be checking their pulse throughout the session and be like, this is never changing, and that’s because they’re on a continuous pacer with a fixed rate. Then we have some pacemakers that only work when needed or when they sense that the pulse is getting too low. You might see people with pacemakers that their pulse does increase during exercise and that might have confused you, but that’s okay. That’s how a lot of pacemakers are actually, is that they only start to work when the pulse gets too low. Now a very cool feature of modern pacemakers, and modern being a bit, I don’t have a great definition of what modern means. I don’t know the history of the pacemaker, but it seems like in the last decade or so we have these more modern pacemakers that have rate responsive functions. Meaning that they allow the heart rate to increase during exercise, which is absolutely phenomenal. This is what we need, right? If somebody is on this fixed pacemaker and their pulse is always kept at 60, no matter how hard they’re working, that’s not really ideal, right? As we exercise, we need blood to pump faster throughout our body to get into all the places it needs to get in a timely manner. Patients actually benefit the most physically from this rate responsive function. If you feel like a blunted heart rate is really limiting your patient’s progress, maybe they’re not able to really achieve higher intensities, that could be something you discuss with the cardiologist. Now there’s another option for a pacemaker. We’re talking biventricular pacemakers, or also known as cardiac resynchronization therapy, or CRT. This has established use in populations of people with heart failure. And it’s used in older adults. Honestly, with these types of pacemakers, it continues to increase. With these pacemakers, instead of just a single lead attachment into the heart, we’re going to have two leads attached to the atria and ventricle. This allows for more control over the timing of the complete cardiac cycle. With more control, this helps to improve cardiac output up to 25%. That can be something very profound for people with these low ejection fractions and really struggling to maintain cardiac output with either medications or just a regular pacemaker. Now, patients with these biventricular pacemakers tend to have a better functional capacity than those with single lead pacemakers. So they tend to be the more optimal device for most folks. And usually, since this cardiac resynchronization therapy is used in patients with heart failure with pretty significant symptoms, you may think, oh, this is like really scary to exercise with these people. Like, I don’t feel very comfortable pushing them to high intensities. However, moderate to high intensity aerobic exercise can be applied to people with these safely without significant risk of adverse events. I think that is such a win and so positive. We shouldn’t be afraid to work out these folks. In fact, they absolutely need it. So I’m giving you the green light. Alright, lastly, we have implantable cardioverteral defibs or ICDs. These are perhaps like the most, I don’t want to say scary because they’re really not that scary, but they’re the most serious devices to work with as a rehab provider. Something that we should absolutely know that our patient has on board. Because we need to know what is going on with these things and what are the limits set on these devices. So ICDs are used to detect and treat life-threatening ventricular tachyarrhythmias. They are typically paired with a pacemaker. So they come usually together, which is good because it’s going to pace the heart a bit lower and avoid these really high heart rates. Now these devices administer shocks to people who have a serious cardiovascular event. So if this device starts to sense a very fast heartbeat, like ventricular fibrillation, the ICD could go off. It is recommended that when you hear about one in your patient’s history, or if your patient didn’t think to mention it because they’ve had it for a while, they don’t think it’s a big deal, but you see the large bulging device on their chest, that is something you should be asking about and asking about the limits of the ICD. A lot of my patients know their upper limit on a heart rate for that device. Like they are actually quite familiar. Sometimes they don’t, and I think that warrants a call to the cardiologist to make sure you’re aware of that. Once that device starts to sense that upper limit, it could administer a shock. Like I said, most of these are paired with a pacemaker, so I’ve never seen my patient’s heart rates get out of control with these devices. But I think it’s something to be aware about and document for. We need to be aware of that upper limit. Try to stay 10 to 30 beats below it. Don’t be afraid to exercise with these people. I’ve never been. It’s just really nice to have that awareness. Exercise actually exerts a really protective effect for these patients, and they end up having less shocks from their ICDs versus people who don’t exercise. So this is actually a very positive thing for patients to have. We want them to be having less shocks from their ICDs, so we need to get them exercising. Now, we should also be aware of not only the device types, the loop recorder, the pacemaker, the ICDs, or the resynchronization therapy. We need to be aware of symptoms that our patients might start having if their implantable cardiac devices stop working, which can absolutely happen. This is technology. We know it’s not perfect. These symptoms that we’re looking out for include dizziness, lightheadedness, fainting, palpitations, shortness of breath, maybe some twitching in the abdomen, chest, or frequent hiccups. Maybe that lead is now not where it’s supposed to be anymore. These symptoms are not going to be there anymore. These are signs that our patients need to talk with their cardiologist as the pacemaker might be malfunctioning or moving. So be aware. If you’re seeing a big change in status, maybe think of the usual things first. Is it a UTI? Did they not sleep well? But also, if it’s somebody with a pacemaker, we might need to ask if they’re experiencing these specific symptoms and then refer them back to cardiology to make sure that pacemaker is working. Also, be alert for beeps and other noises. Remember that these devices are battery powered and sometimes they do like to make noise. There is something a little bit disconcerting about a beeping noise coming from your chest. So I’ve had many patients talk to me saying, hey, my device made a noise this morning. I have no idea what it is. I’m worried about it. What it could mean is the battery is going to go out soon. These devices all have different timelines on when you hear beeps. You can actually look up some handy charts about what certain beeps mean. Like the battery is going to go in six months, etc. So it’s a good idea to have an idea of what’s going on. Reassure the patient that it’s probably okay, but they should contact their provider to make sure that their pacemaker or their ICD is okay and that noise was normal. So the more you run into pacemakers, you’re likely going to be asked what was that beeping noise they just heard. Don’t pay attention to that. Don’t panic. It’s likely all good. But just make sure they contact the cardiologist. I hope you learned something new today about implantable cardiac devices. I know I did as I went to put together this episode. It made me feel more comfortable when I go to work with patients with these. It actually just makes me feel like a more skilled provider knowing more about these devices. So I appreciate the questions that came from our Advanced Concepts cohort about these devices that really elevated all of our practice. I hope you have a great rest of your Wednesday and rest of the week. Bye now.